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National Health Service

8 p.m.

Lord Harris of Haringey rose to ask Her Majesty's Government what arrangements will be made to ensure that, if community health councils are abolished as is envisaged in the National Health Service plan, the new arrangements for empowering National Health Service users and the new patient advocate and liaison service will be independent, and will be perceived as independent, of the local National Health Service structures.

The noble Lord said: My Lords, in introducing this short debate, I should declare that I was director of the Association of Community Health Councils from 1987 to 1998. That experience has of course meant that I am as aware as anyone of both the strengths and the weaknesses of the current arrangements.

It is perhaps worth reminding your Lordships that CHCs were established in 1974 to represent the public's interests in the health service. They are unique institutions. They comprise up to 24 members, and only a civil servant with a particularly bad hangover would have devised the detailed composition: half appointed by the locally elected councils for the area concerned; a third elected by local voluntary organisations; and the remaining sixth appointed by the regional offices of the NHS Executive.

They are the only bodies in the health service which elect their own chair. They have a national body recognised in statute, and that in turn has a democratic governance structure. CHCs act as the independent patients' watchdog on every aspect of patients'

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experience in the NHS. They have a legal right to be consulted by health authorities on major changes in the NHS and can refer major issues for decision to the Secretary of State. They represent the views of local communities in the planning of their local health services and monitor the quality of the services provided, using their rights to visit and inspect NHS premises.

The best CHCs are highly effective in what they do. Plenty of examples can be cited where they have made health authorities or NHS trusts think again. At a local level in the NHS they fulfil the role commonly ascribed to your Lordships' House in respect of legislation from another place, requiring governments to think again and to review what they are proposing. They have tested proposals. No doubt that has inconvenienced over-eager managers. However, the consequence of the work of CHCs has been that proposals for change have been made more robust and health services are better as a result.

Critically, they also support patients and carers who have complaints or concerns about the NHS. Locally, they are able to integrate the various strands of the work that they do, ensuring that the lessons learnt from monitoring and from complaints work informs their input into service planning. As a result, CHC members are often better informed about what is happening in local services than trust or health authority non-executives or even the managers responsible. On a national level, CHCs network so as to promote best practice and learn the lessons of the bad from across the country with the capacity to raise issues of wider concern with the Department of Health.

All that work is now under threat. One line of the National Health Service plan proposes the abolition of CHCs. I am a great supporter of the NHS plan. Indeed, it was extremely widely welcomed in your Lordships' House and by those involved in the health service. It provides the means to modernise the service and genuinely to provide a better service to the public. Therefore, it is a pity that the plan is flawed in its proposals to involve patients.

The plan proposes that a patient advocate and liaison service, to be known as PALS, in each NHS trust will assist patients and their families in resolving their concerns. Each trust will also establish a patients' forum and health authorities will appoint a citizens' advisory panel. Finally, local government will be given the power to scrutinise health services in their area and to take over the power of referring major changes to the Secretary of State.

However, those arrangements have the effect of fragmenting the work of CHCs across a range of bodies. And it is difficult, if not impossible, to see how trends and issues will be picked up and integrated at local level, let alone regionally or nationally.

Of even more concern is the fact that the new arrangements will not be independent of the local NHS. The independence of CHCs has been the key to their effectiveness. They are able to speak frankly in the interests of patients and the public. That is essential

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in ensuring the confidence of individuals who may have complaints or who may simply want to express their views without feeling that any perceived criticism will affect adversely how the service treats them in the future.

I believe that that is critically important. I am sure that my noble friend the Minister will make much of the new PALS service. I recall that in a former existence he was a great proponent of patient advocacy schemes based within hospitals. However, if such services are based within the service itself and are accountable to the chief executive of that service, they will neither be independent of the service nor, perhaps even more importantly, will they be perceived as independent by the people who will need to use it.

I am sure that they will be useful as a type of customer relations trouble-shooter. Of course, in that respect the service in Brighton is cited as a beacon. It has done good work, although I am told that, because of staff sickness, the scheme has not been functioning for the past 10 months. However, in any event let us be clear that the new PALS will not provide a true advocacy service.

As an illustration, one CHC chief officer told me of an incident earlier this week when a man came into the CHC office to inquire whether he could access his medical records to further his complaint against a local trust. The trust had told him that that was not possible because he was in the process of making a complaint against it. He was of course told, as was the trust, that that was nonsense. However, what confidence would that person have had in a so-called advocacy service based within that same trust?

Similarly, the new patients' forums and advisory councils will not be truly independent. They will be hand-picked. The people likely to raise the most challenging issues will not be selected. And even if they are not hand-picked, the public are unlikely to have confidence in such an arrangement because the members are appointed by the authorities and trusts concerned.

