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Mr. Bercow: A serious heavyweight.

Mr. Truswell: That is right--someone who carried the grand order of the blue rinse, probably with bar.

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Mr. Desmond Swayne (New Forest, West): He would not have called himself the "chair".

Mr. Truswell: She.

Mr. Deputy Speaker: Order. We cannot have interventions across the Chamber from a sedentary position.

Mr. Truswell: She made it clear that I would not be allowed to participate. Conservative Members seem to have forgotten the fact that your Government took away from CHC observers to health authorities the right to speak. You ought to reflect on that. If these bodies are so great that you have now found renewed support for them, why did you do that?

Mr. Deputy Speaker: Order. The hon. Gentleman must use correct parliamentary language.

Mr. Truswell: I am sorry, Mr. Deputy Speaker. I got carried away by the argument. I apologise. My comments were directed not at you, but at Conservative Members.

The right hon. Member for South-West Surrey (Mrs. Bottomley) made an interesting contribution. She talked about the handful of Labour party members whom she appointed to health bodies, but not about the several hundred Labour party members whom she and her colleagues removed from those bodies.

My argument is not that of someone intent on the preservation of CHCs in their existing form. My former membership of a CHC and my affection for them does not make me blind to their shortcomings. I do not see CHCs as a classic car that should be preserved at all costs. Throughout the country, they have grown and developed differently, depending on the local circumstances and the quality of the staff and of their members. The strength of many CHCs is their ability to co-ordinate roles and services. My right hon. Friend's proposal has clear merit, but that is devalued by a potential lack of co-ordination.

I welcome the scrutiny role being given to local authorities. In the 1980s and early 1990s, many local authorities set up health committees to discharge that function, so there is a precedent for that. Scrutiny is crucial, but, as others have said, it cannot take place in isolation from other mechanisms for patient representation.

I welcome the fact that patients forums will be given the same status as CHCs in monitoring and inspecting services. PALS also recognise the valuable role that advocacy can play. I should like to hear a little more about the independent local advisory forums before passing any comment on them.

By my calculation, the Bill will result in the setting up of nine new bodies under the NHS plan in Leeds. They include the independent local advisory forum, PALS and seven patient forums. In Leeds there will be a patient forum for the acute hospital trust, the Community and Mental Health Services Teaching NHS trust and the five primary care trusts when the primary care groups make the transformation to PCTs. How will they be serviced to ensure that they operate with maximum effectiveness? Who will advise and brief them and support their nominees to various trusts? Those nominees will have a key role to play, just as CHC nominees to various health bodies do at the moment, but they will not be able to

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discharge that function effectively without the sort of support that I know is provided by CHC staff in Leeds and elsewhere.

If that support is to be made available to so many bodies, I fear that there will be a duplication several times over of that which currently exists within the CHCs. If the support is not made available to those members and nominees, it will undermine their effectiveness. At the moment, in the best CHCs the whole is greater than the sum of the parts, but I am not convinced that that can be said about the new structures that have been proposed.

In conclusion, it would be a pity if, having dismantled the existing vehicle and enhanced so many of its components, we do not reassemble it in a way that provides the most coherent means for conveying patient interests throughout the system. I can understand that Ministers wish to avoid a "should they go or should they stay" debate about CHCs. However, I firmly believe that the issues involved are far too important to pick up after the introduction of the new structures and must be dealt with from the outset. I urge my right hon. Friend and his colleagues to ensure that that is the case.

8.2 pm

Mr. Paul Burstow (Sutton and Cheam): I apologise for not having been in the Chamber for the entirety of the speeches of one or two hon. Members, but I did listen to the hon. Member for Pudsey (Mr. Truswell) and I want to say a little more about his comments on CHCs and the role of the new patients forums and their possible proliferation.

My hon. Friend the Member for North Devon (Mr. Harvey) made the worthwhile proposal that the patients forums be allied to the new overview and scrutiny function, and said that having a patients forum to cover a local authority area would be a much more efficient and effective way of allowing the patient's voice to be heard.

The Bill shatters the patients watchdog role of the CHCs, leaving a confused and compromised arrangement in its wake. The replacement for CHCs is to be a combination of patients forums, local authority overview and scrutiny committees, independent local advisory forums and patient advocacy and liaison services. The Bill abolishes CHCs without making it clear how the new arrangements will fit together. We are told that such matters will be dealt with through regulations and will therefore be subject to the tender mercies of unamendable regulations, which will be debated in Committee, not in the House.

For example, rules governing patients forums access rights over premises owned or controlled by trusts within which they operate will be left to regulations. There should be a clear statutory power of access with no prior permission being required for the forums to be able to discharge their functions properly.

Patients must have access to free, reliable and impartial advice and advocacy when they make a complaint. Liberal Democrats feel strongly that that important issue should be developed, and we welcome the Government's comments on developing advocacy services. However, we shall want to see the details of how they will work in practice.

As things stand, the new arrangements fail to achieve what the Government say they will achieve. Patient advocacy and liaison services are not advocates but are

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employed by the trusts and are not even independent. As a result, PALS will be seen as the trust's poodles, not the patient's advocate. PALS' role, despite their title, is not patient advocacy. It is more about provider advocacy; about putting a customer-care gloss on the NHS rather than delivering what patients want--a genuine partner and advocate of any complaints that they might make during their experience of the NHS. Instead, we shall have meeting and greeting, signposting and information provision and trouble-shooting. All that is customer care.

Mr. Dawson: How do the hon. Gentleman's comments fit with the intention in the NHS plan to shape the future NHS around patients?

Mr. Burstow: I shall develop that point later. The Government say that if patients forums believe that PALS are not working in the best interests of patients, they can recommend that they become independent. Why have such a device in place? Why not simply make them independent in the first place?

