I am hearing a most bizarre rumour – even by the standards of bizarreness fostered by the Health and Social Care Bill.
Apparently, Ministers have instructed civil servants to draft an amendment to the Health and Social Care Bill (which begins its Report Stage in the House of Lords on 8th February) to change the status of the proposed new local HealthWatch organisations. These are the local structures that are being set up to protect the interests of patients in the brave new world of the “reformed” health service after the Bill is passed. (I have already warned that the proposals for HealthWatch are flawed.)
I am told that under this amendment, local HealthWatch organisations will no longer be “statutory bodies” but will instead become “bodies carrying out statutory functions”. This sounds – as, of course, it is meant to – like a trivial semantic point and the amendment will no doubt be presented as a technical change of no significance.
The reality is very different.
In fact, the change of status is important. It implies a downgrading of local HealthWatch organisations and they will need all the clout they can muster if they are to be effective. Some of that clout would come from being a statutory body in their own right.
But the real reason behind this change is that the local councils who are to set up the local HealthWatch organisations will now be required to put out to commercial tender the work of HealthWatch. (You cannot tender for a statutory body, but you can tender for a body to carry out statutory functions.) And as each individual HealthWatch organisation will have a budget above the level at which EU competition rules kick in, the tender will have to be advertised across the European Union in the Official Journal, so that firms and organisations from anywhere in Europe can compete to provide local consumer representation services.
I hate to think what these multiple tendering operations will cost and I fail to see how it is likely to lead to better quality local patient representation.
If this were some new health and safety requirement or some equal opportunities expectation, no doubt the newspapers would be wheeling out the “This is political correctness gone mad” headlines.
In fact, this is another example of the Health Secretary’s privatisation-mania, so all together now:
“THIS IS PRIVATISATION GONE MAD.“
Article 1 of the Universal Declaration of Human Rights adopted by the United Nations states that:
“All human beings are born free and equal in dignity and right. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.”
The words are familiar, but the reference to dignity perhaps does not get as much attention as it might – particularly for those who are in hospital or residential care. The Social Care Institute for Excellence has published its own guidance on the subject which says:
“Dignity is at the heart of personalisation. Dignity means treating people who need care as individuals and enabling them to maintain the maximum possible level of independence, choice and control over their own lives. It means that professionals should support people with the respect they would want for themselves or a member of their family.”
“A Dignity Champion is someone who believes passionately that being treated with dignity is a basic human right, not an optional extra. They believe that care services must be compassionate, person centred, as well as efficient, and are willing to try to do something to achieve this.
Dignity Champions are willing to:
Champions are all committed to taking action, however small, to create a care system that has compassion and respect for those using its services. Each Dignity Champion’s role varies depending on their knowledge and influence and the type of work they are involved in. There are many small things that you can do that can have a big impact on people’s lives, as well as taking on a more active role if you have the time to do so.
Dignity Champions include health and social care managers and frontline staff. They also include doctors, dieticians, porters, care workers in care homes, MPs, councillors, members of local action groups and Local Involvement Networks (LINks), and people from voluntary and advocacy organisations. People who use care services, their relatives and carers as well as members of the public are becoming Dignity Champions.”
I am prepared to play my part and join what I am told are 35,000 Champions already recruited around the country.
David Cameron is on the Today programme banging on about making the NHS more patient-centred and suggesting regular patient-led hospital inspections to ensure that this is the case.
Nothing wrong with this in principle. Indeed, every successive Prime Minister and Health Secretary in the last sixty years has talked about “putting the patient at the heart of the NHS” or some such soundbite. Equally, patient-led inspections are an important tool to support such an aspiration. Indeed, when I was Director of the Association of Community Health Councils in the late-1980s and through much of the 1990s, I was well aware of the importance of unannounced CHC inspections in promoting improvements in patient care at local level and in highlighting wider issues of health policy.
But – and it is a big but – the Government’s proposals for local HealthWatch organisations still fall a long way short of guaranteeing the network of vibrant independent patient-led structures that CHCs (shamefully abolished by the last Labour Government) provided in their hey-day. There are two big problems with the Government’s ideas on this in the Health and Social Care Bill, currently paused in its long slow grind through the House of Lords.
First, the new local HealthWatch organisations will be creatures of the local authorities in their areas, even though they will be expected to monitor the social care provisions commissioned and provided by those same local councils. Hardly, independent.
And the national structure, HealthWatch England, will be packed with Secretary of State appointees and will be a creature of the Care Quality Commission (constituted as a CQC Sub-Committee), even though much of the work of HealthWatch may involve calling on the CQC to take action on specific matters and may require criticism of the effectiveness of the CQC itself as a regulator (hardly easy if you rely on that body for all your support services).
And second, the system is likely to be grossly under-resourced. The Government is planning to “provide” resources for the new local HealthWatch organisations as part of their general grant to local Councils. No ring-fenced money. And, at a time when local government is having to make very substantial cuts in their core provision, it is hard to see that this will be much of a priority in any local council’s deliberations. The evidence in the last year of the way in which the budgets of Local Involvement Networks (LINks – the current iteration of the Department of Health’s attempts to replace CHCs) have been cut – in some instances by as much as 70 or 80% by local councils – does not provide much hope for properly-funded local HealthWatch organisations in the future (especially when they start criticising that council’s own provision).
And, of course, with so much of health and social care taking place outside a hospital setting, the Prime Minister’s comments do suggest a mindset locked in the concept of an NHS that is all about hospital/acute care . Delivering patient-centred community-based care will require both a willingness to invest properly and sustainably in those aspects of the NHS and also a recognition that patient-led monitoring of those services is not only important too but will also need to be resourced properly.
Without any of that, the Prime Minister’s comments today are nothing but empty soundbites. So, no surprise there …
Today was the thirteenth full day of Committee discussion on the Health and Social Care Bill on the floor of the House of Lords. The clauses debated today included a number relating to the operation of HealthWatch England (the national body that the Government is proposing to represent the interests of patients in the new NHS – which is to be constituted rather bizarrely as a sub-committee of the Care Quality Commission) and local HealthWatch organisations (these will be established by local councils – even though one of their roles will be to scrutinise the care provided by those councils).
I spoke in support of a number of amendments designed to strengthen the position of HealthWatch and make it more effective, saying:
“My Lords, we have already debated to some extent the way in which HealthWatch England might operate. However, this group of amendments returns not just to that issue, but to a number of other important issues which go to the core of the extent to which HealthWatch England is genuinely going to be an effective organisation. I give Ministers and the Government the benefit of the doubt on this—that that is something that they want to see happen. Therefore, the way in which HealthWatch England is established, the way in which it functions and the powers that it has are going to be critical to whether or not this body will simply join the long list of organisations that have been set up over the years to represent patients’ interests and have then been dismembered after a short period, or in some cases a slightly longer period, because they are not seen to be effective. If the Government are genuine about putting patients at the heart of the new NHS, then they need to ensure that HealthWatch England and healthwatch organisations are effective.
My noble friend Lord Warner, slightly unusually, pulled his punches. He talked about it perhaps being a major mistake to host HealthWatch England within the CQC. I have to say there is a danger that this could be a disaster. It is a disaster because of the sustained attacks that the CQC is currently undergoing, which seem to emanate in some instances from Government and Ministers who clearly are not satisfied with the direction of travel. There are clearly concerns that this is an organisation which is being asked and expected to do far too much at the moment. To add this additional responsibility is not necessarily helpful.
I can understand that it is important that HealthWatch England relates effectively to the Care Quality Commission: that is one of the organisations it must relate closely to. But it must also relate closely to the NHS Commissioning Board. It must also relate properly, under certain circumstances, to Monitor. Simply saying that the relationship with the CQC is paramount does not necessarily make an enormous degree of sense.