Moreover, the people who serve on the forums and panels will receive advice only from within the authority or trust concerned, and--let us be clear about this--they are unlikely to be advised to raise or push an issue that the authority or trust will find difficult. They will be provided only with information which is deemed appropriate and will certainly not be given the ammunition to be truly effective.

Personally, I support the role envisaged for local authority scrutiny committees. At least for the Labour Party, the party whipping system does not apply on such committees. The proposal is a natural extension of the role of local councillors as community advocates. However, councillors will be effective in that role only if they are properly supported and knowledgeably and independently advised. Supported by the CHCs, local authority scrutiny committees would be formidable scrutineers of local NHS developments. Unsupported, they may end up being rudderless and uninformed.

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My time is nearly up. I am conscious that CHCs vary. Some are very good, a few are poor, and a handful are, frankly, dysfunctional. The most charitable explanation for the proposals contained in the NHS national plan is that CHCs need to be abolished in order to deal with the dysfunctional handful. If that truly is the explanation, there is a danger that all the good work will be lost as well.

I have yet to hear anyone outside the Government support the proposals. They certainly cannot support them if the new arrangements are seen as not being independent of the local NHS and, what is more, there is no mechanism to integrate the lessons learnt from the various aspects of the work currently done by CHCs. Perhaps the Minister will tell me how many representations have been received supporting the Government's proposals in respect of CHCs and patient representation. Indeed, how many representations putting forward those ideas were received in the consultation that preceded the production of the national plan?

However, if the removal of the dysfunctional is the most charitable explanation, the one that everyone will believe is that CHCs are being abolished because they are challenging, because they are an effective irritant and because they make people think. The abolition of CHCs will be seen as a nasty outbreak of Richmond House control-freakery and, as such, will detract from the excellence of the rest of the national plan.

There is no need for that. Instead, let us ensure that the new arrangements are genuinely independent of local NHS structures and that robust mechanisms are in place to ensure that the various strands of work are integrated together effectively. If that means reinventing CHCs, so be it. But we should not throw away a vital mechanism that not only ensures a viable voice for service users in the new NHS but, as a result, delivers a better service because of the robust criticisms and the testing of proposals to all the many millions of people who rely on the NHS and who require an independent voice to represent their interests.

8.10 p.m.

Baroness Cumberlege: My Lords, it gives me great pleasure to congratulate the noble Lord, Lord Harris of Haringey, on initiating this debate. As a former director of the Association of Community Health Councils, there can be nobody who knows the inside workings of CHCs better than he does, although it may be that the Minister knows them quite well because I believe that he started his career as a chief officer of a CHC.

My experience has been very much on the other side. I was chair of a district health authority which ran 16 hospitals and I was also chair of a regional health authority. Both those authorities have been the subject of some fairly acerbic criticism from CHCs. Not a comfortable experience but character-building.

The noble Lord, Lord Harris, said that one argument for abolishing CHCs is that they are not all perfect; and of course, we know that that is true. As a regional chairman, I met regularly with the CHCs in

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my region. I knew that their performance was variable and I believe that that is true today as well. But GPs, primary healthcare teams and hospitals are variable. Through their modernisation programme, the Government are determined to improve that variability, achieve consistency and make the performance better. So here is an opportunity not for the abolition of CHCs but for strengthening and modernising them.

The commission on the NHS, chaired by Will Hutton, which I think is a brilliant piece of work, shows how that can be done. Indeed, there was an extremely interesting debate the other evening at the King's Fund on his proposals which found a large measure of agreement.

I have no doubt that in replying to this debate, the Minister will say how very committed the Government are to involving patients and the public in the NHS. That is a principle which I strongly endorse. In my report, Neighbourhood Nursing, which is now 14 years old, I advocated the setting up of local healthcare associations. They were to influence policy and to monitor primary care because the CHCs did not have any locus in that area. So the principle is absolutely right; it is the Government's method which is wrong.

To kick out an uncomfortable bedfellow because he or she is awkward is a sign of weakness. It is a sign of an Administration who are increasingly centralist, controlling and not sufficiently secure to brook independent criticism. I believe that a plan which neatly removes all the difficult decisions, like hospital closures, from the Secretary of State to a faceless panel, is quite cowardly and a negation of duty.

In the NHS plan, the Government have fragmented the previous powers and responsibilities of the CHCs so effectively that they have made the system impotent. I could go through the proposals one by one. PALS will be just that--hired, fired and paid for by the trusts, so they will have to be pally. The Independent Local Advisory Forum is a mere sounding board with no teeth. The patients fora are blinkered, as they will see only the trust's position and will not be able to view, for example, how limited access to out-of-hours GPs affects the A&E departments. I do not share the enthusiasm of the noble Lord, Lord Harris, for the local authority scrutiny panels. I started my career in local government and I have been extremely sad to see its role diminished. But in this case, the scrutiny which comes through the local authority will be neutered through the whipping system. But worse--and this worries me much more--that may jeopardise the joint working and future establishment of care trusts.

