Health and Social Care

Lord Harris of Haringey Excerpts

Thursday 15th December 2016 Lords Chamber

Moved by

[Lord Harris of Haringey]

That this House takes note of the case for effective service user representation in health and social care, and of the case for enhancing the independence and capacity of Healthwatch England and of local Healthwatch groups.

[Lord Harris of Haringey (Lab)]

My Lords, I am sure the whole House will want to begin by placing on record again its condolences to the noble Lord, Lord Prior of Brampton, who would under other circumstances have been replying to the debate. We are sorry he is not here because of both the circumstances and what he would have brought to the debate as a former chair of the CQC.

I begin by declaring some personal history. For 12 years I was director of the Association of Community Health Councils for England and Wales, which was then the statutory body representing the interests of NHS users at national level and supported a network of 200 or more member community health councils. That is what I bring to the debate.

I apologise in advance if my remarks are coloured by that experience, but it is good to start by considering why patient involvement matters. It begins with the interaction between patients and clinicians, or service users and those who are caring for them. The Eurobarometer qualitative study on patient involvement, produced by the European Commission in 2012, summarised this well, saying that better communication is the central idea of patient involvement:

“For patients, this meant practitioners explaining to them the diagnosis and treatment. For practitioners, it meant patients describing symptoms and keeping them updated”.

The objective is a partnership between the clinician and the patient. There is evidence that where such partnerships exist they improve the outcomes of treatment because the patient is more committed to the treatment proposed and understands it better.

Patient involvement is also critical to service design and organisation. Those responsible for a service often have little understanding of what it is like to use the service in question—although, I have to say, they think they do. The reality is different. A senior clinician or senior manager inevitably ends up being treated differently if they suddenly become a service user.

At the risk of boring your Lordships, I mention a personal anecdote, which one or two may have heard before. This point of not knowing what the service is really like was brought home to me rather forcefully almost 30 years ago. After speaking at a conference, I began to feel increasingly unwell. To cut a long story short, shortly afterwards I found myself at my local accident and emergency, being prodded by a junior doctor, who was clearly completely baffled—as, indeed was I—as to what might be wrong with me. He then did what a junior doctor always does under those circumstances: he follows the protocol, which is to say, “So tell me, Mr Harris, what do you do for a living?”. I know that I should under those circumstances have lied in the interest of getting the true personal experience, but what I actually did was say, “Well, in fact, I’m the director of the Association of Community Health Councils”. The junior doctor then went behind the curtain. Of course, it is a fallacy that you cannot hear what is going on on the other side of that curtain. I could hear him phoning the consultant: “I think you should come down, sir. He says he’s the director of the Association of Community Health Councils”.

That, of course, is the experience when any senior clinician or senior manager is taken into a casualty department or tries to use a service. The reality is that services are better if they reflect the needs of the users of that service, which is why putting patients first at the centre of the NHS has been the mantra underpinning every government statement on the NHS since it was founded in 1948. The noble Lord, Lord Lansley, who is about to speak, will recall using very similar words during his time as Secretary of State. Incidentally, on the issue of personal experience, I seem to recall seeing all sorts of statements on what various clinicians would like to do to the noble Lord if they ever found him in their care, but fortunately that never happened during his period of brief notoriety in that role.

The most recent iteration of this mantra was probably NHS England’s five-year forward view, which advocated involving communities and citizens,

“directly in decisions about the future of health and care services”.

Since 1974, successive Governments have supported different models of involving the public in shaping services and of representing the voice of service users. First there were community health councils, until they were abolished in 2002 and replaced by patient and public involvement forums, which were in turn replaced by Local Involvements Networks—LINks—in 2008. They in turn bit the dust with the arrival of Healthwatch as part of the Health and Social Care Act 2012.

That Act had a tortuous passage through Parliament. Somewhere along the way, the model intended for Healthwatch at local level was changed. Those changes were given very little parliamentary scrutiny despite my personal best efforts, when I warned that the late changes to the Bill risked weakening the new bodies by starving them of resources and laying them open to conflicts of interest with local councils, which were to be their paymasters. The arrangements for Healthwatch England would inhibit its independence and effectiveness.