My noble friend Lord Warner made a specific point. If the motivation for hosting HealthWatch England within some other national organisation is to save money—I understand that it may not be the prime motivation but it is a concern in all this—then there are plenty of other ways of achieving those savings in terms of back-office functions. Those functions can be provided by agency agreements; you can have organisations which are in the same building and able to share some of the physical facilities and so on. It does not necessarily require that the organisation sits as an integral sub-committee within or as part of the organisation concerned. You can do it in other ways; you can achieve those savings in other ways.
However, if you place HealthWatch England in the Care Quality Commission, or for that matter in the NHS Commissioning Board or any of the others, you are in danger of there being either a real or perceived conflict of interest. It may well be the case that HealthWatch England will, on occasions, be asking the Care Quality Commission to do certain things. It may well be the case that there will be, on occasions, circumstances in which HealthWatch England will be saying that the Care Quality Commission has failed to do certain things. That is not a happy situation; nor is it one that is likely to engender the trust of the public if they are seen as being part of the same organisation. That is the principle which underpins some of these amendments.
There is then the question of the extent to which HealthWatch England is seen as being a creature of either the CQC or Government. That then relates to how the ruling body of HealthWatch England—the committee, if it is a sub-committee of the CQC—is appointed. That is why one of the amendments to which I have my name, Amendment 307, specifically refers to the committee of HealthWatch England being,
“elected from local Healthwatch organisations”.
It is a principle of accountability; it is a principle of ownership; it is a principle of safeguarding that independent viewpoint and voice. That is why that is necessary and that is why Amendment 307 in this group is so important.
We also have a series of amendments, Amendments 308, 309, 312, 313, 315 and 316, which try to make sure that it is absolutely explicit that HealthWatch England’s role is not just to provide information or advice but, on occasions, to make recommendations to the bodies concerned. It may be a recommendation to the CQC or to the other major national organisations. This group of amendments specifies that that is part of its functioning. It also makes it clear that there should be proper responses to those recommendations from the bodies to whom they are directed. Again, if the Government are serious about making HealthWatch England effective and about having a genuine and clear voice of the users of the NHS and social care services, surely placing in the Bill the power to make recommendations is central to that.
Amendment 314, to which I have also put my name, essentially requires HealthWatch England to provide the CQC with information and advice on the views of patients and the public, and of local healthwatch organisations. It is not a question of it being a discretionary responsibility but a clear responsibility—it “must” rather than it “may”. I know that, in this Committee or in your Lordships’ House more generally, we sometimes get into esoteric discussions about the relative force of “must”, “shall”, “may”, and so on and so forth. I am quite clear that must is stronger than may. That is to avoid a situation where the national body fails to take into account the views and opinions being expressed locally. It is saying that this is an obligation on the organisation to reflect that. Again, if you want to see an independent voice for patients at national level, it must be clear that that body is obligated to put forward the views of patients, the public and local healthwatch organisations.
Amendment 317 also goes to the heart of the relationship between HealthWatch England and local healthwatch organisations. It is a very simple expectation, which I am surprised was not included in the Bill already. HealthWatch England must send a copy of any report it produces to all local healthwatch organisations. This is about the way in which local healthwatch organisations relate to their national body. I speak as someone who ran a national body for patients for a number of years. I know that we would have had an extremely difficult time with our member community health councils had we been making advice and recommendations at a national level without keeping the local organisations, on whose advice those recommendations were based, fully informed of what we were saying and doing. The Bill sets out some of the people who should receive the reports produced by HealthWatch England, but fails to mention local healthwatch organisations. It is a simple change. I am sure it was a mere error in drafting and that the Minister will be able to accept Amendment 317 without wasting time at Report on the issue.
Amendment 318 relates to the relationship between the Secretary of State and HealthWatch England. Clearly, there is a nagging concern in the Department of Health that HealthWatch England may not do all that the Government are hoping, which it certainly will not be able to do unless they make some of the changes being suggested in this group of amendments. However, the Secretary of State has taken upon himself the power to give directions to HealthWatch England. Personally, I do not have a problem with that. I accept that Secretaries of State like to have that in respect of all sorts of organisations. However, before making those directions, which the Secretary of State should not make lightly, Amendment 318 provides that the Secretary of State,
“shall consult local Healthwatch organisations”.
If the Secretary of State were to give a direction on the basis that it was failing to discharge its functions, that should be in the light of the knowledge that local healthwatch organisations, to which HealthWatch England should be responsible and is, in part at least, servicing and supporting, have been properly consulted.
I think that the amendments are entirely modest, sensible and ones that the Government can accept without further problem. They are integral to ensuring that HealthWatch England is the proper voice of the users, patients and those who depend on the NHS.”
The response from Baroness Northover (who apparently still resents the way in which I defeated her in an election in my ward in Haringey in 1998*) was not exactly encouraging – so much so that she sustained – in House of Lords terms – quite a robust battering from myself and Labour colleagues:
“Baroness Northover: My Lords, this has been another excellent debate. We have returned to the topic of HealthWatch, which we also discussed on 22 November. I listened very carefully to the views expressed in that debate. It seemed that there was a consensus, as there has been again today, about the need to have the patient voice very much at the heart of the NHS. There was agreement then, as I think there is today, that the Bill moves us forward in making sure that the patient voice is at the heart of the NHS. I thank the noble Lord, Lord Warner, for his comments in this regard.
However, I fully recognise that there are significant concerns about the way in which the Government are taking forward these proposals. When we discussed this previously, I made a commitment to continue discussing these issues. We have had subsequent meetings, which some noble Lords have attended; I thank them for their input. I found those meetings extremely constructive. I also attended the meeting between the noble Earl, Lord Howe, and the national association.
Our previous debate focused on the independence of HealthWatch England, which will be a statutory committee of the CQC. I understand that this risks, as the noble Lord, Lord Harris, said, dangerously compromising the independence that I talked about as being so important. Let me be clear why we are proposing this arrangement. There is a reason why, at present, there is no national statutory organisation to champion the patient voice. The last body, to which noble Lords made reference—the Commission for Patient and Public Involvement in Health—was abolished for being ineffective and lacking influence as well as being too expensive and too centralising. To quote from the Health Select Committee’s 2007 report into Patient and Public Involvement in the NHS:
“The evidence we received was overwhelmingly critical of the Commission”.
The noble Lord, Lord Warner, said that the Government should set up an authoritative, stand-alone body, and others have made similar points. This is, however, precisely the point. While I respect the view of the noble Lord, the Government have not been convinced that it would be possible to have such an authoritative stand-alone body in the form that they suggest. The previous Government’s attempt to do this with the commission did not work out well, as noble Lords know. The abolition of the commission was announced five months after it started work. It limped on for a further three years, chewing up £100 million and was universally criticised.
Lord Harris of Haringey: Bandying around figures—“it chewed up £100 million”—gives a completely misleading impression. Could she tell us what proportion of that £100 million was the administrative cost of the commission, as opposed to the provision of patient and public involvement forums in every part of the country? The figure of £100 million is totally misleading.
Lord Harris of Haringey: I suggest that if you use a figure like £100 million, which was not the figure used by the noble Baroness, Lady Pitkeathley, you need to explain that that includes the running of the public and patient involvement forums. It is not the cost of the administration of the national body itself.
Baroness Northover: The organisation used up £100 million. There were criticisms from the local organisations that they were not getting the money they needed, so there was widespread criticism. There was criticism at a national level within the NHS and, in particular and importantly, the local organisations did not feel that it was acting in the way they needed it to, or feeding through to them the resources they needed to do what they felt was appropriate.