My time is up so I shall ask just a few questions. Under the new arrangements, how can local communities hold the Secretary of State to account? Is there to be consultation on the criteria permitting referral on major change? Will councillors sign a code of conduct on political impartiality? How will patients or relatives who wish to complain access competent, truly independent support in doing so? Finally, are the proposals to be carried through on a negative order without proper consultation?

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8.14 p.m.

Baroness Barker: My Lords, I too thank the noble Lord, Lord Harris of Haringey, for giving us this most welcome opportunity to debate what I believe is a very substantial flaw in the NHS plan; namely, a fundamental confusion within the plan about what the patient advocate and liaison service is intended to do.

It may be useful if I were to bring to your Lordships attention a definition of advocacy which was drawn up some years ago by the Institute of Public Policy Research and the members of a number of leading voluntary organisations, including the noble Baroness, Lady Pitkeathley:

    "Citizens Advocacy is a one-to-one ongoing partnership between a trained advocate and a person who is not in a strong position to exercise or defend his or her rights, and is at risk of being maltreated or excluded. The citizen advocate must be free of conflicts of interest with those providing services to their partner and should represent the interests of their partner as if they were their own".

I offer that definition because nowhere in the NHS plan is advocacy actually defined. I believe that what has been proposed in the NHS plan is a confusion between three different aspects: information, support and advocacy or representation.

The new PALS system is described variously on pages 91 and 92 in terms of information, facilitation, negotiation and support for complainants. But those are very different matters which require very different skills. There is a significant difference between a service which eases the path of hospital patients through an organisation's structures and services and one which enhances and supports the ability of people--patients, families and carers--to negotiate the wider NHS, an understanding of their rights as users and their ability to obtain redress if things go wrong.

PALS appears to deal only with patients in hospital, not patients in primary or rehabilitative care. Such patients usually need the following things. First, they need practical information about the services of a hospital in easily accessible formats. They need information about aftercare, benefits and adaptations.

If the proposed system is to work, the integrity of the information which is provided must be assured. There must be no conflict of interest by dint of those responsible being employed by the hospital.

Secondly, patients need support. Lots of patients just need a bit of help to get simple things done. Reading the plan, I believe that that is what the Secretary of State really intended this proposal to achieve. But that is not advocacy. I am not being pedantic here. We are talking about a major structural change on a basis which is wholly unclear.

Here is a tremendous need for advocacy. I cite one example--language difficulties. Many patients suffer simply because of language difficulties. In certain boroughs in London, more than 130 languages are spoken. I cannot see how one hospital or one NHS facility can meet that sort of need. And yet there is

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scant mention in the plan about the organisations which have that expertise; namely, voluntary organisations.

I have two questions for the Minister. First, why is there no mention in the plan about national standards and criteria for evaluation of the PALS system? Secondly, if the Minister accepts the need for independence and the advocacy skills which exist outside the NHS, is there a case for going down a route similar to that of the community legal service and establishing an NHS advocacy standard to which a number of groups, which prove that they are up to the required standard, could bid to provide that service?

The major flaw is that this does not cover general practice or even PCTs. By far the largest number of incidents in the NHS are in the community services. Will the proposals for PALS and patient forums ever reach down to that level, which is the level at which most people experience the NHS?

In conclusion, I do not think that what is on offer is PALS. It is PILS--a patient information liaison service. If the Minister's department really wants advocacy, then the voluntary and statutory sectors will need to be "PALS" together.

8.19 p.m.

Lord Rea: My Lords, the NHS has never been a very democratic organisation and when the last vestige of local authority control went, along with the medical officers of health in the 1973 Act, the community health councils were created in part to compensate for that deficit. They have held the fort for 26 years against a trend towards increasing top-down control on an extremely limited budget.

I am delighted that the NHS plan proposes to begin to reverse the trend of centralism. Each CHC usually has only one executive secretary or chief officer, with some clerical help and very modest premises. Nevertheless, they have had notable local successes. They act as patient advocates, similar to the proposed PALS or PILS--one can think of PILS meaning something else too--but their main achievements have come from their ability to contribute to the planning and implementation of local services. That is because it is the statutory duty of health authorities and trusts to consult community health councils on proposed changes and to represent the views and needs of their local population.

