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Dr. Brand: I welcome the greater independence that is now being proposed for patients forums. Although patients are important, are not people important before they become patients, and communities too? Are we not at risk of handing over an important function to a special interest group? Is the Minister not designing a scheme for a national illness service, rather than a national health service? Are not we likely to lose the public health input, which is so important and was available through community health councils, and especially through their local authority membership?

Mr. Milburn: I thought that the Liberal party was committed to the idea of democratising the national health service. Does the hon. Gentleman oppose the idea that we should transfer the extremely important function of monitoring on behalf of the local community how well the local health service is performing from an unelected body--the community health council--to an elected body that, in the end, has to face the crucial test, doing what we do every few years, which is to stand for election? That seems to me to be precisely the right thing to do.

The patients forum will also oversee the work of the patient advocacy and liaison services, which will provide an entirely new tier of service in the NHS: someone to sort out problems within hospital or community services on the spot, be they poor communication, worries about cleanliness or discharge arrangements.

PALS will be placed in every trust to have the knowledge and clout to sort out problems for patients before they escalate into serious complaints. To safeguard against their "capture" by NHS trusts or primary care trusts, the independent patients forum will be able to recommend that a patient advocacy service be taken out of the trust and be run independently from it.

The fourth element of the new system will be an effective complaints procedure. The existing complaints system is being reviewed and I want the new system to be much more independent than the old. It is likely, for

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example, that when necessary it will be fully independent of the NHS body being complained about, unlike in the current system. In addition, there will now be an independent advocacy service commissioned in each area to support complainants. Some have suggested that there would be particular advantages if the services were provided by a local authority. There is merit in that argument, and we will be very happy to consider it further in Committee.

To ensure that there is a strong voice for patients nationally as well as locally, we are working with voluntary and patient groups, including the College of Health and the Long Term Medical Conditions Alliance, to explore how best to form a national patients' organisation to act as an independent umbrella body for NHS patients. The feasibility work is being funded by my Department, and I expect that when it is completed in March the Department will in turn provide the funding needed to establish and run the new national patients' organisation.

Ms Debra Shipley (Stourbridge): As the long title of the Bill says that it is intended

will my right hon. Friend consider favourably a small amendment to allow my constituent Marian Jordan to register her late husband's name on her son Daniel's birth certificate? As the law stands, birth information--and therefore medical history--is inaccurate by omission. I might add that such a commitment was given by my hon. Friend the Minister for Public Health in August.

Mr. Milburn: We have agreed the policy, I am told--so it must be right. I know that my hon. Friend the Minister for Public Health has agreed the policy, and I will be happy to chase it up. Clearly, if we can make progress on it, we should do so.

Helen Jones (Warrington, North): Will my right hon. Friend clarify the role of the independent appointments commission? I am concerned that large parts of constituencies such as mine remain under-represented throughout the health service. Will the commission actively seek applications from unrepresented groups and areas rather than simply appointing from among those who put themselves forward?

Mr. Milburn: That is obviously the right thing to do. Before 1997, women and people from black and ethnic minority backgrounds were under-represented on trust and health authority boards. We changed that precisely because Ministers operated to a clear set of guidelines that increased the ethnic and gender mix on those boards. We can give precisely the same guidance to the independent appointments commission.

It is important to recognise that, for too long, decision making in the national health service has been behind closed doors and that all too often it has resembled a secret society rather than a public service. We have to open it up to all sections of society because the national health service does not serve just one part of the community; it serves the whole community and we must have a means of decision making that properly reflects all interest groups.

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The changes proposed in the Bill respond to many of the concerns expressed about the abolition of community health councils. The Standing Committee will allow further detailed consideration, but I believe profoundly that the reforms will give more power to patients in the health service and more independent scrutiny than ever before.

Mr. Paul Burstow (Sutton and Cheam): Will the Minister give way?

Mr. Milburn: I must move on. I have been speaking for about 40 minutes and I now want to refer to the royal commission.

The steps that we are taking to make the funding of long-term care fairer are also important. From October this year, with the consent of Parliament, nursing care will be free at the point of use and fully funded by the NHS. Residents in nursing homes will, in future, be treated in the same way as people who are being cared for at home, with NHS services and equipment being provided according to need, not ability to pay. This is indeed an historic step. It is long overdue. It will make a huge difference to thousands of older people.

By 2004, we will be spending an extra £1.4 billion on those reforms and on new services for older people. New intermediate care services, for example, will promote independence and allow more older people to stay at home for longer, in many cases avoiding altogether the need for them to enter residential care.

We could, of course, have chosen to spend the money instead--as I think the Liberal Democrats suggest--on implementing the royal commission's recommendation that all personal care, as well as nursing care, should be free. I believe that this would not have improved front-line services in any way, shape or form--[Interruption.] The hon. Member for Sutton and Cheam (Mr. Burstow) is nodding. Perhaps he should look again at the Liberal Democrat amendment, which, thankfully, has not been selected.

Not one more older person would have received any extra care or support to remain independent for as long as possible. Nor would it have benefited the least well-off, as seven out of 10 people in residential care already get all or some of their personal care costs paid for. Instead, it would have locked in place the existing range of often inadequate services that have been the frequent subject of criticism from many older people.

I know that these are hard choices, but in future our priority must surely be to develop a wider range of services that will meet the health and social care needs of our society much more effectively than in the past. That is what the NHS plan does and what this Bill supports.

Mr. Hinchliffe: I welcome the steps that the Government have taken to go part of the way towards what was recommended by the royal commission. My concern relates to how we distinguish between personal care and nursing care in a practical sense. For example, if in a care or nursing home a care assistant, supervised by a qualified nurse, bathes an elderly resident, is that social care or nursing care?

Mr. Milburn: It would depend on the assessment--

Mr. Burstow: Ah!

Mr. Milburn: I had managed to get only four words out. If the hon. Gentleman would allow me 40 words,

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I would provide an explanation. It would depend on the assessment of the case. First, the royal commission accepted the premise that we could differentiate between nursing care and personal care. Secondly, we are going further than the royal commission recommended, not least in spending more money on this package of measures. We are also going for a wider definition of free nursing care. As my hon. Friend is aware, we have had discussions with the Alzheimer's Disease Society, with our colleagues in Scotland and with the Royal College of Nursing to come up with a definition of free nursing care that provides some consistency, but which also must afford some flexibility.

Each patient has different and individual needs. We need flexibility to ensure that the needs of the individual are taken fully into account, consistent with the national framework that we are trying to hammer out with voluntary organisations, patient organisations and clinical organisations.

Mr. Burstow: I am grateful to the Secretary of State for giving way. Will he confirm that the definition in the Bill means that it is not an assessment of the need for nursing care but who provides it that will determine whether such care is free? If a dressing is changed by a care assistant, that must be paid for; if it is changed by a nurse, it is not.

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