Lord Harris of Haringey: One of the failings of the commission was that it did not have a relationship with local public and patient involvement. The purpose of the amendment which talks about direct election would be to obviate that problem and provide a constraint in terms of whether or not there were going to be overly centralised administrative costs, because the body itself would be accountable to the local bodies that would be the recipient of most of them. My concern and my frank irritation with the commission—which I had no part in at the time—was the suggestion that all the £100 million was somehow used by the central administration. That was not the case.
One of the failings of the commission was that it was not accountable and did not have a proper direct relationship with local public and patient involvement. That was a fault both of the way it was constructed in terms of the legislation, for which the Labour Government of the time must take responsibility, and of the way in which the commission chose to work, with the support of the Department of Health at that stage.
Baroness Northover: What the noble Lord has said bears out the point. This was a nationally established commission which we all agree did not work. We therefore need to learn from that costly experience to try to move on and to work out a way in which you can have local healthwatch organisations as the local eyes and ears, feeding through to HealthWatch England, a national organisation. We are at the moment looking at how that national organisation should be sited. Everyone has said that the relationship between the national organisation and local organisations did not work previously. We are seeking here to make that relationship work much better. I can see another noble Lord is about to hop up.
Lord Warner: The Minister will be pleased that it will be the noble Lord who pulls his punches, as my noble friend said earlier. I wish to pursue this issue of how much money the Government think they need to spend on funding HealthWatch England. This is the real issue: say, for example, it has £10 million—I do not know what figure is being considered, but there will be a sum of money. It seems to be agreed that there ought to be some kind of national body. I do not altogether understand the Minister’s argument that we got it wrong in the past, because we fully accept that we got it wrong. However, it does not follow from that there should not be a national public body called HealthWatch England. The Government seem to accept that. The argument is over whether you should place that body in the Care Quality Commission. I can see that one might argue that costs could be reduced by doing that, but we first need to know what the Government are prepared to spend on this body, and then we can discuss the best way of spending that money in terms of independence.
Baroness Northover: Perhaps I may come on to the points that I was going to make regarding why we are making our proposals in light of the experience of the national organisation that did not work brilliantly. They address some of the issues that the noble Baroness, Lady Pitkeathley, raised and are implicit in the points made by the noble Lords, Lord Warner and Lord Harris, and others about the independence and status of the new organisation.
I cited what happened with the previous national organisation, and the point about where we are placing HealthWatch England is that it is an attempt to ensure that it is in a strong position to influence the regulator, the CQC, rather than sitting off to one side and not necessarily being listened to. A lot of concern has been expressed about how that relationship would work, but I point noble Lords towards the other side of the issue. If HealthWatch England is sitting there alongside the CQC, with local healthwatch feeding into HealthWatch England, what better way to make sure that you flag up to the regulator concerns from local areas. Noble Lords should try to look at the issue from that point of view, as opposed to seeing the CQC as somehow silencing HealthWatch England. It is vital that the views of patients and other service users are taken on board by the CQC and that it does not close its ears and eyes to what is happening.
Lord Warner: I am still struggling. I am sorry to keep interrupting the noble Baroness, but let me give her an example. Could HealthWatch England, as a sub-committee of the CQC, run a national campaign against what is being done by that regulator on an issue such as feeding elderly people in hospital?
Baroness Northover: HealthWatch England has a statutory obligation to represent the position of patients and, if it is concerned about the feeding of patients, yes, it indeed has the right to set its agenda, to campaign on that and to argue that this must be checked on and brought up to a much better standard. As my noble friend Lady Cumberlege said, we have throughout the NHS and through its recent and long-term history, problems and challenges in meeting basic standards of care and attention. All of us know that, whatever party we come from. The previous Government did not get this right; we are seeking to move forward, and we need to ensure that we consider these questions fundamentally and address why these problems continue to arise. They have been intractable; we will continue to address them; I welcome noble Lords’ contributions on that.
Lord Harris of Haringey: The noble Baroness made a very important point just now. She said explicitly that HealthWatch England could and should be a campaigning organisation, although it would be a sub-committee of the CQC. This is irrespective of the debate about where it is located. I think that the principle of creating a national patient organisation as a campaigning organisation on behalf of patients is extremely important. I am very grateful to the noble Baroness for making that commitment on behalf of the Government.
Baroness Northover: HealthWatch England will represent the voice of the patients. It will publish on that; it will advise on that; to take up a point raised under one of the earlier amendments, it will no doubt make recommendations within the areas of its advice. It has the obligation to make those recommendations to various organisations within the NHS. Various organisations, including the CQC, have the responsibility to respond to that. All those obligations will flag up problems, so I do not see that I have made a startling admission. I would have thought that the noble Lord, Lord Harris, would know that transparency—publishing information—was the best way forward.
However, I agree with many noble Lords that this has been rather a patchy area. We have to try to give greater strength to these organisations both locally and nationally. Much of that is not based on their structures, because all sorts of structures have been tried, but we are trying to take them further forward.
Lord Warner: I just want to pursue the issue of the campaign, because it is very important. Currently, there has been a very effective campaign about literacy run by the Evening Standard. That has attracted lots of voluntary money to run it and led to some interesting changes and the Government supporting it. To be absolutely clear, I ask: are we saying that a sub-committee of the regulator—the Care Quality Commission—could run a campaign on the feeding of elderly people in the National Health Service in association with a national newspaper and criticise the Government strongly, implicitly, about the way that they are running the NHS in that area? If the Minister, on behalf of the Government, is saying that yes, it can, I start to get more convinced about the Government’s commitment to independence of the sub-committee of the CQC.
Baroness Northover: As I said, HealthWatch England will need to look at what works well and what works not so well right across the country, gathering the information from local healthwatch. It will flag up things which, no doubt, will be uncomfortable at all levels of the NHS and the Government. Noble Lords would not expect change to be driven in any other way. If things are unsatisfactory locally, as fed by local healthwatch to HealthWatch England, if it is doing its job it will obviously flag up areas where change is required.
Lord Warner: I am not talking about flagging up; I am talking about a campaign. A campaign means that you take action, using the media, to put serious pressure on the Government in relation to their record in running the NHS for elderly people. I am not saying that that should happen; I am trying to understand what power this body would have as a sub-committee of the regulator, which is the point that we are discussing.
Baroness Cumberlege: Does the noble Lord, Lord Warner, agree that much depends on the membership of this body and whether it is independent? I am not sure why people call it a sub-committee. In the Bill it is called a committee. I have chaired the top board in organisations and I know that you get very close to some of those committees—you listen to them. If an organisation is totally independent and it goes left field, making a whole lot of noise, you just dismiss it and say, “Oh, they’re always making problems”. The opportunities are far greater if part and parcel of what it does is informing you of what is going on. I honestly think that you will listen much more carefully to people whom you meet in the corridor, in the chambers or wherever the debates are going on.
I take the point made by the noble Baroness, Lady Emerton. The Care Quality Commission does not always say that everything is dreadful. The Healthcare Commission used to say, “This bit’s good; this bit needs addressing”. I can see that this committee—not sub-committee—of the Care Quality Commission will serve a very useful purpose. It could put enormous pressure on the Care Quality Commission really to understand what is going on and it would not just be an irritant that is offside.
Baroness Northover: I thank my noble friend Lady Cumberlege for that and I agree with her very much. We all wish, and have all sought, to drive up quality in the NHS. That is so often difficult to achieve but this is one of the means by which we hope to make that happen. No doubt some people will be made to feel uncomfortable by what the committee reports and says, and I hope that that will be the case.
Baroness Pitkeathley: Perhaps the noble Baroness can take that a little further. For example, could HealthWatch, in the position envisaged for it by the Government as a committee of the CQC, join with a national campaigning charity—I am thinking of something such as National Voices—to put pressure on the CQC itself about how it was reporting patient outcomes?