By having a "shop front", CHCs are easily accessible. Through listening to the problems brought to them, as well as to the often expert views of their members, CHCs are able to help health authorities and trusts to fine tune their services to the needs of their community. Those successes can range, for example, from the provision of a care and occupation centre for young adults with learning difficulties to the creation of a small community hospital for low dependency patients in a deprived neighbourhood. Both those examples come from Lambeth, just across the river. It is interesting that in neither of those cases was health service money initially involved but local social

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services and education committees in the first example and the Department of the Environment, through an inner-city regeneration programme, in the second.

Because of their independence, CHCs can mobilise funding from different branches of local and central government as well as from the voluntary sector. In Lambeth the CHC facilitated joined-up government long before it became a trendy catchphrase. These particular gains were small in themselves but, accumulating throughout the country, CHCs have helped to create a more caring and cost-effective service. Among the plethora of organisations looking after the interests of patients which are mentioned in chapter 10 of the NHS plan there is no provision for a body with the independent, proactive role which the CHCs have. They also represent whole communities rather than advocate the needs of particular citizens. In paragraph 10.27 CHCs are castigated as being unelected. However, the all-party scrutiny committees of local authorities which are proposed will consist of councillors with many other duties, while CHC members have a dedicated role in looking after the health interests of their communities.

I hope very much that my noble friend will be able to explain why community health councils were not consulted before the NHS plan was published, and that the sentence in paragraph 10.35 which states that "CHCs will be abolished" will be replaced by a sentence which includes the words, "CHCs will be strengthened". It does not matter very much if they continue with their name. The name perhaps might be changed but the function, status and expertise of the CHCs should be preserved. If the Government want guidance as to how CHCs could be preserved and strengthened, they have only to look at the appendix in Will Hutton's report on the Health Commission entitled Life for Health.

8.24 p.m.

Baroness Pitkeathley: My Lords, I too thank the noble Lord, Lord Harris, and declare an interest, not only as a long time champion of user and carer recognition in health and social care but also once upon a time as chief officer of a community health council.

I have much admired the work of CHCs and also the work of the Association of Community Health Councils for England and Wales, of which the noble Lord, Lord Harris, was a much respected chief executive for many years. Fan though I am of CHCs, we must acknowledge, as other noble Lords have done, that they vary tremendously in the quality of work they do and in their effectiveness. As we know, the reasons for that variability are many, but we have to acknowledge that such variations exist.

Moreover, CHCs are now 25 years old and it is entirely right that the role and function they perform on behalf of patients is reviewed. I do not want to argue tonight necessarily for the retention of CHCs but rather to emphasise the importance of ensuring that the patient voice in the NHS is as strong as

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possible and to give examples of factors which must be taken into account when any new arrangements are being considered.

Perhaps I may acknowledge the huge progress which has been made in recognising patients' needs in recent years. No one can possibly pretend that when it was set up the NHS put patients first. But today the experience of patients and their families is valued. Even since 1974 when CHCs were established, the culture around recognising the importance of patients has changed radically.

Any system for improving patient experience of the NHS must first and foremost concentrate on empowering patients and making them feel centrally involved in their own health care. Public advocacy is therefore absolutely crucial. The Government must be sure that any new arrangements they consider will strengthen, not weaken, that advocacy function. In addition, as we have heard many times, one of the criticisms of CHCs is their variability, so we must not make that problem worse. I am all in favour of allocating more power to patient organisations which are run by patients, but clarity is needed about how they will relate to the NHS and to each other. This argues too for some kind of national structure or body to oversee the new system.

Next, I should like to emphasise the importance of relating to primary care, as other noble Lords have done, as well as to trusts. As the noble Baroness, Lady Barker, reminded us, that is where most people experience the NHS. Again, the functions of the CHCs or any other body must be reviewed and care taken to ensure that primary care is not only included but given complete recognition as the most important interface between patients and the NHS.

Concerns have been expressed regarding local authority involvement in the proposed new arrangements. That concern usually revolves around the politicisation of patient advocacy and complaints procedures. But that could work to advantage, particularly if we think about the overlap between health and social care which is so important. We are beginning to see evidence of the Berlin Wall coming down, and that could help. Above all, we must ensure that the new arrangements are not only independent but seen by patients to be independent.

I am also concerned that so far there has been no mention of statutory rights for the new bodies. That must be addressed. Notwithstanding the more favourable and sympathetic climate in which we now operate in regard to patients' rights, we must ensure that sufficient power is vested in any new arrangements to enable the voice of patients to be as strong as possible.

8.28 p.m.

Lord Greaves: My Lords, not for the first time in my life, I find myself rising to support most of the eloquent case put forward by the noble Lord, Lord Harris of Haringey. I speak as a former member of the Burnley, Pendle and Rossendale Community Health Council. Perhaps I may also apologise in advance to the

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Minister and the House. I have to catch a train and, with the present state of services, I may have to leave before the Minister sits down. If I have to do that, I promise that I shall carefully read Hansard.

