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Decision-making in the NHS

1.30 pm

Dr. Richard Taylor (Wyre Forest): The debate is a tremendous opportunity to speak on behalf of the public on this important subject, and I am grateful to the Minister of State, Department of Health, the right hon. Member for Barrow and Furness (Mr. Hutton), for coming to respond to the debate.

The national health service belongs to the people. For far too long, decisions have been made by professionals, managers and politicians without much public involvement. I want to make three points. First, I shall dwell briefly on history. The Government do not like it when I do so, but I want to show the lessons that we have learned on how not to consult. Secondly, I shall discuss the weakness of the current arrangements for public involvement, and welcome the Government's additions to them. Thirdly, I want to mention some of the major decisions that will face the NHS in the near future, in which public involvement will be crucial.

In my county, we have learned bitterly how not to consult. The first lesson is to treat citizens as intelligent people, and to not talk down to them. I do not blame the Government for that; I blame the Government's servants in the area. When there is a problem, it must be faced openly and discussed with the people. Worcestershire has certainly had problems. They could have been faced much more openly, but the health authority made decisions before consultation, and consultation was then carried out to force measures through.

The authority had a closed mind to any alternative. It used spin and half-truths to force measures through. It said that a comprehensive hospital would remain in Kidderminster, but normal people would not consider a hospital to which they could not go for any in-patient emergency treatment comprehensive. Statistics were used in the most amazing way to justify measures. The 3.5 million contacts between Worcestershire patients and the NHS each year—contacts with general practitioners, outpatients and community nurses—were compared to the 12,000 patients who had to travel further for their hospital services. The authority was saying, "What are you worrying about? Less than 1 per cent. of people will have to travel further for their treatment." But that 1 per cent. was 100 per cent. of patients from my area who had to travel for in-patient treatment, and a few other patients from elsewhere.

The other tool is to misquote or selectively quote documents. Recently I have had consultations with the president of the Royal College of Physicians, which is my own college. The royal colleges are angry about how often they are blamed for reconfigurations when, in fact, they only issue guidelines, which can be misquoted. The health authority spokesman said that a particular college document had identified that hospitals

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What the document actually said was that such hospitals

That is a completely different statement, because with partnerships the hospitals could be sustained.

The worst example of all was the previous chairman of the NHS Executive, who wrote to campaigners, trying to defuse the situation. He said:

That is exactly how to rub salt into a wound. It shows a devastating lack of understanding. It is almost as bad as Marie Antoinette telling the people to eat cake during the French revolution.

The faults are there—the use of spin, half-truths, the misuse of statistics and the failure to grasp other people's points of view. The final lesson is too obvious: it relates to the inability to take into account the response to public consultation. Those responses should not just be swept under the carpet when they go against the wishes of the authorities. A stock answer given by health authority officials at heated public meetings was, "I cannot help it if you don't like my answer. It is the only one I can give." That response shows that officials had closed minds before the consultation.

I move on to the weaknesses of the current arrangements, and my hopes that the Government's plans will improve things. Community health councils have been variable and patchy in their distribution, although some have been superb. Whole counties and big cities have only one community health council. In Worcestershire, there are three community health councils for three different conurbations. I welcome the alternative, and I hope that the Minister will tell us that he has a better name for them than primary care trust patients forums. They will be consistent nationwide and will link with overview and scrutiny committees of local councils, so they have tremendous potential for allowing the citizen a voice. I hope that the Minister will tell us about the process of appointments to patients forums. I am a little alarmed about the cost because, whereas community health councils were relatively few in number, there will be many primary care trust patients forums.

I have had a helpful communication from the National Consumer Council about patients forums. I quote:

the Commission for Patient and Public Involvement in Health—

Now that PCTs have so much power, after the crucial devolution, the post of non-executive director has become even more important than before. I hope that the new appointments system and the NHS

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appointments commission will remove the fear that so many directors have political allegiances. Hopefully, we will get strong, knowledgeable local people who can challenge the executives and represent local people in a way in which they have never been allowed to in the past, and who will not be tied by consensus management, pressurised from above, or even, in some cases, intimidated.