Baroness Northover: I am sure that it could. If it felt that it was not managing to persuade the CQC or some other part of the NHS to do what it considered to be in the best interests of patients, then I am sure it would go to greater lengths to ensure that it got its message across. It is very important that we have a louder patient voice within the NHS, and this is one means of seeking to achieve that.
I return to some of the amendments that noble Lords have flagged up. This is a very important debate. I think we agree on where we wish to head and what we are seeking to achieve, but I hear noble Lords’ concerns about whether this is the right way of going about it. Noble Lords talk about an independent organisation and so on but that route was tried. This is another route for trying to make sure that there is a body close to an organisation which itself must have a major role in driving up quality. The synergies there are very important.
The question was raised of how local healthwatch is going to influence HealthWatch England. I heard what the noble Lord, Lord Harris, said about elections to HealthWatch England from local healthwatch. Clearly, as my noble friend Lady Cumberlege said, a great deal will depend on who is on these organisations nationally and locally, and it will be necessary to ensure that they are as strong as possible. The Secretary of State will determine how the membership is comprised through regulations and we will be discussing with a wide range of stakeholders the contents of those regulations. I can confirm that we will discuss the suggestions put forward by noble Lords. We had from the noble Lord, Lord Harris, an emphasis on election and a concern about that route from the noble Baroness, Lady Pitkeathley. Both noble Lords might wish to feed in to how those regulations are taken forward so that we can best comprise HealthWatch England and local healthwatch.
Lord Harris of Haringey: Can the Minister indicate the timetable for consultation on the content of those regulations? Those of us who wish to see an election process in the Bill will need to know sooner rather than later whether that is the way in which the Government’s thinking is going. When is that consultation going to take place and when is it likely to conclude?
Baroness Northover: In the meeting that I was in yesterday with NALM this was an issue. The noble Lord, Lord Harris, is probably aware of that. No? That was one of the issues—perhaps the noble Lord, Lord Warner, referred to it—that did come up. The consultation will be early next year. Given that we are almost in next year, that is pretty soon.
The noble Lord, Lord Harris, wanted to make sure that HealthWatch England’s annual report was shared with local healthwatch. While we do not feel that that is a matter for the Bill, the annual report must be published. It is important that that information is made widely available. I am sure that the noble Lord’s suggestion will be noted by HealthWatch England and local healthwatch as the information between the two must go back and forth, in both directions.
If HealthWatch England were significantly failing in its duties, the Secretary of State has powers to intervene. An amendment addressed whether the Secretary of State should consult local healthwatch. This was on the assumption that HealthWatch England was in effect failing local healthwatch. While the Secretary of State should not be bound into a rigid consultation—something else entirely could be in question here—we would fully expect him to seek the views of others where appropriate in coming to a decision to intervene. I hope that that will reassure noble Lords.
My noble friend Lady Jolly talked about local healthwatch needing to look widely at all groups of patients, including those with rare diseases and so on. She is right. We will be coming on to other amendments where we look at this a bit more. LINks and its predecessors recognise that they have not had as wide a coverage as they would like or been as representative of their communities as they would need to be. This concerns us. The noble Baroness, Lady Pitkeathley, referred to it briefly in relation to whether local healthwatch should elect to HealthWatch England. We are seeking to learn from this. We want to try to make sure that local healthwatch has as broad a spread as possible. It is worth bearing in mind that it has a place on the board of the health and well-being boards and so there will be information feeding back to local healthwatch from the others on the health and well-being boards and from local healthwatch into the health and well-being boards. We will come on to local healthwatch in relation to local authorities, but there is synergy there too.
While I feel that the Bill provides safeguards for the independence of HealthWatch England within CQC, I would like to repeat my commitment that we are prepared to listen to further views. It is very clear that we are all trying to head in the same direction. There is a variety of views about how best to do this. We would welcome noble Lords’ continued input as we take this further forward. In the mean time, I thank noble Lords for flagging up these issues. I hope that the noble Lord will withdraw his amendment.
Lord Warner: My Lords, this has been an interesting and spirited debate. I will certainly reflect on the Minister’s willingness to consider some of these issues further. My noble friend Lord Harris and I will certainly be considering this further and I would not rule out the possibility that we might come back to this on Report. I beg leave to withdraw the amendment.
Amendment 306 withdrawn.”
*For the record the figures were:
Toby Harris (Lab) 846 votes Elected
Catherine Stafford (Lab) 806 votes Elected
Lindsay Northover (LibDem) 293 votes Not elected
In Question Time in the House of Lords a succession of Labour Peers (including me) pressed the Government on their attitude to the Health Lottery run by Richard Desmond of “Daily Express” and “Asian Babes” fame, which only pays just over the legal minimum of 20% of the money raised to the good causes it supports.
Here are the exchanges:
To ask Her Majesty’s Government what assessment the Gambling Commission has undertaken of the contribution being made to good causes by the Health Lottery.
Baroness Garden of Frognal: My Lords, the Gambling Act 2005 requires that at least 20 per cent of the proceeds of a society lottery go to the good cause that it supports. Each of the 51 society lotteries that are promoted under the umbrella brand of the Health Lottery must comply with this requirement. We understand from the Health Lottery that 20.3 per cent of the proceeds of each individual society lottery will go to the relevant good cause, addressing health inequalities in specific geographic areas of Great Britain.
Lord Faulkner of Worcester: My Lords, may I ask the Minister two questions? First, is she aware of the great concern that has been expressed by the beneficiaries of legally run society lotteries in the health sector, which have benefited immensely from those local society lotteries, about what is seen as the unfair competition from the Health Lottery? Is she aware that the hospice movement is particularly alarmed, because it depends very heavily on society lotteries? In Worcester, for example, our two hospices receive £70,000 a year from the South Worcestershire Hospices Lottery, which pays 50p in the pound—not 20p in the pound—to those good causes.
Secondly, notwithstanding what the Gambling Commission may have decided initially about the Health Lottery’s legality, how can it be legal to have 51 community interest companies linked to the Health Lottery which have no independent existence, but which all have the same three directors and all operate out of the same virtual office? How is that legal?
Baroness Garden of Frognal: My Lords, the noble Lord has great expertise in these matters. In his first question, he raises the concern about the hospices. We share the concern about the potential impact on society lotteries, although a number of existing health-related charities have been supported through the Health Lottery arrangements so far, and we will ensure that the impact on other society lotteries is monitored.
On the noble Lord’s second question, about the legality, he will also be aware that compliance with the requirements of the Gambling Act 2005 is a matter for the Gambling Commission, which has issued the necessary licences for the Health Lottery. As with any major scheme entering the market, however, it will work with the operator to ensure that what is delivered is actually compliant. We expect initial findings from that monitoring to be with us by next March.
Lord Addington: My Lords, would my noble friend give some thought to the idea that charities which are created to allow a lottery to be organised might be against the spirit that was initially taken on in this field? If that is right, will she undertake that the Government might look at the whole legal framework? If it is against the spirit, we can change the rules.
Baroness Garden of Frognal: My noble friend makes a very valid point that, so far, the legality has been in the matter of the fact of the law. However, as I have mentioned, there will be ongoing monitoring and, as he so rightly says, all these things can be changed if it turns out that the spirit of the law is not being respected.
Lord Brooke of Alverthorpe: My Lords, are the Government content with the system that they have in place for monitoring the operations of the Gambling Commission and, if not, what can they do about it? Are they content that Mr Desmond is a fit and proper person, given what was said at the Leveson inquiry last week and the failure of his organisations to associate themselves with the independent press commission, and that this is the way forward given some of the issues which now surround the operation of this lottery?