This is not the first time that central government have tried to abolish community health councils. The last time it was the Tories. One questions where these ideas, which do not appear in manifestos, come from. We all know the answer. Why is it happening? CHCs are relatively cheap. Considering the job they do, they are very cheap. They are usually representative of the local community. However, as noble Lords have said, they are varied in what they do and how they do it. I refer not only to the quality of what they do but the nature of what they choose to do in response to the circumstances as they see them. To some extent, therefore, they are seen as being untidy and messy by people who would prefer them to be a much more uniform management tool within the health service.

Community health councils provide a wide range of information and advice and have the ability to look at health problems as a whole, including outside the narrow confines of the health service. They have the ability to look across the National Health Service at community services, hospital services and the rest, and bring them together. That is something in which the new proposals appear to be deficient.

Community health councils are able to challenge local management; sometimes they challenge national politicians. And they do so in public. As the noble Baroness, Lady Cumberlege, said, that can be uncomfortable for those being challenged. But it is crucial and central to the whole nature of democracy. And if sometimes they embarrass or are seen to be running campaigns, that is all to the good.

I have examples of some of the reports produced by my local community health council, Burnley, Pendle and Rossendale. One is a report on Choices in Maternity Care for Women. It was produced on the basis of finding out what those in the community, particularly mothers, wanted. A report the previous year had been on the subject of Team Midwifery. A recent report dealt with cardiology services for Burnley, Pendle and Rossendale, which has some of the highest incidence of heart disease in the country.

Those reports are not untypical but probably unique as a selection of what a specific community health council does. That is the nature of the beast. The problem is that the role of community health councils is in many ways a political role; not a party political role; not a capital "P" political role. That is what managers in the health service are often less than comfortable with.

A good friend of mine, a chief executive of a community health council in the West Midlands, asked me to put this question: do we really think that any of the proposed successor bodies will act as advocate for a public view that is known to be highly unpopular with the powers that be? That is the crunch of this debate.

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A government that tries to abolish CHCs will find that the councils have a great deal of hidden support in the community and they will find it politically difficult. If they are sensible, they will listen to what noble Lords are saying tonight and reconsider their plans.

8.32 p.m.

Baroness Ashton of Upholland: My Lords, I too am grateful to my noble friend Lord Harris of Haringey for raising this issue and pay tribute to his work with community health councils.

Noble Lords may recall that I am chairman of a health authority and have just completed consultations on primary care trusts, a mental health and learning disability trust and the merger of two health authorities. All that has been done with the support of the community health councils across Hertfordshire and I nominated my own community health council for a public involvement award. I trust that it found dealing with me as character-building an experience as I found dealing with its members.

Like many colleagues in the health service, I was sorry that the demise of community health councils was heralded in the NHS plan document. I say that not because I am a huge fan of the present structure of community health councils, but because I am a huge fan of those who spend many thousands of hours volunteering in their local communities and I worry about any messages that might lower their morale.

There is a real need to overhaul the way in which the health service interacts with its patients, carers and its local community. That is especially true at a time when the drivers for change in health demand a radical rethink of our structures, resources and our pathways of care. I support the need for radical change. But I am also conscious of the need to preserve what works and, more importantly, to understand why it works.

Independence, real and perceived, is what gives any structure in any area credibility. Those who go to advocates must believe that they will receive impartial, confidential advice and support. And we need to retain that first and foremost in any patient advocacy and liaison service. We also need to consider what gives the patient the reassurance of independence.

For example, as many noble Lords said, while there is a need to look at a service being on site at hospitals, we need to be careful that "on site" does not mean taking away their independence. Those offering support and advice will need to be seen to be separate and impartial, especially when advising whether or not to pursue a complaint. It is easy to see that some patients would prefer the site to be away from the hospital which provided their care.

How organisations are funded is often the big give away when deciding on impartiality. As with other advocacy services, funding has to be separately provided and distributed without reference to the NHS organisations locally, and it must be ring-fenced. The service needs a formal and national structure, capable of lobbying on its own behalf for more resources or changes in its role. It needs clear

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mechanisms to ensure that information it provides about service care is fed not just to the local organisations but also nationally to identify patterns and areas for attention.

I believe--and this is where, in my experience, community health councils have faced the greatest challenge--that perceptions of independence need to go hand in hand with the importance of representation. I cannot speak for other community health councils, but I know those with whom I am most closely associated have found it difficult to attract younger members and members from ethnic minorities. It is important that, where we give a leading role to lay organisations, we ensure that they are able to represent and obtain the views of their communities.