I am sorry to say that the concerns I expressed then have been borne out. Healthwatch England remains a sub-committee of a regulator, the CQC, a body that is already overstretched and to which requests for action and, from time to time, criticism may be directed by Healthwatch England or local Healthwatch. For Healthwatch England to be located there compromises its independence and must limit its scope to highlight when the CQC is not being as effective as it should be. Recent changes appear to have made Healthwatch England’s relationship with the CQC even more subservient, with changes to the chair and chief executive being used as an opportunity to make the role even more subordinate to the CQC.

I am grateful to have received in advance of this debate a letter from David Behan, chief executive of CQC, seeking to reassure me of the independence of Healthwatch England from the CQC, but in it he records:

“The National Director for HWE will be line-managed and accountable to myself as the CQC Chief Executive”—

apparently a new distinction. He further states:

“The HWE Chair is already accountable to the CQC Chair”,

and that the strategy of Healthwatch England has to be submitted to the CQC board for endorsement. That hardly sounds like independence.

Healthwatch England is reasonably generously resourced for what it does, with a budget of £4.5 million, but in 2015-16 it could not spend that and used only £3.7 million, a 17.3% underspend. A very small proportion of that goes on developing and supporting local Healthwatch. Nor does local Healthwatch feel that Healthwatch England is there for them and they have little scope to influence it or its work.

Healthwatch England also seems to fail in capturing and articulating the views and concerns of local groups, so much so that a private company, Glenstall IT, has stepped into the void by collating reports and publications of local Healthwatch groups, something you might have expected Healthwatch England to do, and selling the digest back to 2,000 health and social care professionals. The fact that Healthwatch England is not doing the job means that a private company has come in to sell it back to the people funding the system.

What about the resourcing of local Healthwatch groups? In 2013-14, the Department of Health passed over £43.5 million to be included in the local authority block grant to fund local Healthwatch organisations, but the total funding given to local Healthwatch groups in that year amounted to only £33.5 million—£10 million had disappeared along the way. That is before taking into account the cost of the cumbersome arrangements for competitive tendering and commissioning through third parties imposed by those late changes to the Health and Social Care Bill.

While there was £33.5 million in 2013-14, that fell to £31.8 million in 2015-16 and again to £29.9 million in this financial year—a third less in cash terms than the DoH thought was necessary and had handed over three years earlier. I warned the Department of Health that this would happen and that other pressures on local authority budgets would produce this squeeze, yet it acquiesced in allowing the money to go across unring-fenced. Was this a deliberate attempt to hobble patient representation and independent local scrutiny?

There is a big variation in the funding of individual local Healthwatch groups. Bristol provides £400,000, while Manchester only £80,000. Are the needs of the citizens of Manchester for effective patient representation one-fifth of those of the residents of Bristol, whose population is 50,000 less? Some areas have seen big cuts year on year: Barnsley down 25%; Blackpool down 50%; Bradford down 25%; Ealing down 25%; Harrow down 40%; Hounslow down 50%; Leicestershire down 30%. I could go on.

Some of the reductions are of course a consequence of the enormous continuing pressure on local council finances, but how much is it a consequence of local Healthwatch having a role in monitoring local social care provision—the responsibility of the same local authority that fixes their budget and may perhaps not like the criticism that an effective local Healthwatch group might occasionally have to make? Local authorities have a conflict of interest here and I am told of a number of local Healthwatch areas where this has had a deadening effect, particularly on the willingness of paid staff members to criticise those who provide their monthly paycheques.

One example is of a 30% reduction in funding imposed on Oxfordshire Healthwatch by Oxfordshire County Council, which seemed to follow, as night follows day, from criticisms that the local Healthwatch had made of the county council record on social care—precisely the job that Healthwatch was created to do. As one of its board members tells me, “The cut inflicted on us drove us to relinquish our strategically located premises close to the CCG headquarters and move to the cheapest possible accommodation on the edge of a farmyard in remote countryside. We have had to cut back on project work, assistance for voluntary groups and a range of community engagement activities. All this arose because our funding was not independent and ring-fenced, and was routed through a body we had criticised”.