Baroness Garden of Frognal: My Lords, as I say, it is for the Gambling Commission to look at this. We recognise all the issues around Mr Desmond and his other organisations, but those are not perhaps directly relevant to this. One thing that the Government have done is to merge the Gambling Commission and the National Lottery Commission, which we expect will make regulation easier and create cost savings but also help to produce a more robust form of monitoring.
Lord Collins of Highbury: My Lords, may I press the Minister on the issue of what I consider, as I think many would, an apparent loophole exploited by the Health Lottery with its 51 separate companies? Will she give an assurance that this loophole will be examined and perhaps closed by the Government, bearing in mind that the Health Lottery has a turnover of £510 million a year and is in effect an alternative national lottery, affecting funding not only for other health charities but for the arts in general?
Baroness Garden of Frognal: My Lords, the noble Lord raises an important point about the issue of whether the Health Lottery will impact on the National Lottery. We are well aware of the vast amount of good work that the National Lottery does for the arts and a whole range of charitable organisations in this country. This is the first time that a lottery has been set up in this mode, with 51 society lotteries under an umbrella. It is a new model, which is why we are looking to the Gambling commission to report back to the Government on how it is going to operate. Of course, the Health Lottery has been going for only eight weeks so it is early days as yet to see how it will pan out, but I hope that the noble Lord will rest assured that the Government are monitoring the situation.
Lord Haskel: Following on from my noble friend Lord Faulkner’s question, should the Minister not be speaking up for those charities that give 50 per cent of their income rather than those that give only 20 per cent?
Baroness Garden of Frognal: My Lords, I am sorry if I was not speaking up loudly. One indeed commends the society lotteries that give on average 51 per cent to good causes overall, which is a much more significant proportion than 20 per cent. The question remains whether this will be a form of raising additional funding for good causes, and only time will tell whether that is the case.
Lord Harris of Haringey: My Lords, is it not the case that the public assume that a much higher proportion of the money that they put into these lotteries is going to the good cause concerned? Should the Government not be looking to raise the 20 per cent threshold to a more realistic figure? That may then squeeze out those who see setting up these lotteries as a way of making extra cash for themselves rather than for the charities that they are supposed to be supporting.
Baroness Garden of Frognal: My Lords, the raising of the threshold has been under discussion. We feel that at the moment, with the Health Lottery still so new, this is not the moment to change the thresholds for the lotteries as a whole. As I say, though, we are monitoring the situation since, as far as we are concerned, it is a new set-up in the lottery world. We shall wait and see, with the promise of a report of that monitoring early next year.
Lord Brooke of Sutton Mandeville: When I had the privilege of moving the Second Reading of the National Lottery etc. Bill in 1993, I gave way 28 times in the hour it took me to complete my speech. It was perfectly clear at that time that scrutiny of the lottery was being carried out extremely effectively by Parliament. I hope that the amount of time that we need to scrutinise this new development will be shorter rather than longer.
Lord Faulkner of Worcester: If the Minister reads the prospectus of the Health Lottery, she will see that in order for it to meet its targets of paying money to the 51 community companies it will need to raise something in the order of £250 million a year from the British public. Where does she think that money is going to come from? Surely it will be from existing charity giving, existing society lotteries and the National Lottery.
Baroness Garden of Frognal: My Lords, this is one of the things that we shall need to look at. At the moment, the Health Lottery is raising £2 million to £3 million a week compared with the National Lottery which is raising somewhere between £150 million and £190 million a week. So the latter is still far and away the major source of public money in this area but, to pick up an earlier question, it is very important that the public are made aware of just how much of their money is going to good causes from the Health Lottery compared with how much goes to good causes from society lotteries and indeed the National Lottery.”
Apart from the Minister (Baroness Garden) and interventions from LibDem Lord Addington and Tory Lord Brooke of Sutton Mandeville, only Labour peers seemed interested in the issue.
Yesterday also saw the first discussion of the role of HealthWatch during the Committee Stage of the Health and Social Care Bill. HealthWatch is the proposed new structure to represent the interests of patients and the public in the new NHS. It is potentially hugely important, as patients will need a strong voice to protect their interests. However, the Government is proposing that the national body, HealthWatch England, should be constituted as a sub-committee of the regulator, the Care Quality Commission, and that local HealthWatch organisations should be run by local authorities (even though they will be responsible for some of the social care services that HealthWatch will be monitoring) without any protection of their budgets.
This is what I said on the subject:
“My Lords, I apologise to my noble friend Lord Patel if he in any sense felt beaten up by me. I absolve my noble friend Lady Wheeler from any involvement in that process. I also apologise to the long-suffering officials in the Government Whips Office. If my robust style is mistaken, they should really see what I am like when I am angry.*
I added my name to a number of amendments in the various versions of this group. I also proposed Amendment 305. If the noble Baroness whom I believe is replying to this debate is planning to highlight any technical flaws in that amendment, I should point out that I drafted it myself. Therefore, it no doubt does contain a number of technical flaws. But the purpose of the amendment is to assess the feeling within the House and the strength of feeling in the department about the extent to which it is important that HealthWatch England and healthwatch organisations at local level should be independent.
The principle underlying this group of amendments is straightforward-the centrality of the voices of patients and users in the NHS. That voice must be, and must be seen to be, independent of the various provider and regulatory interests. That is what underpins all of the different amendments.
I find it difficult to understand how the Government will oppose the amendments. They keep telling us that the voice of the patient and the user will be central to all these arrangements. They say that that is their intention. But they must be aware, because everybody else is, of the cynicism and doubt that is being expressed around the country about this whole package of NHS changes. Therefore, they should be able to reassure patients and users that their voices will be heard at every level within this complicated restructuring that will take place. That is extremely important.
What is more, it will be important for that voice to be seen to be independent. Members of the public will be concerned about what is happening. They will worry whether their doctors, who that they do not fully understand as being part of commissioning groups, will somehow be making judgments about their care, influenced by financial interests. They will want to be assured that they can go somewhere for proper advice and support, and that that place will genuinely be independent of all of those interests.
A huge expectation is now being placed on local healthwatch organisations. They are expected to provide that independent advice and information, to be able to monitor the nature of the service at local level and to be able to comment on the various changes that are taking place and on the proposals that are coming from the plethora of commissioning groups, senates and goodness knows what else we are going to have. They are going to be there to make recommendations. So, there will be enormous expectations on behalf of the public as to what these groups are going to do. Similarly, the national body, HealthWatch England, will have enormous expectations upon it. That is why it is so important to get these arrangements right. The
proposals for HealthWatch England and local healthwatch are an advance on what we have at present in terms of LINks. There is no question about that-they are a step forward. The record of successive Ministers and Governments in terms of patient representation in the NHS is not very good. This is a step forward from where we are at the moment. So, let us try to get it right. Why not deal with what are comparatively small issues in terms of how the system works?
The trouble is that, at the moment, the arrangements that the Government are proposing are flawed in two key respects: first, on the issue of independence, as the noble Lord, Lord Patel, has already indicated; and secondly, in terms of the resources available. Let us consider for a moment the position of HealthWatch England as a sub-committee of the Care Quality Commission. That might be a very neat way of not increasing the number of quangos by one; it may be that was the sole motivating feature. However, the reality is that it dangerously compromises the independence that I talked about as being so important. Often, HealthWatch England will have to say, on behalf of local healthwatch organisations, that the regulator should be doing something, has failed to do something or has been inadequate in the way that it has done that. In the last few weeks, we have seen the Minister’s colleagues in the Department of Health making quite critical comments about the way in which the CQC has fulfilled its remit. If Ministers are saying that-and Ministers are, after all, the paymasters of the CQC-what is it going to be like for those people whose remit is to raise these issues but are themselves subordinate to that regulatory body? It is going to be a real conflict and a very difficult position for them. The nature of that relationship-the fact that they are a mere sub-committee and are subjected to all of the panoply of arrangements that go with that-is going to be seriously limiting.