The same flaws that can be laid at the door of PALS also apply to patients forums. How easy will it be in practice for forum members, individually or collectively, to spotlight service failures, and how will they maintain the distance and independence from the trust in which they are taking a close interest, especially as we now learn that they will be on the board itself? Being on the board places a legal duty on members to act in the best interests of the trust. How can they do that when they are meant to be acting in the best interests of the patients forum and the patients whom it seeks to represent?

Reform of the NHS complaints system is needed, but not necessarily the current package. Public confidence requires that the reforms are firmly grounded in the outcomes of full, frank and detailed consultation that seeks the views of those with experience of the current system.

The health ombudsman is an example of someone with experience of the existing system, but the health ombudsman was not consulted. Why not? Could it be that Ministers feared that the ombudsman might say something that would be unhelpful to this package of measures? Without such consultation, how can anyone have confidence in the new arrangements? The new system will be so full of loopholes that the concerns will go unreported and bad practice will go unidentified and even unchallenged.

We welcome the news tonight that an attempt is being made to put together a national overview body, but it is essential that we have a strategic overview, nationally, regionally and across the local health economy, drawing all matters together rather than fragmenting them, which is what the Bill appears to do.

To succeed, care trusts must be genuine partnerships between the NHS and local government. Both parent agencies should share responsibility for a jointly accountable body. The local link and the accountability of local councils should not be lost or diluted when it comes to services for older people and the wider services that the new care trusts could be providing. I hope that, in Committee, we shall have time to explore in more detail the checks and balances to be put in place to ensure that care trusts do not simply medicalise social care.

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Help the Aged, in its brief for today's debate, rightly says how important it is that there is a genuine balance between medical, nursing and social care. That is a concern that was echoed by the Local Government Association, which rightly seeks assurances that community based services will not find themselves submerged in an organisation that focuses on treatment and ill health.

The key is cultural change, not organisational change. It is not about patient-centred care but about people-centred care and the need to consider the whole person, his medical and social needs. That is what a care trust could and should do and I hope that that addresses the earlier intervention of the hon. Member for Lancaster and Wyre (Mr. Dawson).

The Bill leaves open the possibility that NHS services provided through a care trust could be charged for. For example, an Alzheimer's or dementia sufferer receives a service free in an NHS facility but could suddenly find himself in a private or local authority facility paying for the same respite service. The Bill must ensure that care trusts do not allow new charging policy anomalies to emerge and thwart all the good intentions.

On the grounds of equity, fairness and practicality, I believe that the proposals regarding free nursing care are the meanest in the Bill. The Government's free nursing care plans are fatally flawed and take no account of the unsustainable squeeze on care home fees over the past few years or the accelerating rate of care home closures.

The Bill is trying to get free nursing care on the cheap and will force more care homes to go out of business, deepening the existing crisis. In written answers, Ministers have admitted that the three-year £420 million estimated cost of the nursing care package is little more than a back-of-a-fag-packet calculation. No effort has been made to measure the true cost of free nursing care and no assessment has been made of the level of need.

The figures used in the Government's calculations come from market analysts Laing and Buisson. The Government's figures are derived by taking average residential homes fees from average nursing home fees, giving a difference of £100 a week. Those same analysts warn, however, that fee levels are unsustainably low, and the figures that the Government have relied on date back to 1999.

The proposed definition of nursing care will leave care home residents unclear about what they will have to pay for. The management and delivery of care involves a variety of nursing and care staff. Who performs what task can vary depending on a person's state of health. The bureaucracy involved in recording billable care will be formidable and costly. Who will foot the bill--the individual, the care home manager or the NHS?

Vulnerable old and disabled people will have to pay for care that should be free, such as dressing ulcers, changing a catheter or skin care. If such tasks are delegated to a care assistant, they will have a price tag attached, but they will be free if performed by a nurse. A definition of nursing care based on who performs the task, rather than on what the task is, is plain wrong.

The Secretary of State said that there will be constant assessment of the individual's nursing requirements. There will certainly need to be, because a person's needs are not set in stone and may change from day to day. To say that an initial assessment will set the basis on which

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a person will be charged is impractical and unfair and will create new anomalies. The Government have not fully thought through the proposal.

Where are the extra nurses to do all these assessments to come from? We know that the Government want 20,000 extra nurses in the NHS and that the Royal College of Nursing says that over the next four years there is a nursing gap of 57,000. That is before one even talks about extra nurses in the private sector to make the proposals stand up. How can we make the system work in practice?

We believe that the Government should implement the royal commission's recommendation for free personal care on the basis of an assessment of need. In Scotland, the First Minister has signalled a rethink of policy, and the Scottish Parliament's Health and Community Care Committee was unanimous in endorsing the recommendation. The Committee took its decision not only on the basis of equity and fairness but because the evidence convinced it that it would lead to better service delivery and would add value. Adopting the royal commission's proposals in full would underpin many of the Government's developments on care trusts and pooled budgets, not undermine them. Unlike the Government's proposals, it would be fair to all, and not just the few.

The Bill tears up by the roots the independent system that CHCs represent and substitutes a confusing army of bodies that lack the teeth or the authority to act independently on behalf of patients. It also fails the test of fairness and equity in respect of long-term care. People with dementia and many other chronic conditions will be forced to pay for personal care such as help with washing and bathing that hospital patients get free.

Before the last general election, the Prime Minister said that he did not want to live in a country where people were forced to sell their homes to pay for their care. The Bill means that that promise has been broken. The debt collector will still come a-calling on some of the most frail and elderly people in the country. That is why the Bill should not receive a Second Reading.

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