In Manchester, the city council swallowed most of the Healthwatch budget, leaving what has been described to me as, “a puny organisation. They are not very effective and they don’t relate to any of the other patient organisations”. As the King’s Fund put it in its review carried out for the Department of Health:

“Local Healthwatch organisations are very small in comparison to the potential scope of their statutory activities, and the population and services they cover”.

The effectiveness of the input that local Healthwatch can provide is critical at present, as the sustainability and transformation plan process rolls forward throughout the country. According to NHS England, this process is supposed to be about building and strengthening local relationships, and service users should be at the heart of the process.

How has this worked out? Frankly, it is very variable. In some areas—Sheffield, Staffordshire and Bath—there is good involvement, but not in others. In Berkshire, Devon and County Durham, local Healthwatch was neither involved nor consulted. In Liverpool, local Healthwatch complains that the process has not been open or transparent. Its chair says, “We have not yet had the opportunity to review or scrutinise the detail of the plan”. In the East Riding, there has been no involvement. The MP for Tottenham had to ask a Parliamentary Question to find out who was consulted during the development of the STP for North Central London. None of the local Healthwatch groups was part of the transformation board. As one local Healthwatch rep from elsewhere in the country put it, “The STP thing is a nightmare. They think we patient reps are just a box to tick and the patronising attitude from some is breathtaking”.

Local Healthwatch also has the important power to enter and view services, but the King’s Fund study for the Department of Health found that this power was used in a wide variety of ways, with some of the case study sites doing none because they were unclear about what would justify an enter and view visit. Many local Healthwatch groups only carried out visits on a prearranged basis. Some saw it as a routine part of their intelligence gathering, while others felt it was only justified when “serious or multiple concerns are raised”. Clearly, there is no guidance and local Healthwatch organisations are left time and again to reinvent their own wheels.

As one local Healthwatch activist put it to me, “Too many of us do little E&V. What they do is announced and done by employed staff who have a vested interest in not rocking the boat”, because their salaries are paid by those they are inspecting. All this comes at a time, as the CQC admitted recently to the Health Committee, when it is struggling to manage inspections of establishments every other year. Local Healthwatch could provide an enormous resource to supplement and inform inspections by the CQC, but its potential enthusiasm is simply being stifled.

None of this should be taken to imply that the work done by hundreds, maybe thousands, of local Healthwatch volunteers is not valuable. I am aware, of course, of the many dedicated staff supporting them, but the reality is that the Department of Health has set up a deliberately flawed system. In the name of localism there is allowed to be an enormous variation in how local Healthwatch organisations structure their governance, as highlighted in the King’s Fund review. As a result, there is a lack of clarity in who speaks for local service users. Is it the board, is it its members, is it the host organisation, is it the staff or is it the volunteers? As a result, the authority of that voice is undermined. The King’s Fund criticised the lack of transparency of local Healthwatch and, as one volunteer put it, its structure and governance should follow the same pattern everywhere and not be determined on the whim of a local authority or a private host company.

It could be so different. As the King’s Fund review said:

“Some of the challenges that local Healthwatch face could be addressed through greater support, advice and shared learning on how to operate effectively”.

The tragedy is that Healthwatch has enormous potential. It could be a tremendous force for good in enabling health and social care services to be much more effective and user-centred. It should not be a box-ticking exercise or provide a woolly voice, but provide effective scrutiny with real influence and a real ability to involve the public. That is what the vast majority of those engaged in Healthwatch activities want to do but, alas, their ability to fulfil that role has been hampered by the cack-handed way the system was established, by the department’s failure to prevent the erosion of funds and, just possibly, by the fact that too many local and national service managers would prefer a quiet life, without having to respond to an effective user voice. I beg to move.