I am aware that the CQC is making enormous efforts to try and demonstrate their good faith in all of this. I am sure that the individuals involved have good faith as far as this is concerned. However, we are here considering legislation that will set those arrangements. Once those arrangements are set, the good will of the individuals who may be trying to make it work at the moment may not persist-not because those individuals will change their minds, but because, over time, those individuals will move on and others will take their place. Budgetary and other pressures on the CQC will rise. The feeling that they do not like being criticised by a body that is technically subordinate to them will increase. That is why that arrangement does not work.
There is an even stronger argument as to why local healthwatch organisations should not be subordinate to principal local authorities in their area. The Government’s flaws here are flaws twice over. Not only are they imperilling the independence of local healthwatch organisations by saying that-even though they are supposed to be independent-they are creatures of the local authority, the funds will be provided by the local authority and many of the facilities may well be provided by local authority but, because the funds will not be ring-fenced, it will be far too easy for local authorities to start to apply the screws if they do not like the criticisms that come from it.
A major conflict of interest is being created. HealthWatch cannot be accountable to, and at the same time funded by, local authorities because the bodies which commission and provide the services are the local authorities in many instances. However, the Government are saying that HealthWatch can advise members of the public about those services. How can HealthWatch organisations be funded by the same bodies that are commissioning and providing those services? This is precisely the area where the confidence of members of the public and of individual patients is so important. They have to go for advice to a body which is funded by the people about whom they wish to take advice. That hardly looks independent or satisfactory. If HealthWatch is made accountable to local authorities as the Bill proposes, the public will, frankly, have no confidence in that and all the efforts that the Department of Health and the Government have made to try to create a better structure will be wasted. That resource will be wasted because the public will not have confidence in these arrangements.
There is also a failure to protect the funding. I do not know how many hot coals Ministers in the Department of Health had to crawl over to get £60 million out of the Treasury for HealthWatch. I am not suggesting that the Department for Communities and Local Government is any more evil than any other government department, but if you hand the funding to that department, which then hands it on to individual local authorities without a label saying, “Not only is this money to be used for HealthWatch but it cannot be used for anything else”, my experience as a former council leader tells me that you cannot guarantee that the money will be used for the purpose that you wish.
I spoke earlier about localism and said how wonderful it was that the Government should devolve responsibility for this issue. However, it is not a wonderful example of localism if you expect something to happen, you pass the money on and then you are shocked if the money is not used for that purpose. If you want the money to be used for a particular purpose, you have to label it and ring-fence it. However, the Government will not do that. They say that they cannot do that as it would be inappropriate in the spirit of localism.
“I have spent 30 years as a senior business professional and business consultant and it is ludicrous to set an organisation targets to be funded by set criteria and then reduce those funds by 65 per cent. This makes a mockery of the organisation’s ability to carry out its public remit”.
There is a technical point here. The Department of Health has presumably secured these funds through the comprehensive spending review. Who will own those funds the next time that the comprehensive spending review is negotiated? Will it be the Department
of Health or the Department for Communities and Local Government? If it is the Department for Communities and Local Government, how will it rank given its other priorities which have nothing to do with HealthWatch? If it is the Department of Health, how will it answer the question from the Treasury, “How do you know that this money is being spent in the way that you intend?”. It will not be able to answer that question, as I suspect that the correct answer is that the money will disappear. LINks already have huge concerns about the resources question.
The other element of this concerns what sort of patient representative mechanism we want. Do we want something which is top-down or something which comes from local organisations? The amendment that stands in my name seeks to establish an arrangement whereby local healthwatch organisations have ownership of the national body which speaks in their name. I believe that that is essential. Even if you created HealthWatch England as an independent structure without the problems of it being a tool of the regulator, you will still not get the necessary buy-in at local level unless local organisations feel that they are part of it and have a say in its organisation. I speak as someone who was director of the Association of Community Health Councils for England and Wales for 12 years, and I know how important it was for the member organisations to feel that what we were saying as the national body reflected-not to the letter, but reflected-what they felt was important as local organisations. If you do not have that mechanism, if you do not have that process built into the legislation, I am afraid that you will create a gulf between the national body and the local bodies. That is surely unsatisfactory.
The Government’s proposals could make an enormous difference to patient representation in the new NHS, and patient representation is going to be enormously important in the new structure, because I think that many patients will feel disempowered and worried by what is happening. However, those arrangements are flawed unless the Government accept the spirit of the amendments in this group-and unless they accept that HealthWatch, both nationally and locally, should be independent, and that resources should be clearly ring-fenced and clearly identified and cannot be used by bodies that have no interest, necessarily, in patient representation used for other purposes.”
*This relates to a procedural manoeuvre instigated by the Government late the day before that I thwarted.
Yesterday was the seventh day of the Committee Stage of the health and Social Care Bill. In theory this should be the half-way point of the discussions, but the Committee has only got up to Clause 20 and there are another 323 Clauses to go.
One of the debates yesterday centred on the “mandate” (crazy word, crazy Bill) that the Secretary of State will give to the National Commissioning Board (this is the biggest quango in the known universe and it will effectively run the NHS). The “mandate” is essentially the Government’s instructions to the Board, but as they are claiming that they are giving away all responsibilities to the Board (and thereby absolving Ministers from taking responsibility for what happens to the NHS as the budget is cut) the content of this “mandate” is really rather important. How detailed will it be and will it be subject to proper Parliamentary scrutiny?
I am afraid the Government’s attitude brought out the normally-hidden (!) cynic in me:
“My Lords, I confess that I am something of a cynic about some of the proposals in the Bill. I am a great believer in the principle of localism, the local determination of services and local decision-making. Therefore, in principle I would applaud any Government-even this Government-who desire to devolve responsibility for various things to local authorities and, in this case, local commissioning groups.
However, my cynicism kicks in because what I suspect is happening here-I suspect that it will happen in other service areas-is that Ministers are cynically saying, “We are leaving these responsibilities to you, the local bodies concerned. We are very happy for you to make all these decisions. The snag is that we will not provide you with the resources to meet all the expectations that the public, who rely on those services, might legitimately have hoped to be provided. However, we are not taking these decisions. We will not be involved. It is a matter for local determination”. To be honest, I think that is what underpins much of the localism, devolution or autonomy agenda that we are seeing.
However, the experience of all previous experiments of localism is that while Ministers say, “Yes, this is a wonderful idea. We want to do it”, pressure starts to be applied to particular things. They want to have a mechanism whereby they can say, “It is, of course, your decision. However, we want you to make sure that these things happen”. Gradually, the list of the things that must happen gets longer and longer and the list of areas of discretion gets shorter and shorter.
When I saw the proposal for a mandate to be in the Bill, I thought that that was the mechanism whereby on the one hand Ministers will proclaim that they have no involvement in these decisions and say that they are all local decisions, but on the other hand this will enable them to ensure that certain things still happen because they are being subjected, as elected politicians, to pressure to make sure that they happen. That is why the amendment of my noble friend Lord Warner, which would restrict the extent to which this could be done, is very important. If we do not have an amendment of that sort in the Bill, I can tell you now what will happen; every single pressure group, voluntary organisation and lobby will say, “We want included in the mandate”, which is being issued to the national Commissioning Board, “the following service. We will want to see it there.”