My final point concerns local government. The relationship between local government and health is in a very important phase. As a strong advocate of joined-up thinking, I am extremely hopeful that the partnerships we have in place between social care and healthcare, and education and health will offer real benefit to our clients. I have no difficulty in responding to local government and discussing plans with them, in fact I do so regularly. But I am concerned about how we will make sure that the views of local government on strategic healthcare changes are truly independent and do not reflect the political persuasion of any local authority.

In Hertfordshire we have differing political views, and that is just among the labour councils. Some councils are opposed to fundholding; some now oppose primary care trusts. We need to ensure that at least we do not lose time, if nothing else, because we are caught up in a party political debate prior to an election. That point needs serious attention. Suffice to say, whatever system we put in place must be at least as good as the system we had previously and must pay tribute to those who have worked so hard in community health councils.

8.37 p.m.

Lord Clement-Jones: My Lords, as someone who has not sat on a CHC, I can say that we have had some notably well-informed speeches tonight. It was interesting that even those who are not wholly opposed to the Government's proposals would probably need to reinvent CHCs in order to put into effect their own proposals.

The fact is that after 26 years of useful life, community health councils could have expected rather more consideration from a Labour government, many of whose members, like the noble Lord, Lord Harris, have links with them. We heard that from many noble Lords on the Benches opposite. Also we must thank the noble Lord, Lord Harris, for raising an extremely important issue.

The reference to abolition of CHCs is almost an afterthought in the "Changes for Patients" chapter of the national plan. It is not difficult to unpick the proposals. The scrutiny role goes to local government, but there will be a potential conflict of interest with the increasing integration of health and social services.

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There is also the question of how their boundaries will fit with hospital trusts. The consultation role goes to the patients' forums, but will be dependent on the good will of the hospital trust. How well will they be supported in terms of resources?

The advocacy role will go to patients' advocacy and liaison services, but they will not be independent. The complaints role will probably go to CABs, but how will they develop the specialist expertise? All that will take place without any indication in the national plan of the resources to be allocated or the training to be given in the new roles.

The Government's proposals generated considerable heat within my party, and were described as "fragmented" and "ill-conceived" at our recent conference in Bournemouth. The truth is that we need to integrate the various roles, not fragment them. For example, complaints help to inform scrutiny and consultation. There may well be patterns of behaviour in complaints. To discern patterns, there needs to be overview by a single local body. It is rather ironic that the national plan talks about patient empowerment and then proceeds to abolish CHCs.

Of course, community health councils are sometimes awkward customers, but that is their merit. Independence is their key asset, as the noble Lord, Lord Harris, pointed out, especially in making complaints. They are not part of the medical establishment. No reasoned case has been made out for abolition; it is simply tagged on to the end of a chapter of the national plan. It would be better to look at some of the proposals put forward by the commission on the NHS chaired by Will Hutton in its report, New Life for Health, which we debated--thanks again to the noble Lord, Lord Harris--in June. It did not deny that CHCs had their problems. There is no legal indemnity for its members and no adequate definition of the variations in health services which entitle them to be consulted. There are differences in availability and commitment of their members, variable standards and unlimited statutory rights as health services have changed, particularly in primary care and community services.

At the end of the day, however, the commission said that there needs to be more accountability in the NHS, not less. It suggested greater powers for CHCs, not their abolition. On Tuesday, the Secretary of State said that people have long argued that there is a democratic deficit at the heart of the NHS. That is perfectly true, but we on these Benches do not believe that abolishing the one body which currently carries out independent scrutiny is the way to cure the deficit. I prefer what his predecessor, Mr Dobson, said in 1998:

    "I look to CHCs to continue to play a role in ensuring that patient and public views are known to the NHS decision makers both nationally and locally".

I wonder which of those quotations the Minister prefers.

We should follow the example of the Welsh Assembly in seeking not to abolish CHCs but to make them more effective. The answer is not abolition; we need to ensure that they have adequate powers and

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resources. At the end of the day, the abolition of the CHCs will require primary legislation. It will have to be very different from the proposals in the national plan if it is to receive support from these Benches.

8.41 p.m.

Earl Howe: My Lords, I should like first to express my thanks to the noble Lord, Lord Harris, for initiating this debate. I hope he will share my perception that the concerns that he has so clearly expressed are widely held both inside and outside the NHS. However, in many respects, the NHS plan is a document full of plans and aspirations with which we can all readily agree. If I had to single out the section which gives me the greatest personal grief it is that which announced the new patient advocacy service.

Community health councils have been with us for 26 years. Depending on where you go around the country, you hear different opinions of the job they do. In some areas, the CHC is not regarded as being particularly effective. In others, such as the one near my home in the Chilterns, for example, they are highly thought of and seen as performing a useful role. But even if the way that CHCs have worked has been variable, one thing is agreed upon by everyone; the concept of CHCs is sound. A watchdog for patients keeps the NHS on its toes. And if it is to mean anything, such an organisation must be independent of the NHS and able to exercise the legal right to be heard and consulted. Without those features it will not command the confidence of the public.

