At the end of last week, I reported that Andrew Lansley was planning to change the status of the new local HealthWatch organisation so that patient representation could be put out to competitive tender.

The Department of Health has form on this: the organisations acting as “hosts” for Local Involvement Networks were selected following a competitive tendering process in 2007 and bids were sought from throughout the European Union and here, so I am told, is the text of the advert in the Uzbechistan Times:

Umumiy ma’lumot
Davlat:	??????????? ???????????
Shaxar/axoli punkti:	GLOUCESTER
Kontrakt yoki xabarnoma raqami:	eu:281809-2007
Chop etilish sanasi:	Noy 30, 2007
Amal qilish muddati:	Yanv 7, 2008
Xaridor:	GLOUCESTERSHIRE COUNTY COUNCIL
Original matn tili:	??????????
Bog’lanish uchun ma’lumot
Manzil:	GLOUCESTERSHIRE COUNTY COUNCIL GLOUCESTER , Gloucestershire ??????????? ???????????
Veb-saxifa:	http://www.gloucestershire.gov.uk/index.cfm?articleid=14857

 (I am afraid the cyrillic script doesn’t come out very well in WordPress.)

The fact that the previous Government allowed this function to be tendered doesn’t make it right for the proposed new system, particularly as Ministers have complained about the cost of administering previous patient representation structures which were based on this “hosting” principle.

All in all it looks like “dogma gone mad” with no regard to the cost or to whether it will deliver more effective patient representation.

I have this afternoon tabled two Parliamentary Questions on the subject:

“To ask Her Majesty’s Government:

1. What would be the cost of requiring local authorities to put out to competitive tender contracts to run local HealthWatch organisations?
2. What was the cost of putting out to tender contracts to act as hosts to Local Involvement Networks?”

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.“

It is well known that there has been a major drop in crime in New York.  What is more that drop in crime was twice the rate of fall in crime across the United States and has been sustained over a twenty year period.

So what was the secret of success?  And could it be translated to the UK and to London in particular?

Professor Franklin Zimring of the School of Law at Berkeley has applied scientific analysis to the figures and has come up with a number of interesting conclusions.  The improvement was not so-called “zero tolerance” policing, focussing on stopping the spread of crime into new areas.  Instead, the results were delivered by “hot spot” policing – robust, sustained policing of those areas with the highest rate of crime (especially violent crime).

The aim should be harm-minimisation as far as things like drug use are concerned (disrupting public drug markets where associated violent crime tends to happen, for example, rather than trying to eliminate drug use itself).

Crucially, he also finds that police numbers matter – provided those numbers are directed to the areas with the highest crime and, when there, officers police “robustly”.

He is also not convinced that simply locking criminals up cuts crime.  As he puts it:

“We used to think that all we could do with high-rate offenders is lock ‘em up or they’re going to offend on the street. But NYC has 28 % fewer people locked up in 2011 than in 1990. And it has 80 % less crime. The [individual] criminals didn’t go anywhere. They’re just doing less crime. So the bedrock of prediction on which incapacitate imprisonment was built, has turned out to be demonstrably false. And the proof of that is in New York City.

The data shows that the criminal activity of people coming back to NYC from the prisons dropped as the crime decline proceeded. In 1990 the odds that a prison released from prison coming to NYC would get reconvicted of a felony over the next three years was 28 %. But over the next 17 years, the odds of being reconvicted of a felony dropped to 10 percent.

The street situation changed and so had the things that their friends were doing. People were now smoking marijuana and drinking wine. Cocaine use was down. Street robbery has gone down 84 %. Burglaries 86 %. And that meant that the people that the released offender used to hang out with as a persistent offender from a high-risk neighborhood, are no longer doing those things. So he’s not doing crimes with them.”

This obviously has implications for the current debates on prison numbers and suggests that Kenneth Clarke’s approach is potentially right, if – and it is a big if – the rest of  Zimring’s conclusions are taken on board.

So what else does his work mean for policy here?