For any sensible Minister the simple answer to all this is to write an extremely long mandate that covers all those points rather than sticks to them. If they were
obliged to be limited to just five or six or another small number of issues, that would be extremely salutary. It would stop the creep that would happen. However, I suspect that the Government are not going to say suddenly, “My goodness, the noble Lord, Lord Warner, has come up with an excellent idea. Why didn’t we think of that? We must accept it, of course”, because unfortunately that is not always the way in which government Ministers react. They will stick to the letter of the Bill without those specifications. They will say, “Well, why five? Why not 10? Why not 12? What about three?”. All these different things will be argued as an excuse for not doing it. You will then get the drift and the pressure to say that more and more things must be added.
Amendment 100A is so important because there must be parliamentary scrutiny of what is happening, because this will be the mechanism that drives decision-making in the NHS. It is not going to be a pure version of devolution, localism and autonomy; this is going to be done through the mandate. The mandate is then going to be the most important document that drives the NHS at any one moment. That is why parliamentary scrutiny is essential. Parliament must have the opportunity not just to see it and to know what is being done in the name of the public but to comment, amend, or put forward amendments and have the Government respond to them.
I therefore hope that when the Minister responds he will accept not only the principle of my noble friend Lord Warner’s amendment but the principle of detailed parliamentary involvement in this process in the amendment of my noble friend Lord Hunt of Kings Heath.”
The full debate is here.
Earlier this evening I seconded an amendment to the Health and Social Care Bill which would have placed “a duty of candour” on those providing health services requiring them to disclose “full information to patients, their carers or representative about any incident or omission in or affecting their care which may have caused harm, or may in the future cause harm.”
My speech was as follows:
“Lord Harris of Haringey: My Lords, when I was director of the Association of Community Health Councils, the message from community health councils around the country was that people who complained were seeking not compensation from, or retribution against, those who had perhaps caused the reason for their complaint—for example, the death of a loved one—but information. They wanted to know what had happened, and they wanted some reassurance that what happened to them or their relatives would not happen again.
Always, the most tragic cases were those in which people had not known what had happened and discovered the actual circumstances only much later, perhaps when their relative’s case came to an inquest or, in some cases, even long after that. I would like to hope that, in the 10 years or so since I was director of the Association of Community Health Councils, this problem would have become less, but it remains a serious blemish on the health service that, too often, such mishaps are covered up.
In a case reported only three weeks ago—the most recent case that I have come across, but I am sure there are many others—a mother discovered long afterwards that the death of her seven year-old daughter, which she had blamed on herself for not being able to perform the necessary first aid, was actually the consequence of a failure by a paramedic called to the scene. She discovered that only ages afterwards when she became aware of the transcript of the inquiry which led to the paramedic being dismissed. That case, reported in the Doncaster Free Press only three weeks ago, is an indication of the sorts of incidents that one is talking about.
I met the family of someone who had died while detained in a secure mental health facility. They discovered the circumstances in which their loved one had died only when the matter was reported at an inquest. In such incidents, the health service officials knew what had happened and had conducted their own inquiries but did not think it necessary or appropriate to tell the families concerned. That is why it is so important to have this amendment, which would place a statutory duty of candour on the health service, to make it something that runs right the way through the system.
Of course, accidents can never be eradicated. Healthcare is of its very nature a risky business and health professionals are only human, so these things will happen. However, what is unforgiveable is that the fact that something has gone wrong is not told to those concerned. The noble Baroness, Lady Masham, quoted Sir Liam Donaldson, but I thought that she was also going to quote the maxim that he gave:
“To err is human, to cover up is unforgiveable”.
That is precisely the concern that motivates this amendment.
In the White Paper Equity and excellence: Liberating the NHS, the Government said that they will require hospitals to be “open and honest” when things go wrong. That stems directly, I think, from the Liberal Democrats’ manifesto commitment, but, unfortunately, their manifesto referred only to hospitals rather than to the wider health service. I think that the Liberal Democrats intended that such a duty should be statutory, but my understanding is that the Department of Health is looking at this as something that could be written into contracts. As the noble Baroness, Lady Masham, has pointed out, having a lesser status than a requirement to inform a central agency that something has gone wrong would mean a lesser status in terms of informing the family. It is really important that we look at this issue and take it seriously, so I hope that the noble Earl will accept the amendment.
In 2005, a National Audit Office report revealed that only 24 per cent of NHS trusts routinely informed patients of a patient safety incident—that implies that more than three-quarters of NHS trusts do not do so routinely—and 6 per cent admitted that they never informed patients of a patient safety incident. Quite clearly, there is a “culture of denial”. Noble Lords may think that that is rather an alarmist statement, but I am simply quoting from a Department of Health document from 2006.
Lord Mawhinney: My Lords, I am extremely grateful to the noble Lord for giving way. I do not want him to interpret my question as opposition to the general point that he is making, but before he finishes will he say a word about the role of lawyers of health service bodies in these circumstances? I am not a lawyer, as I have told the House before, but in both cases that he has cited I could see legal advisers saying, “Say nothing”. If we are to take this amendment seriously, we need to have some idea of what part the law might play if the Bill were to be so amended. As the noble Lord has experience, I would be grateful if he would reflect on that.
Lord Harris of Haringey: My Lords, the noble Lord, with all his experience—albeit, like me, as a non-lawyer—is speaking exactly the truth. In many of those cases, the legal advice would be, “Say nothing”. There therefore needs to be a statutory duty, because then the responsibility of the lawyers concerned would be to advise, “There is no option but to tell the patients or their families”.
An interesting point is that insurers in the United States often require open disclosure policies and practice by health providers to qualify for insurance. The international evidence is that, as well as being the right thing to do morally and ethically, being open and honest when things go wrong can actually reduce litigation and complaints.
My concern is that the Government will say that they are doing enough by saying that the duty of candour can be achieved through a contractual process. However, as the noble Baroness, Lady Masham, has pointed out, this would apply only to hospitals with an NHS contract; it would not apply to GPs, dentists, pharmacists or private healthcare providers. I do not see why the duty of candour to patients and their families should be regarded as of lesser importance and impact than those things where there is direct regulation. I hope that the Minister will say that the Department of Health will take this away and that he will come back to the House with proposals to give a statutory duty of candour to protect the interests of patients.”
After a debate of over 90 minutes, the Minister was not prepared to concede a statutory duty of candour although the Government is consulting on how they might make a “contractual” duty of candour work.
I am sure there will be more debate on this at the Report Stage of the Bill.
Eight days ago, the House of Lords adjourned in mid-debate on an amendment to the Health and Social Care Bill which would have restored the role of the Secretary of State for Health to “provide or secure the provision” of health services (which the Government’s Bill would have taken away).
Adjourning in mid-debate is a pretty rare (if not unique) procedure, but it has allowed for all sorts of last minute discussions to take place behind the scenes before the debate resumed this afternoon.
The original amendment was moved by Baroness Williams of Crosby (Shirley Williams as was) and was signed by Lord Patel (former President of the Royal College of Obstetricians), Baroness Glenys Thornton (Labour spokesperson on health in the Lords) and Baroness Margaret Jay (former Leader of the House). Also debated at the same time was an amendment from Lord Mackay of Clashfern which talked more vaguely about the Secretary of State having “ultimate responsibility to Parliament for the provision of the health service”.