Of course it would be odd if, after 26 years, we could not identify any scope for changing or improving CHCs but what we certainly should not do is scrap them without being sure that the arrangements we put in their place retain the features of CHCs which we all value. At this stage I suspect that I am not alone in not knowing exactly how the proposed new structures will function and interact with each other.

What strikes you immediately when you read the NHS plan is that the functions of CHCs are to be divided up between a number of different bodies. That fragmentation is bound to mean that no single body will be able to take an overview of the broader patterns which emerge from individual complaints or from problems which come to light in the provision of services. Still less will it be possible to do what the ACHCHW does so valuably at the moment in looking at failures in the system from a national perspective and feeding its views to government. From the point of view of an individual patient, it may often mean having to seek help from a number of different bodies instead of just one. That does not seem the way to achieve greater patient empowerment. Empowerment of patients depends ultimately on rights enshrined in law. At the moment, CHCs have the right to be consulted, the right to require information from health authorities, the right to inspect and report on hospital facilities and others, and the right to refer contested plans to the Secretary of State for Health. Those rights are valuable levers. It is all very well the NHS plan stating that patients' forums and independent

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advisory forums will act as "sounding boards" but what does that really amount to? It looks to me like a dilution of rights, not a strengthening of rights.

On an individual patient level, the role of an advocate presupposes a degree of genuine detachment from the organisation being criticised. I do not believe that if PALS are employed by the trusts and situated on hospital premises patients will view them as truly independent. Advocates worthy of the name must be free of any conflicts of interest, either real of perceived. They have to be in a position to take the initiative in providing support and advice and to do battle on behalf of the patient. Again, PALS seem to be a step down from present arrangements.

I refrain from attributing any motives to Ministers for the changes they have announced. I simply say to the Minister, with considerable regret, that I believe these proposals to be a mistake. I hope that the Government will find it possible to think again.

8.46 p.m.

Lord Hunt of Kings Heath: My Lords, first, I thank my noble friend Lord Harris for having raised the issue and instituted an interesting debate. He led the Association of Community Health Councils with great distinction for a number of years. I have always enjoyed listening to his views about the future of patient representation and public involvement in the NHS. As the noble Baroness, Lady Cumberlege, suggested, in early 1975 I was one of the first CHC secretaries to be appointed and I found the experience extraordinarily valuable. It certainly gave me enormous insights into a wide area of NHS endeavour.

There is no doubt that back in 1974 they were a radical step for the NHS. Never before had the NHS been required to take account of patients' views in a systematic way. There is no doubt that we owe much to the sterling work of CHC staff and members over the years. I acknowledge, as much as my noble friends Lord Rea and Lady Ashton, the noble Earl, Lord Howe, and the noble Lord, Lord Greaves, the many achievements of CHCs since their establishment in 1974-75. The noble Lord, Lord Greaves, mentioned work in relation to maternity services. I well remember conducting a survey on those services in Edgware/Hendon in the mid-1970s and I believe that it had a real impact in changing the views of the people running them .

Therefore, there is no doubt that we can find excellent examples of work which CHCs have done and continue to do. Nor should we deny that there are examples where CHCs have not done so well. We have heard about the variable performance and my noble friend Lord Harris has acknowledged the strengths and weaknesses of CHCs. If I were to make a judgment about their achievements over 25 years, I do not believe that they have made a sufficient impact on the way in which the health service operates in terms of being sensitive to the needs of patients and the public.

That is why, in the context of our radical reforms of the NHS, as in the NHS plan, we have decided against reforming the existing system and have seized this

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opportunity to build a new system of patient representation and involvement. My noble friend Lord Harris referred to something completely unknown to me; that is, Richmond House freakery. That is not, as some have suggested, about getting rid of irritating CHCs which are causing problems to grey-suited managers in the NHS. Frankly, I could not stand here before your Lordships if that were the case. The fact is that our proposals are designed to do better than we have achieved in the past 25 years. I readily accept that that is the test we face in putting forward these proposals.

I also accept the challenge of my noble friend Lady Pitkeathley to do better. I believe that we can do better both nationally and locally. At national level we have made it clear that one third of the members of the NHS modernisation board, which will help us drive through changes in the NHS, will be representatives of patient groups and frontline staff. At national level we shall ensure that, for the first time, the Commission for Health Improvement and the National Institute for Clinical Excellence, which have such crucial roles to play in the high quality service that we need to offer in future, have patient representation. So it is at local level. I believe that the combined effect of PALS, the forums which will be present in every trust and the local authority scrutiny role will be to provide a much stronger voice for the public and patients than at present, and that is how we wish the proposals to be judged.