It certainly implies that police numbers are important and that the last Labour Government (and the last Mayor in London) were right to boost the number of police.  The cuts envisaged by the present Government and those that are being carried out quietly in London by the present Mayor are therefore almost certainly unhelpful. (The lack of certainty derives from the fact that it does, of course, depend on what the police officers remaining are actually doing and whether their activity is in fact robustly tackling crime hot spots.)

It also suggests that policies favouring policing the suburbs at the expense of the areas with higher crime that tend to be in the inner cities are misconceived.

I suspect that the robust and sustained “disruptive” policing of crime hot spots is consistent with the approach that Commissioner Bernard Hogan-Howe would wish to follow.  It will be interesting to see whether this is encouraged by the Mayor’s Office for Policing and Crime (MOPC – pronounced “Mopsy”) or whether the MOPC will be nervous about the political implications in the run up to the Mayoral elections in May.

 

I see Mark D’Arcy has picked up on the rumours that have been sweeping the House of Lords for the last few weeks that Number Ten is about to announce the appointment of another sixty life peers: forty Tories; fifteen LibDems and five Labour.  This would be a net gain for the coalition of fifty votes – enough to swamp two of the three defeats that the Government suffered on the Welfare Reform Bill last week.

The current membership of the House of Lords is a whopping 787 (excluding 22 peers who are on leave of absence and 17 who are disqualified or suspended for one reason or another).  The new additions (which would mean approaching two hundred – yes, two hundred – new peers since the General Election) will bring the size of the House of Lords to 847.  (Contrast this with the plans to cut the elected House of Commons by fifty members.)

The extra members will make the Tories the largest grouping in the House of Lords and give the combined coalition 364 members against Labour’s 244 – an effective majority of 120.  (Although there are 186 cross-benchers they tend to split on votes with some supporting the Government and some opposing and their rates of participation tend to be lower as well.)

Anywhere else in the world this would be regarded as packing the legislature, termed as gerrymandering or deemed to be crony politics of the worst sort.

The scale of increase of membership far exceeds that an any previous time in the House of Lords’ history.

In the two years since the General Election, the Government has been defeated 28 times in the House of Lords – in all but a handful of instances the margins of defeat have been less than fifty.  So had the new peers been in place most of those defeats would not have happened.  Twenty-eight defeats over two years is in any event a small number compared with the average of more than forty defeats a year during the lifetime of the last Labour Government.

The cost of the extra peers will be two to three million pounds per year – so I suppose from the coalition’s point of view that will be money well spent to ensure that they are not troubled with poor quality ill-thought through legislation being sent back to the House of Commons for reconsideration.

This is a piece I have written for the Mayor Watch blog on the occasion of today’s last meeting of the Metropolitan Police Authority:

“The Metropolitan Police Authority was established in July 2000 as a by-product of the legislation that also created the London Mayoralty, the GLA and the London Assembly.  Until then the Metropolitan Police had been solely accountable to the Home Secretary, who was uniquely the Police Authority for London.

The MPA is now to be abolished and replaced by the Mayor’s Office for Policing and Crime (MOPC – pronounced “MOPSY”) as a by-product of the legislation that will see Policing and Crime Commissioners elected outside London in November.

The MPA’s final meeting is taking place today and the MOPC will take over responsibility on Monday 16^th January.

So what did the MPA achieve in its eleven and a half years of existence?

The early years of the MPA saw a dramatic transformation in the Metropolitan Police. In 2000 morale in the Service was poor, more officers left the Met each month than joined (police numbers had declined each year for a decade), public confidence was low, financial controls were virtually non-existent (the Met had no system for telling if bills had been paid more than once) and the quality of many serious investigations was poor.  The first tasks of the new Authority included the introduction of financial controls and discipline; establishing a new culture of openness and accountability; and reversing the decline in the number of police officers so that the MPS saw the most significant increase in its size in its history.

This was followed by a sustained focus on turning round street crime and cutting burglary.  The MPA led the way nationally on the introduction of Police Community Support Officers and then the setting up of the first Safer Neighbourhood Teams before rolling them out across London.