I shall briefly mention some of the issues that will arise in the future where meaningful public involvement is vital. The issue that is closest to my heart is obviously hospital reconfigurations. I welcome with tremendous enthusiasm last week's Health Service Journal, as it refers to a draft Department of Health framework on hospital reconfigurations that it somehow got hold of. The document, which has not yet been published, states that hospital reconfigurations must be based on "socially sustainable decision-making" and on services designed

That accords well with a local lady who, referring to politicians in general, said "I do not elect a politician to tell me what I want." That is a very important comment. The framework document, we are told, continues:

That approach is vital, because as far as hospital reconfigurations are concerned, the terrible challenge of the European working time directive will threaten large and small hospitals alike. The report from the Royal College of Physicians on isolated acute medical services states that 46 hospitals in England alone probably cannot sustain acute medical services.

Health care rationing demands open debate with the public. The National Institute for Clinical Excellence is the first brave attempt at that, and I am more than interested to hear about the progress of its attempts to involve patients and citizens. I would love to believe that citizens could be involved in the debate about the nurses' pay review. I do not know if that is living in cloud-cuckoo land, but the cost of agency nurses is ridiculous. I would love citizens to be involved in discussions on foundation hospitals. This morning, I received a communication from the Terrence Higgins Trust, stating:

Those are just some of the points, but there are many others to which involvement of the citizen is crucial.

To conclude, ordinary people are intelligent and have been disregarded for far too long. Problems in the NHS should be admitted. The Government must take people with them by being fully open, frank and honest, and by being able to respond to people's views even if they force the Government to change their mind. At this very moment, the British Medical Association is holding a consultative seminar with representatives of patient groups and professionals working in accident and emergency departments to identify and address areas of concern about access to

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emergency care. The Government are very good with words, and I hope that the Minister will tell us that actions are being moulded to the words.

1.44 pm

The Minister of State, Department of Health (Mr. John Hutton) : I hope that it will not come as too much of a surprise to the hon. Member for Wyre Forest (Dr. Taylor) that I agree with much of what he said—I hope that that does not disappoint him. I probably start from probably the same position as him. He criticised existing arrangements and said that public involvement in the national heath service is not as good as it should be. The Government and I agree, which is why we proposed and implemented changes. The hon. Gentleman asked some specific questions, and I hope that I can answer them.

There is no better place to start than the hon. Gentleman's first remark—the national health service, of course, belongs to the public. They pay for it through general taxation and have the right to be fully involved with, and consulted on, the planning and delivery of local NHS services, as well as decisions on the best ways in which to improve them. I do not want to go into the long and painful history of developments in the hon. Gentleman's constituency, but there is room for improvement in the way in which we ensure that change is effective in future.

A further problem is that when the NHS was set up—if one consults the history books—ownership was taken away from local communities. That was the basis on which many hospitals were put together. Ownership was instead invested in the state, which brought huge benefits, but there was a cost because a gulf grew between local communities and the way in which NHS services were run. Our challenge is to find a way to bridge that gap. Professor Kennedy, in his report on events at Bristol Royal infirmary, argued that patients should be inside the NHS rather than on the outside, as they often appear to be. Our proposals in the NHS plan and our response to the Kennedy report are designed to achieve that.

The hon. Gentleman spoke about community health councils. CHCs have been the principal mechanism for reflecting the public's interest in the NHS for nearly 30 years, and have done that job very well in many cases. However, CHCs have never empowered the public to speak for themselves or provided opportunities to that effect—that is not a criticism because it was never part of their remit. Modernisation of the NHS, centred on the needs and views of patients, which both the hon. Gentleman and I would like, requires mechanisms that enable systematic public involvement. Such a system should be proactive and not merely reactive, as present arrangements largely are. The system must work in partnership with the NHS, and should not always be pitched against the NHS. Patients forums, the Commission for Patient and Public Involvement in Health, and overview and scrutiny committees will replace community health councils. I hope that those new arrangements will ensure that the system to involve the public in the NHS will be more inclusive, proactive and democratic.

