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Baroness Cumberlege: We could have a ding-dong on this matter. It is true that the previous government phased awards, but the Labour government before them were alone in failing to honour nurses' awards. If the framework is already set by the pay review body and Whitley councils, what will happen to the Whitley councils in future? The previous government introduced local pay which provides the flexibilities about which the Minister speaks. I believe that this clause usurps the agreed framework of the pay review bodies and the Whitley councils and substitutes the Secretary of State. As to that, there are real reservations on this side of the Committee. Secretaries of State come and go. It is right that National Health

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Service staff should know where they stand. They should be aware of the framework and have an input into it, as they do now.

Lord Hunt of Kings Heath: The discussions with staff organisations and employers have shown great support for the direction in which we are proceeding. I believe that nothing I have said could undermine the role of pay review bodies. They are independent bodies which make recommendations to the Secretary of State. If we want a modern pay system, the real problem is that there are different groups of staff with different terms and conditions at local level. That is inflexible and sometimes it is very difficult to enable staff to cross professional barriers. The NHS Plan is very keen, rightly so, to try to break down some of the professional barriers. Job evaluation is a very important component in trying to break down those barriers so that there is greater consistency of approach between different staff groups. That will not work unless there is confidence that when agreement is reached at national level it will be implemented at local level. But the whole purpose of an area like job evaluation is to allow for local flexibility, and that is why the power would be used only when it was needed. As always, we wish to ensure that there is as much local freedom as possible.

Earl Howe: I thank the Minister for his comments. I am also grateful to my noble friends Lord Peyton and Lady Cumberlege whose remarks are, as ever, 100 per cent apposite. Despite the Minister's reasonable tone, there are lingering worries about the clause. The noble Lord spoke about the setting up of a national framework to facilitate hybrid contracts of employment. I cannot help but believe that, at the end of the day, the local flexibilities which remain will be a good deal narrower than those that obtain at present, which is a pity.

I should like to put one further question to the Minister, who apparently seeks to respond in any case. I may have an unworthy suspicion. Can the Minister tell the Committee whether the clause is perhaps a Trojan horse? Is it seen by Ministers as a means by which a consultant contract could be imposed unilaterally by the Government?

Lord Hunt of Kings Heath: Of course, this clause could be used in relation to the employment of doctors. But I assure the noble Earl that the current situation causes real problems for local employers in securing the flexibility they want. Even with the so-called freedoms on local pay, which they have very great difficulty in implementing, the health service is hidebound by years of tradition and national agreements, all of which produce different terms and conditions for different groups of staff. If at national level we can sort out a good deal of that, we can provide greater flexibility at local level and ensure that as between employers and different staff groups there is more effective team working because of greater consistency of approach.

Clause 6 agreed to.

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Lord Clement-Jones moved Amendment No. 36:

    After Clause 6, insert the following new clause--

(1) The Secretary of State shall make regulations providing, in relation to Community Health Councils ("Councils") in England, for--
(a) the delivery by Councils of support and advocacy services to patients and others with complaints about health services;
(b) Councils to advise and make recommendations to the relevant overview and scrutiny committee, Health Authority and trust about matters arising from complaints;
(c) reports on the operation of the complaints support service to be compiled by Councils and provided to the Secretary of State to the relevant overview and scrutiny committee, Health Authority, trust, and other appropriate organisations;
(d) annual reports to be published by Councils detailing the arrangements maintained in that year for obtaining the views of patients;
(e) the establishment of sub-committees of each Council to be known as Patients' Forums, for each NHS and Primary Care Trust in the district of the Council, made up of representatives of the Council, and co-opted representatives of the local authority overview and scrutiny committee, patients, carers and the wider community, with duties to--
(i) monitor and review the operation of services provided by, or under arrangements made by, the trust to which it relates;
(ii) obtain the views of patients, carers and the wider community about those services and report on those views to the Council and the trust;
(iii) provide advice and make reports and recommendations about matters relating to those services to the Council, the relevant Health Authority, and the trust to which it relates;
(iv) make available to patients, carers and the wider community advice and information about those services;
(v) in the case of primary care services, carry out the functions as may be prescribed by regulations made by the Secretary of State;
(vi) carry out such other functions as may be prescribed by regulations made by the Secretary of State;
(f) the appointment of representatives from the Patients' Forum as non-executive directors to the board of the trust to which the Forum relates;
(g) for functions of Patients' Forums to be performed under joint arrangements between Councils, where such arrangements are appropriate to meet the needs of their communities;
(h) the extension of Councils' rights of inspection to all premises from which services as defined in subsection (3) are provided; and
(i) matters of concern which Councils may refer to the National Institute for Clinical Excellence, the Commission for Health Improvement, the Audit Commission and the Secretary of State.
(2) References in subsection (1) to "services" are references to--
(a) services provided as part of the health service (within the meaning of the 1977 Act) in England;
(b) services provided in England in pursuance of arrangements under regulations under section 31 of the Health Act 1999; and
(c) services provided elsewhere in pursuance of such arrangements with a local authority in England.