This contribution led to a general increase in public confidence in the police service, but specific initiatives led by the MPA on stop and search, on hate crime, and on recruitment and retention of black and minority officers also changed perceptions of the Met.

Inevitably, the direction of travel changed somewhat with a change in administration in City Hall after the 2008 elections, but the MPA continued to deliver a much clearer visible accountability of the police in London than had existed before.

Certainly, throughout its life the MPA has ensured that far more information about the policing of London has been put in the public domain.  The MPA also meant that the Commissioner and senior officers were seen to answer questions in public at full Authority meetings and at its Committees.  And this was supplemented by detailed MPA scrutinies ranging from rape investigation and victim care to counter-terrorism policing, crime data recording to mental health policing, and landmark reports on the Stockwell shooting, of the Race and Faith Inquiry, and on public order policing.

So will all this disappear with the MOPC?

The first thing to emphasise is that London’s model will – as ever – be different from that in the rest of the country.  There will not be a directly-elected Police and Crime Commissioner.  Instead, the functions will be carried out by the MOPC, led by an appointed Deputy Mayor for Policing and Crime.

The policing priorities will be set by the MOPC and it remains to be seen how much these will change from those previously set by the MPA with its more widely drawn membership.

The real danger is, of course, that much of the visible accountability and answerability will be lost.  Some will be provided by the London Assembly who will have a new and enhanced role in respect of policing and crime, but their focus – as envisaged by the new statute – will be very much on the MOPC and not on the police service itself.

How this will develop will depend on the personalities involved – both at the MOPC and on the Assembly – and on the willingness of the Met itself to be open and transparent.  There are certainly no guarantees on any of this, yet police accountability in the capital will remain as important as ever – as the events of the last few months have demonstrated.

Perhaps the message is watch this space.”

 

Just in case LibDems in London were in any doubt about Tory triumphalism, the LibDem role as (very) junior partners in the coalition and what the Government’s stance on Europe is all about James Cleverly AM, Leader of the Tory Group on the London Assembly, has spelt it out:

“The Indi is running a story about a potential “rift” between Clegg and Cameron over Europe and the veto.  This is such a non-story, Clegg’s position on Europe is well known.  Cameron’s position on Europe has been made clear and is much more in tune with the wishes of the British people.

David Cameron is the Prime Minister and his position is both right and popular.  Nick Clegg is not Prime Minister and his position is wrong and unpopular.  Bets please on whose views will win out.”

Squelch!

At some point, the LibDems are going to realise that their post-General Election sell-out to the Tories is getting them nowhere …..

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.

Baroness Northover: I suggest that the noble Lord talks to his noble friend Lady Pitkeathley about some of the details.

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.

Lord Harris of Haringey: The Bill does not refer just to the annual report. It refers to all reports.

Baroness Northover: It is clearly important that the information goes back and forth between the local and national organisations.

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

 

Earlier tonight I had the opportunity to enjoy Rory Bremner’s updated rendering of Offenbach’s “Orpheus in the Underworld” at the Young Vic, but you only have one more day to do the same.

It really is a satire for our times and a reminder of the importance of the wider remit of the Leveson Inquiry.  Throughout the action is influenced by “Public Opinion” a sanctimonious voice akin to the Daily Mail, terrifying and manipulating celebs (in the shape of Orpheus), while the Gods are being required to be “transparent and accountable” and show that “We’re all in this together”.  You will be sorry to have missed it.

I have only just caught up with a speech made in the Moses Room (an alternative Lords Chamber for hosting smaller debates) last Thursday by Lord John Eatwell which sets out cogently what is wrong with the Government’s response to the economic situation and sets out a clear alternative vision.

He was responding to a motion from Lord Lamont of Lerwick on ”the economic situation of the United Kingdom, including the impact of the eurozone crisis on the United Kingdom and other non-eurozone members.”

He said:

“My Lords, like other noble Lords I am grateful to the noble Lord, Lord Lamont, for securing this debate, even though the topic has widened from that he initially intended. I also wish to congratulate the noble Lord, Lord Wolfson of Aspley Guise, on his witty maiden speech.