--- Later in debate ---

[Lord Harris of Haringey]

My Lords, I am enormously grateful to all noble Lords who have contributed to today’s debate. I am particularly grateful to the noble Baroness, Lady Chisholm, for standing in at short notice and speaking from the Front Bench, and to my noble friend Lord Tunnicliffe, who at even shorter notice has stood in for our Front Bench, who are also away for reasons of illness and other matters.

This has been an interesting debate, and lots of important points have been made. I particularly welcome the point made by the noble Lord, Lord Lansley, that shared decision-making in terms of the individual should happen anyway, irrespective of the structures in place. He outlined—and I do not dispute it—that when he was Secretary of State the Government’s objectives in creating Healthwatch were good, and the intention was to improve the system. It is just a question of how well it has worked subsequently. He asked a very valid question about why the Labour Government abolished community health councils. That is a question that I certainly asked at the time. I am sure that, had he been in his place, my noble friend Lord Hunt of Kings Heath, who was the Minister at the time, may well have wanted to comment on those matters. The fact that the arrangements that were then put in place were felt not to be working only a few years later suggests that perhaps the model was not absolutely right.

My noble friend Lady Pitkeathley, along with a number of other contributors, talked about the whole point of the involvement of patients being that it challenges the existing power structures and orthodoxy, which therefore produces a backlash. She also made the point, which I agree with, that in the Bill that ultimately became the Health and Social Care Act, the creation of Healthwatch was potentially a ray of hope in terms of how things would progress.

The noble Baroness, Lady Brinton, quite rightly reminded us of the role of the voluntary sector and the way in which users can shape the different patient pathways that are available. That too is something that often gets neglected. The noble Baroness, Lady Masham of Ilton, talked very pointedly about the lack of local knowledge about Healthwatch and its role, as well as the suspicion that is growing about the STP process—which could be extremely important, because it is intended to be transformational—in terms of the lack of openness and transparency. It is an important process, which is why it was so vital that health service users and social care service users were fully involved in the process.

My noble friend Lady Warwick of Undercliffe talked about how the role of local Healthwatch could be critical and said that it was one of the few organisations that really has an overview across the health and social care divide. She highlighted the concerns about the changed relationship between Healthwatch England and the CQC. She also reminded us, very importantly, of the potential role of housing associations. The noble Earl, Lord Listowel, talked about the value of senior people listening to service users. That is the essence of most of the models that have existed over the years—senior people directly hearing the voices that are there. The noble Baroness, Lady Watkins, also made that point when she talked about challenging the orthodoxy. She made interesting points about how users should influence and shape things.

I was very amused by one element of the speech made by the noble Baroness, Lady Walmsley, because she said it was not the Liberal Democrats who had said that the structure should work through local authorities. In that case, I am beginning to wonder whose idea it was. The noble Lord, Lord Lansley, speaking 10 years ago about the previous system, said that LINks may “struggle to be credible as long as they are funded through local government”. Just a few years later, he felt impelled by something or someone—we now know it was not the Liberal Democrats—to say that the new system should be funded through local government, with the consequences that I have described.

The noble Baroness, Lady Chisholm, in her reply, tried to reassure me about the relationship between Healthwatch England and the CQC, and reiterated what I already see as the accountability lines which render independence slightly more difficult. She then told us that the CQC would in future be deciding the funding of Healthwatch England, which seems to put even more into question the way in which that independence would operate. She also talked about local councils’ accountability for how much they allocate to Healthwatch England. This is very important, but the sanction Healthwatch England has available—which I think we have discussed before in your Lordships’ House—is that it can send a letter to the council lead saying it is not good enough. As a former council leader, I know what response I always gave to letters saying that something that my local authority was doing was simply not good enough.

In conclusion, I am grateful to all noble Lords who contributed to the debate. There is a great warmth around the House about what could be achieved by Healthwatch, both locally and nationally, and the message going back to the Department of Health must be that it is important to build on the Healthwatch network. If it really wants to get this right, and deliver what all your Lordships have said they want to happen, then it needs to resource local Healthwatch organisations properly through a freestanding Healthwatch England. I suspect we might then well find that we have a system which genuinely delivers a user voice and influence into the centre of health and social care in this country.

Motion agreed.