In last week’s debate, I commented:
“I rise to speak to the amendment in the name of the noble Baroness, Lady Williams of Crosby, because this is an issue that requires greater clarity, and the debate and discussion that has already taken place in Committee this evening demonstrates why that is so. As my noble friend Lord Warner has reminded us, Professor Malcolm Grant, the newly appointed chair of the national NHS Commissioning Board, has made clear what appears to be the Government’s intention with regard to the role of the Secretary of State. I assume that he did so under advice, because you do not take on a role like the chair of the NHS Commissioning Board without extensive discussions with Ministers and civil servants. He must have been briefed on the matter and quite clearly the intention is to separate out the day-to-day responsibility and answerability of the Secretary of State. There has to be some clarity on this point. …
I have some reservations about the wording used by the noble and learned Lord, Lord Mackay, in that he talks about ultimate responsibility. We may have an inkling about what ultimate responsibility means, but I wonder where else in legislation a phrase such as this is used. I defer of course to the noble and learned Lord’s far superior knowledge of the law. However, in my limited experience in this House, I have never before come across the words “holds ultimate responsibility to Parliament”. It seems a very strange usage and I think that there needs to be greater clarity and understanding about what it means. That is why it might be better to revert to the wording chosen by the noble Baroness, Lady Williams. It is tried and tested and at least we understand it. …
The final test that your Lordships need to consider is: what do the public expect? The public’s expectation is that government is responsible for what happens in our health service; and unless there are locally elected officials who are responsible for what happens at a local level, they will expect their elected Government to be responsible, and that means the Secretary of State.”
The Government had indicated that they were prepared to accept the Mackay amendment – indeed eight days ago they announced that the amendment had been agreed, even though the debate had not been finished. And Baroness Williams had also hinted in her speech that she might accept the “compromise” offered by Lord Mackay.
Labour Peers, however, were standing firm and had indicated that they would divide the House on the Williams amendment even if she tried to withdraw it in favour of the Mackay version.
The Government was clearly running scared and at the last minute – just as the debate resumed this afternoon – indicated that if both amendments were withdrawn they would consult all sections of the House to try and find a form of words that would be acceptable to everybody.
There followed forty-five minutes of debate when all sides of the House indulged in an orgy of mutual admiration on reaching a sensible way forward.
This orgy, however, began to go rather flat (if that is not an inappropriate metaphor) when the Minister, Earl Howe, having promised further discussions then began to explain in some detail why the Government disapproved of the Williams amendment, saying:
“In future, all NHS services will be provided by NHS trusts or foundation trusts, both of which have their own self-standing powers to provide services and do not rely on the Secretary of State’s duty to provide under Section 1(2), or by independent providers. The Secretary of State will have no powers to provide NHS services. That is the reality. …
There is another reason why it would be wrong to reinstate the duty on the Secretary of State to provide. Under the legal framework of the Bill, the Secretary of State no longer possesses powers to direct others to provide services. Therefore, unless we were to re-impose a system of regulations or directions by which the Secretary of State could delegate his duty to provide and control its exercise, which would risk replicating the micromanagement of the status quo, it is hard to see how this legal obligation to provide services could be fulfilled. For obvious reasons, it would be undesirable to create a situation in which the Secretary of State provided services himself. Also, in practice he would lack the capacity to do so, for example in terms of staff and facilities.”
At which point, the House began to become rather restive – the Minister seemed to be saying that there could only be more discussions provided the eventual wording still restricted the role of the Secretary fo State and the right of Parliament to scrutinise what was happening in the NHS.
So, Baroness Patricia Scotland interrupted:
“My Lords, I hesitate to intervene on the noble Earl, who knows I hold him in the highest possible esteem, but I think he is now treading on some contentious legal issues. Bearing in mind the wonderful consensus that we have now reached, I would just ask him to consider whether, at this stage, some of those issues are really helpful because the noble Earl will know that the Secretary of State does, by his servants, agents or otherwise, provide services and, indeed, there have been times when there has been a pandemic when the Secretary of State has had to make such provision. These are contentious issues which I am sure could intrigue us for many hours, but since we have happily come to the conclusion that we have had a surfeit of such happiness and wish to go forward, I gently say to the noble Earl that this might be a moment when we could swiftly do that.”
Then Baroness Glenys Thornton had a go:
“I respectfully say to the Minister that we could start the whole debate all over again if he continues telling us what the Government do or do not believe on this because that is presupposing, and possibly pre-empting, the discussions that we are about to have. The noble Lord may find it useful, but we have had a lot of this discussion. We have now, I thought, agreed to move into discussions outside the Chamber.”
The Minister kept reiterating that he thought it would be helpful to put on the record the Government’s position.
As he seemed to be preempting future discussions, I tried to get some clarity which elicited the following exchange:
“Lord Harris of Haringey: I appreciate that the noble Earl is moving to a position of not addressing those questions, but it is important that he tells the Committee whether the Government have a fixed mind on these matters or whether they are going to approach with an open mind the discussions that we, in an outbreak of consensus, have agreed should happen and try to build on that consensus. If the views are closed, it raises some very difficult issues for the Committee.
Earl Howe: No, my Lords, there are no closed views. That is the reason why I suggested earlier that it was time to reflect and engage in discussions in the spirit of co-operation. I would not have said that if I had had a closed mind to them. There would not have been any point in the discussions. I simply wished to do noble Lords the courtesy of answering their questions and addressing the points that they had made. If noble Lords would rather that I did not do that, then we can make life easier for ourselves. I will certainly write to noble Lords if they would like to inform me afterwards that they wish to receive a letter. If they do not, I will not write. It is entirely up to them. I do not wish to make work for myself unnecessarily.
I have said that I believe the balance of advantage for this Committee lies in our agreeing collectively not to amend the Bill at this stage and I am pleased that there seems to be consensus around that view. I believe instead that it would be profitable for me to engage with noble Lords in all parts of the House, both personally and with the help of my officials, between now and Report to try to reach consensus on these important matters. I would just say to my noble friend Lord Marks that that includes the issues that he has helpfully raised this afternoon. I believe that he is right to associate Clause 4 in particular with the matters that we have been considering. Those discussions can be carried out in an informal way with interested Peers or in individual meetings in the House or my department. There is a place for either type of discussion. My concern is only that it is an inclusive process involving Peers from all sides of the House, and that will include listening to the views of the Constitution Committee should it choose to continue its valuable role.
With that, I hope that no noble Lord will feel cheated by the brevity of my contribution and I shall sit down.”
So we’ve been promised discussions and a Government with an open mind.
We’ll just have to wait and see what transpires.
The first day of Committee stage consideration of the Government’s Health and Social Care Bill is taking place in the House of Lords today.
To no-one’s surprise the LibDems again demonstrated that they are happy to place their loyalty to the Coalition with the Tories above the future of the National Health Service.
They voted en masse to reject a Labour amendment which would have reaffirmed the basic principles of the NHS as the first clause of the Bill.
The amendment was to begin the Bill by stating:
“Principles of the Health Service in England
(1) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England must have regard to the principles and values outlined in the NHS Constitution.
(2) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England, or providing services as part of the Health Service in England, must provide quality, equity, integration and accountability, not the market.
(3) The primacy of patient care shall not be compromised by any structural or financial re-organisation of the Health Service in England.
(4) There must be transparency and openness wherever taxpayers’ money is being spent, and all accountable individuals and bodies should abide by the Nolan principles.
(5) “The Nolan principles” means the seven general principles of public life set out in the First Report of the Committee on Standards in Public Life (Cm 2850).
(6) Schedule (Principles of the Health Service in England) has effect.”
The amendment was rejected by 212 votes to 244.
59 Liberal Democrats voted against the amendment with only one (Baroness Tonge) in favour.*
So can someone just remind me – after all the fuss about how the LibDems were going to fight for the NHS – when did they decide that it wasn’t necessary to require providers of health and social care to provide ”quality, equity, integration and accountability”, when did they decide that it doesn’t matter if the primacy of patient care is compromised by structural or financial re-organisation, and when did they decide that the Nolan principles of public life weren’t necessary for those responsible for the provision of the NHS?
* The full figures were as follows: in favour of the amendment - 172 Labour Peers, 37 Crossbenchers and others, two Bishops and one LibDem; against the amendment – 147 Tory Peers, 38 Crossbenchers and others, and 59 LibDems.