Despite appearances to the contrary, the debate has not been about economics. Instead, as the noble Lord, Lord Ashdown, pointed out, it has been about politics-the political choices made by Governments in the eurozone, most notably the Government of Germany, and the choices made by Her Majesty’s Government. Indeed, the common theme that has run through much of the debate has been the severe austerity that Germany demands of the rest of the eurozone and the similar economic misery that the coalition is inflicting on Britain. It is now clear that the eurozone embodies fundamental design flaws. These have been addressed by the noble Lords, Lord Lamont, Lord Alderdice and Lord Higgins, my noble friend Lord Myners and the noble Baroness, Lady Wheatcroft. A successful monetary union requires a powerful and active central
bank, an all-Union bond market managed by a central treasury function, some means of balancing the economic benefit between the most successful and least successful parts of the Union, easy migration and, it is hoped, some sort of all-Union employment policy. This is a reasonable description of the United States of America, with the employment policy being provided by the military.

My noble friend Lord Desai was right to point to problems in the bond market as far as short-term financial stability is concerned, for it is the existence of an all-Union bond market that is crucial. Given that the eurozone economy is the largest in the world, any major bond fund must have significant exposure to the euro, just as it must have exposure to the US dollar and, to a lesser extent, to sterling. This can be obtained by holding any eurozone sovereign bond. Moreover, the exposure can be maintained by switching between different sovereign bonds with no foreign exchange risk whatever. Hence the huge flows between eurozone sovereigns that have produced wild gyrations in interest rates over the past few months as uncertainty and rumour have fuelled massive capital flight. The point was made by the noble Lords, Lord Wolfson and Lord Flight: it is like walking along a rocky path carrying a large amount of water in a shallow pan.

Compare this with the situation in the US. The state of California, which represents 13 per cent of the US economy, is bankrupt. This has no impact on the US Treasury bond market at all. Similar problems in Greece, which represents 2 per cent of the eurozone economy, have produced a wave of destructive contagion. The creation of a eurobond market equivalent to the market of the US Treasury-no bailout, no austerity, no ECB as lender of last resort-will bring durable financial stability. Of course, creating a eurobond market is a formidable political problem, but it is not impossible to imagine that this could be solved. It is not necessary to have a United States of Europe, as the noble Lord, Lord Lawson, claims. It is conceivable to have a powerful central bank, a central bond market funding a monetary union with a centre that is still politically weak relative to powerful member states. Indeed, that is a description of the most stable monetary union in the world, the Confederation of Switzerland. Clear identification of the design flaws of the eurozone that have resulted in such appalling financial instability should finally dispose of the illiterate comparisons often made between Britain’s fiscal problems and those of the eurozone members.

Are the Government right to argue, as they do over and over again, that their austerity policy is necessary to maintain the confidence of the bond markets and keep UK interest rates low? Perhaps it is, but only because of their own political folly. The Government have repeated this mantra so often that the markets probably believe it by now, and in believing the Government’s pro-cuts propaganda, they demand a redoubling of austerity. We have financial stability, but it is the stability of the grave. We are repeating Japan’s lost decade in an economy that is much poorer and much more unequal. I warned at the time of the Budget that the Government’s austerity policy risked creating a vicious cycle in which expenditure cuts and tax rises would lead to lower growth, which in turn
would lead to falling tax revenues and rising costs of recession. This in turn has led to yet further higher deficits, and so on in a downward spiral. But there is another twist in the tail that I had not fully appreciated until I read the OBR report.

The austerity programme also reduces the medium-term productive potential of the economy and hence reduces the possible future growth rate that is supposed to restore the nation’s finances, so now we have two mutually reinforcing engines of economic decline-the merry-go-round of cuts that do nothing to cut the deficit, and the recession-induced fall in growth potential that is making the deficit bigger too. And what is the Government’s response? It is more of the same. That is not my verdict. As the noble Lord, Lord Hollick, pointed out, it is the verdict of the OBR. Reviewing the plethora of schemes to turn the economy around, the OBR concludes:

“We have not made any material adjustments to our economy forecast on the basis of these policy announcements”.