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As the hon. Gentleman will know, Mrs. Sharon Grant has been appointed as chair designate of the new commission. I am very confident that she will make a hugely important contribution to its work, given her record of achievement and commitment. Mrs. Grant and her interim team are considering such issues as the core values under which the commission will operate, the different ways in which it could be structured, and staffing. The commission will start its formal work in January. The hon. Gentleman asked about the title of patients forums. I understand that Mrs. Grant wants to examine that—I am sure that she will have something to say about it.

One of the commission's first jobs will be to begin setting up patients forums throughout the country, and ensuring that patient and public involvement is consistent throughout the country. Patients forums will be made up of local volunteers who will monitor and review health services from a lay perspective. They will submit reports and recommendations to NHS managers, and a member of each forum will sit on the local trust board. The commission will organise the recruitment of volunteer members to forums and the recruitment of staff to forums to support their activities. I hope that the recruitment campaign for volunteers will target all corners of local communities. Some staff recruited to support forums will promote community involvement. Everywhere in the country there will be people with the capacity, inclination and skills to be effective members of patients forums. Many others will have something to say about the future of their local NHS, but will not know the best way to go about saying it. Some may not have the confidence or the opportunity to attend meetings.

It will be the job of community involvement staff to use existing community networks and visit different parts of the community to seek the views of the wider community. Where possible, they will take meetings to the people, and will work in innovative ways to ensure that as many people as possible can influence decisions. We will have to leave behind traditional ways of doing things as they have not always worked. In particular, we must look critically at the meetings culture. However, getting involved in decision-making processes is meaningless if the mechanisms for implementing decisions do not have teeth. It is one thing for a patients forum to make a series of recommendations to NHS manager, but that is futile if the NHS ignores what is said. In other words, the NHS must be more than just a good listener.

Not everyone will agree on the right way forward—I think that the hon. Gentleman cited a document on that issue, to which I shall refer in a moment. Trusts will not always be able to react positively to recommendations, but the flip side is that forums have the right to expect a proper response and explanation from trusts. Fundamentally, the NHS will need to treat the new forums as equal partners. Both sets of partners will have to work hard to ensure that they are viewed in that way—as a resource, not an obstacle.

We are not only empowering people directly, but providing new powers so that democratically elected members of local authorities can have real influence

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over the NHS. The Health and Social Care Act 2001 gave new powers to the overview and scrutiny committees of local authorities to review and scrutinise the planning, operation and development of local health services. I hope that that will tackle directly the lack of local accountability by ensuring that democratically elected representatives with responsibility, as a matter of law, for the well-being of local people have influence over the NHS.

To facilitate health scrutiny by local councillors, the Act places three key obligations on the NHS: to provide information to overview and scrutiny committees; to consult on the substantial variation and development of services; and for senior NHS officials to attend meetings to explain decisions. On top of the new scrutiny powers there is a specific right of referral to my right hon. Friend the Secretary of State for Health where an overview and scrutiny committee contests either the adequacy of public involvement and consultation or the merits of proposals for change.

Public interest is highest when proposals are made to reconfigure local services. The hon. Gentleman drew on his own experiences in making that point. The NHS plan committed the Government to establishing an independent reconfiguration panel to consider contested proposals. Where a referral is made, the Secretary of State may seek the advice of the panel, which will be made up of key stakeholders, a third of whom will be patient representatives. We expect to confirm the panel's membership shortly, but its work must be seen in the context of our undertaking to develop a framework to address service reconfigurations—the hon. Gentleman also spoke on that subject.