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(3) In subsection (2)--
(a) "relevant overview and scrutiny committee", means the committee of the council or councils whose district corresponds, or is included within, the community represented by the Council,
(b) "relevant Health Authority" in subsection (1)(e) in relation to a Patients' Forum for a Primary Care Trust, means the Health Authority whose area is, or includes, the area for which the trust is established.
(4) Before making regulations under this section the Secretary of State shall consult with Councils and such patients' and carers' organisations as he considers appropriate."

The noble Lord said: The Committee moves on to what I believe will be one of the most contentious parts of the Bill. I do not intend to rehearse all the arguments against the current structure set out in the Bill which many of us on all Benches expressed at Second Reading and in other debates in this Chamber. In moving Amendment No. 36, I should like to speak to Amendments Nos. 85, 88, 90 to 95 and 139, but not 136 and 137, which should come later in the Committee's deliberations.

I should like to present a menu of possibilities which the Minister may care to inspect. Both in Committee in the other place and, to some degree, in the run-up to this debate the Government have demonstrated some flexibility in relation to the pattern that they tried to establish in the national plan, which was a hasty concoction. They produced for our inspection a very fragmented plan which effectively disaggregated consultation from advocacy, advocacy from scrutiny, scrutiny from representation, and so on. We were in danger of being left with so many different bodies doing different things that the public would be even more confused than we as politicians might be. A number of these amendments try to bring some of this together.

Various approaches are reflected in the amendments. The first one, which is reflected in Amendments Nos. 36, 85 and, to a degree, 88, is more or less a return to a reformed status quo. The amendments try to indicate that the way forward is to build on the existing CHCs. It is probable that too much water has gone under the bridge for that approach to be the right one to adopt. Nevertheless, in passing many of us believe that that is the approach which the Government should have adopted originally, and if at later stages of the Bill in this House the Government do not demonstrate flexibility, that might be the approach that we would be forced to take, simply because there would not be time to adopt a structure which would build in more of the powers and safeguards that we believe are right. I simply place that on record for the benefit of the Minister.

The second approach is not to be very prescriptive about the way forward. Amendment No. 139 attempts to put together something along those lines. One may say that reform is necessary and the Government should have powers to achieve it. That does not appear to be wholly satisfactory, since obviously Ministers are given far too much discretion on which to build. Nevertheless, it has the benefit of preserving the CHCs

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in a transitional period and would allow the Government to take rather longer over this somewhat hasty set of reforms.

The third approach, which, for the purposes of this Committee, we on these Benches prefer, is to try to pull together and add to the powers of the patients' forums and patients' councils to give them some additional meaningful powers and duties. In particular, I would commend to the Minister Amendment No. 92, which provides for independent advocacy services to be brought into the net of the patients' councils. We believe that it is very important that there should be a clear nexus between the two. That nexus is not sufficiently clear under the terms of the current Bill.

We believe that further, more radical restructuring is required so that the patients' councils, rather than the patients' forums, become the units on which we can build. The patients' forums are in danger of proliferating. If we had a patients' forum for each trust, we would have a large number of patients' forums, which would make it difficult for members of the public to identify who was leading in terms of consultation, representation, etc. We believe that the patients' councils should form the key units, with the patients' forums essentially bolting underneath them.

Amendment No. 94 grants further power to the councils. Amendment No. 97 includes coverage of the complaints system, which we believe is a very important function performed (perhaps non-statutorily) by the CHCs and should be continued by the patients' councils. In passing, we also believe that the complaints system should cover not only acute trusts and other parts of the NHS but also care homes and the independent healthcare sector. We have previously debated that point. However, I believe that the Minister's reaction to it would be of great benefit.