In other words, the OBR concludes that the Government’s much spun “growth strategy” will achieve a net result of precisely nothing. However, I believe that the OBR is being overly optimistic.

First, the OBR persists in being excessively optimistic about where future demand will come from. In March, it predicted that private sector investment would grow this year by 6.7 per cent. Now, eight months on, it admits that investment has fallen. In March, it predicted that investment next year would grow by 8.9 per cent, and it still thinks that that is almost achievable. It says that investment in 2015 will be roaring along at 12.6 per cent growth a year, up from the 8 per cent it predicted in March. Where do these fantasy figures come from? Where is the incentive to invest when household incomes are going to be as low in 2014 as they were in 2002? It does not matter if interest rates are low: if there is no demand, there is no reason to invest.

Secondly, the other component of the rebalancing of the economy referred to by the OBR is supposed to be net trade. Again, the OBR is being excessively optimistic. It admits that most of the beneficial impact of the devaluation of sterling has now been exhausted, and recognises that markets in Europe will be depressed for some time, and yet somehow conjures up a significant improvement in trade performance, so overall the OBR is far too optimistic. The situation is much worse than it thinks. The people for whom matters are really worse are the poorer members of our society. If the OBR’s predictions are correct-I think that they are over-optimistic-household real disposable income will fall by 4.7 per cent over the next three years. However, that is an average figure and well over 60 per cent of the population have below-average incomes. If we examine the impact of the Government’s policies on median income-that is, the level of income in the middle of the income distribution-then the fall in disposable income will be 7.5 per cent. The cuts in real income are concentrated at the bottom end. Indeed, as the IFS analysis of the Autumn Statement has shown, the measures taken this week will lead to further cuts in the real income of the bottom 30 per cent and give benefits to the top 30 per cent. Nothing is more disgraceful and distasteful than the savage pleasure that Liberal Democrats and Conservatives take in cutting support for the poorest in Britain.

There is one further chapter of this dreadful story that must be taken into account in any overall assessment of the state of the economy: that is the level of unemployment, particularly of youth unemployment. It is simply uncivilised to have more than a million young people unemployed and their lives blighted at just the time when they should be looking forward to building a future, careers, stable households and families. Yet the prolonged recession holds out that prospect not just for the 22 per cent of young people now unemployed but for thousands more. We can begin to solve these problems only if there is a return to significant rates of growth in the eurozone and in Britain. The austerity imposed on the eurozone by Mrs Merkel, and on Britain by the coalition Government, will achieve nothing but a lost decade, or more. Stable financial markets will not produce an automatic increase in business confidence. There is no confidence fairy; she was killed by the Government’s austerity rhetoric.

What is necessary is a radical rethink of economic policies and even economic institutions. We need a major increase in government investment to kick-start private sector investment. We need new funding for industry on a greatly enhanced scale-not just what the Financial Times called the “gimmicks” of the Autumn Statement. We need a realisation that demand can be boosted by redistributing income towards the poorest, because they spend every pound they get and their spending has a lower import content than that of the wealthier sections of the community. The Government must become an employer of last resort to tackle youth unemployment.

How should we pay for all this? First, we should realise that unless something radical is done, the deficit will go on rising; we will go on borrowing more as we cut more. Secondly, if there is to be quantitative easing, it should be far better directed than it is under the shotgun approach used at the moment. Thirdly, even small amounts of redistribution could have a significant effect on the rate of growth of demand.

It will be evident from what I have said that I am fearful for the prospects of the eurozone and of our economy. Of course our current economic circumstances are dreadful, but they are made by human hand and they can be unmade by human hand. The key is political: political will and political intelligence, allied to sound economic analysis. All three ingredients are notably absent from the Government’s policy.

In a few short words he set out an effective three point plan for the economy:

• A National Investment Bank to target the “quantitative easing” to where it will really make a difference - in business investment to deliver future jobs;
• A recognition that further cuts in the income of the poorest in society will have a disproportionate impact on demand; and
• The role of the Government in being an employer of last resort for young people.

It would make a real difference – a pity that the Government isn’t listening.