My noble friend Lord Harris rightly said that I am a very strong advocate of PALS. I have seen the system operate in the US and have been very impressed by the ability of patients to have direct and immediate access to people who can act on their behalf and deal with problems there and then, not via a system that takes time to operate and goes through many procedures. At present, if an NHS patient is unhappy with the service he or she receives, whether it relates to food or facilities, or the patient does not understand what is happening, or there are issues to do with the provision of clinical services, it is not clear whom the patient can approach for help and advice. We know that many patients simply suffer in silence. Some feel so strongly that they complain but often only after the event, in which case the opportunity to address the situation as it arises is lost.

The whole point of PALS is that in future patients and their carers will be able to contact the service based in each trust. From my experience of the practice in the US, those members who are part of PALS will have direct access to the chief executive, with power to negotiate immediate solutions, where appropriate. They will also be able to put the patient and his or her carers in touch with other bodies that may be able to help, such as patient support groups or, as has already been mentioned, CABs, for assistance with formal complaints.

My noble friend Lady Ashton and the noble Lord, Lord Clement-Jones, referred to the independence of PALS. I well recognise the issues that that raises. Our aim in developing PALS is to ensure that services respond and change to meet the needs of patients. We

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are convinced that to achieve that PALS will need to be based in trusts and have the necessary clout to achieve change. I assure noble Lords that currently we are consulting patient groups and CHCs and drawing on the experience of trusts which already operate a scheme of this kind before we decide by whom the PALS should be employed. We are also consulting on the extent of its remit, and, in answer to the noble Baroness, Lady Cumberlege, when it may be appropriate for PALS to refer people to other sources of advice and support. I assure the House that our decision will be based on what is best for patients.

Alongside PALS we propose that every trust, including those involved in primary care, should have a patients' forum made up of patients and their representatives who will have power to visit premises to check on standards. That forum will elect one of its number to be a non-executive director on the board of the trust. I believe that that will put patients and their needs at the heart of decision making.

The third leg of our proposals relates to the role of local authorities. We propose that major planning decisions will be scrutinised by local authority all-party scrutiny committees, with power to refer those decisions to the new independent reconfiguration panel which will review and advise the Secretary of State on contested decisions. I believe that that is one of the most important proposals that we have put forward. I agree that since 1948 the democratic deficit has always been a problem in the NHS within the context of a national service. This system enables democratically elected local government to play a strong role in future decisions relating to the NHS, and I believe that that is to be warmly welcomed. It will strengthen the process and the connection between the health service and local people. The suggestion of the noble Baroness, Lady Cumberlege, about a code of conduct is an interesting one. I can assure the noble Baroness that as we take forward these ideas we shall have discussions with the Local Government Association.

I was asked about funding by my noble friend Lady Ashton. We propose total funding of about £33 million per annum. A further £10 million of new money has been set aside to contribute to the new arrangements, alongside the budget of £23 million which will be freed up when community health councils are abolished. The noble Baroness, Lady Cumberlege, asked me about affirmative and negative orders. That is a matter for primary legislation which will be debated in your Lordships' House in due course.

I believe that I have answered the question about primary care. The system relates as much to primary care as to other parts of the service. I also agree with the noble Baroness, Lady Barker, about national standards. That matter will be discussed with interested parties in the next few weeks.

I accept that issues to do with the definition of "advocates" need to be carefully considered. We do not intend that PALS should replace existing advocacy services. The incredibly valuable advocacy services which are now available need to continue and be supported. We want to draw on expertise within the

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existing CHC community. During the next few weeks we shall hold stakeholder meetings to discuss issues with, and hear contributions from, CHCs, voluntary organisations and patient groups.

Both the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, suggested that we are making these changes because CHCs are awkward customers or they keep the NHS on its toes. That is not the reason. We believe that the proposals will lead to a much more effective system in which patients and the public have a bigger say in what is happening to their health service. Problems will be dealt with as they arise when people are either in hospital or are receiving primary and community care services.

When we first talked to NHS managers who believed that CHCs might be abolished they might have been tempted to throw their hats in the air. However, when we explained the impact that PALS, local scrutiny committees and forums in trust would have the smile quickly disappeared from their faces. They recognise that what we put forward is a much more powerful and effective system of patient and public representation than we have now. In so doing, we wish to draw on the enormous contributions which CHCs have made so far; and many people who are now involved in CHCs will be extremely valuable in the context of some of the services which will replace them.

This has been a most interesting debate. I am sure that when legislation in this area comes before your Lordships' House--we do not know when--we shall spend many more hours debating these issues.

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