I should emphasise certain key points about these amendments, many though they may be. I think that if the independent advocacy services were pulled under patients' councils, we should have made great progress in this matter. In addition, if the oversight of the new complaints system, however it is shaped, were in the hands of patients' councils, many of us would feel much more sanguine about the scheme that the Government have adopted. I beg to move.

4.30 p.m.

Earl Howe: I rise to speak to my amendments included in this group, namely, Amendments Nos. 85 to 88, 90 to 95 inclusive, 97 and 319.

Those amendments, like those of the noble Lord, Lord Clement-Jones, leapfrog us forward to Clause 13. Perhaps I may begin by saying that, in tabling almost every one of my amendments to this part of the Bill, my main aim was to try to make the structures proposed by the Bill more coherent, less confusing, and generally more joined-up. These amendments to Clause 13 are perhaps the most important in that category. Although at first sight they may seem complicated, they are in fact designed to rationalise and improve the fragmented arrangements that otherwise appear to lie in store for us.

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The Minister knows my strongly-held views on CHCs. There are effective ones and less effective ones. The best are excellent and achieve a very great deal on behalf of patients and the community. Others have not made such an impact. Unless I misrepresent him, I believe that the Minister is of the view that CHCs overall have failed to live up to the promise that they generally enjoyed when they first started in 1974, and that he uses that argument to justify their abolition.

My view is different. I believe that the rational approach would be to consider the powers and functions of CHCs, decide what are their good points and which of them are worth preserving, decide also how they are deficient, and then work towards reforming them.

As currently constituted, CHCs have a great deal going for them. Perhaps their most obvious useful feature is that they are a one-stop shop. They combine the role of watchdog with that of complaints handling. They have the right to be consulted in the planning and operation of services and to make recommendations about those services. They inspect premises, including private sector premises. The best CHCs have established advocacy services as part of their day-to-day functions. Every CHC has the precious privilege of a direct line to the Secretary of State. Above all, they are valued, and hence respected, because they are independent.

I therefore suggest that the extent to which the CHCs have failed to deliver is not the fault of their structure. It has much more to do with the level at which they have been resourced and the fact that their powers are not sufficiently all-embracing. Advocacy has never been a statutory duty of CHCs, but many CHCs have either supported or provided advocacy services. We should try to build on that.

It will not be an easy task to reshape this Bill to give effect to what I have just said. However, I believe that it is possible to take a number of the Bill's provisions as the starting point for effective reform. In so doing, we should aim to deliver both what the Government would like to see, which, I take it, is an enhanced degree of involvement and empowerment for the patients and the public, and what I would like to see, namely, a way of building on the inherent advantages and merits of CHCs, and, in that process, provide better and more effective CHCs. Like the noble Lord, Lord Clement-Jones, I suggest that the way to achieve that is through patients' councils. I believe that CHCs, if reborn as patients' councils, would be a major move in the direction of rationalising the fragmented structures currently proposed by the Bill. That rationalisation would also serve to reconcile what I fear is an otherwise irreconcilable gap between us and the Government. Patients' councils would preserve the existing structures for patient representation and advocacy, except that independent advocacy would become a new core function.

To give effect to this, I have transposed the key elements of Clause 17 to Clause 13, with the notable additional feature that the advocacy role undertaken

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by patients' councils would extend to patients of private hospitals and care homes. Patients' councils would be able to report and make recommendations to NHS bodies, to local authorities and to the Secretary of State, thus facilitating the essential sharing of information. Like CHCs, they would have a statutory right to be consulted by health authorities, and they would have the right to whistle blow.

I suggest that it would make a great deal more sense if patients' forums, instead of being separately constituted bodies, were established as sub-committees of patients' councils. In that way, there would be absolutely no doubt in the public's mind as to the independence of patients' forums, which, rightly or wrongly, I fear may be an issue in the future if the Government proceed. Under my model, there would be no prospect at all of the members of patients' forums feeling isolated or lacking in proper support.

One of the beauties of that approach is continuity. Looking at the Government's proposals, I confess that I am worried about the transitional arrangements that may be put in place, and about the expense of running two systems in tandem, which for a while would doubtless be necessary. The benefit of enabling CHC personnel, with all their expertise, to continue in post would be obvious. As I said at the beginning of my remarks, these amendments may seem daunting. However, I hope that the logic is clear and that the Government will take them in the constructive spirit in which they are offered.

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