The forces that historically have underlined the need for reconfiguration of NHS services are well known, not least to the hon. Gentleman, who has had a distinguished career in the NHS. Patient safety, technological change and affordability have tended to act as centralising forces in the past, and we must carefully reconsider all those issues from the patient's perspective and experience, remembering people's strong wish to retain the best possible local access to the highest quality services as close to home as possible. The best solutions have a number of common factors, to which the hon. Gentleman referred. We should design services with local people, not for them. In west Cornwall, for example, the NHS, the local authority and local people have united around an idea for developing services to meet local people's needs and maintain access to locally based services. They are working in partnership to put the new model of care in place, and we are providing them with financial support to do so.

We should take a whole-system view. Hospitals are more effective and stronger if they work in partnership than in isolation—I agree with the hon. Gentleman about that. Merged clinical teams permit far more flexibility in the way in which services are provided. There should be an emphasis on redesign, not relocation. The experience with service and work force redesign shows that alternative models of care can be developed to deliver safe, effective care for patients, and we should explore all those avenues. Patient safety must,

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however, come first. Innovations such as the local medical emergency unit in Cornwall, of which the hon. Gentleman is aware, need thorough testing before they can be implemented more widely. Smaller-scale innovations such as extended roles and clinical networks are already working well in many places.

The aim of our work on those issues is to help the NHS to get it right first time. The framework to which the hon. Gentleman rightly drew attention will assist, or seek to assist, the process of decision making at local level by offering signposts for the future and by helping local communities to develop innovative and sustainable service models that are supported by local populations. We expect to publish that framework in the very near future, and I am sure that the hon. Gentleman will be the first to write to me about it.

Section 11 of the Health and Social Care Act places a new duty on the NHS to make arrangements to involve and consult the public on decisions to be taken about changes to local services. It will come into effect in the new year and underpins new arrangements for patient and public involvement across the country. It will enable members of trusts to whom involvement is second nature to capitalise on their good experience, and will bring up to speed those trusts for which it has not been such a high priority. It will give more people the chance to get involved.

Promoting a "Trust me, I'm a patient" culture is a real challenge. For many in the NHS, involving patients and the public in decision-making processes will mean changing the way in which they work. I believe that that is the right thing to do. To ignore the views and experiences of patients and the public would be to ignore the biggest pool of expertise available to the NHS. I accept that involving patients and the public in the decision-making processes of the NHS is a challenge, but it is also an opportunity that we should seize with both hands.

The hon. Gentleman referred to the big challenge posed by compliance with the European working time directive. It is an opportunity rather than a threat—we should look at it in that context. We have worked closely with the royal medical colleges, the British Medical Association and others to find the right combination of measures to ensure that we do not, as the hon. Gentleman suggested, face an unacceptable range of solutions that would take people further away from local services. I do not believe that anyone would want that, as there are solutions at hand.

We will have to examine critically arrangements for cross cover and new arrangements for staffing on-call rotas. Skill mix in the NHS—the classic question of who does what, and why it must be done in a particular way—is a significant challenge. There are opportunities for us to re-examine the way in which we provide services. Compliance with the European working time directive will not provide a fig leaf, as it were, or an excuse for wholesale service reclassification. Neither I nor my constituents want that. If there is one baseline test that we as right hon. and hon. Members should always set ourselves when examining NHS issues, it is

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whether a policy will work for our constituencies, and whether it is the right thing to do for the people whom we represent. That is my approach to such issues.

I believe—I hope that you, Mr. Deputy Speaker, and the hon. Gentleman agree—that the NHS is a public service. It does not belong to me, or to any of us in the

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House, but to the public, who support it strongly and pay for it through their wallets. The public have an absolute entitlement to expect that the service delivered to them meets their local needs. That is our objective.

Mr. Deputy Speaker : A very constructive and interesting debate.

Question put and agreed to.

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