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The Earl of Listowel: I support the amendments of the noble Baroness, Lady Cumberlege. Speaking as a volunteer, I decry the way in which the community health councils--which are mostly staffed by volunteers--seem to have been treated by the Government. The perception is that they have been abruptly discarded without consultation or consideration. I have other reasons for supporting the amendments, which I shall come to as we proceed. At this point, I simply state that involving community health councils in the new arrangements--for instance, giving them charge of the independent advocacy service--would be a good way to recognise the work of volunteers and staff in the past. I support the noble Baroness's amendment.

5.15 p.m.

Lord Hunt of Kings Heath: This has been taken as a debate on the principle surrounding the abolition of community health councils and the arrangements that we seek to put in place to provide an enhanced mechanism for public involvement and representation in the National Health Service.

My noble friend referred to my background in community health councils when they started back in 1974-75. It was an exciting time because the NHS was not used to the concept of user or patient involvement. My noble friend is right. Some of the community

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health services which were previously run by democratic local government were brought over for the National Health Service to run. Certainly my experience in those first two years was quite exciting in terms of developing this new concept, of seeing the impact that it had on the culture of the NHS--community health councils were quite a culture shock for the health service--and, importantly from my point of view, of encouraging the NHS to think rather more than it ever had before about how the delivery of its services impacted on individual members of the public.

I have no hesitation in saying that the work of CHCs over those 27 years has been positive; that people have been helped; and that the NHS has been encouraged to start to look at changing its culture. But, at the end of the day, can we absolutely say, in 2001, that the NHS is sufficiently patient and public orientated? Can we really say that it is a health service which really deals with issues and complaints as immediately as it ought? The record is that we still face many issues and challenges in attempting to make the NHS as user and public friendly as possible.

I fully accept that there is a choice. Is it better to reform and change CHCs--I certainly pay tribute to my noble friend for the work that he did at the ACHCEW in establishing a fundamental review of CHCs--or is it better to produce a new and better system of patient involvement and representation? The decision that the Government have quite clearly made is that we want to start to build a new system.

The noble Lord, Lord Peyton, asked what CHCs had done wrong. Had they been too inconvenient to Ministers? No, that is not the purpose of the changes. We are making the changes because we believe that what will come through will be a much more powerful public involvement in the National Health Service and that the National Health Service itself will have many more incentives to change and improve the way in which it delivers services to the public. That is the test on which these proposals should be based.

If we go back to the NHS Plan and the widespread public consultation that we held, there is no doubt that we had a lot of comments coming back saying that the NHS was poor at dealing with complaints on the spot; that people did want the option of independent advocacy to support patients wishing to make formal complaints against the NHS; and that they did want to have an input and influence over local decisions about NHS services. It is my contention that the proposals we are putting before the Committee will enable us to do that more effectively than community health councils.

I suspect that Mrs Archibald will be with us for quite some time today. I do not believe that it is possible to say that under the current arrangements Mrs Archibald would be well served. Surely it is a reflection of the problem of getting the NHS sufficiently user conscious and involved that the noble Baroness was able to raise this example. I agree that the new arrangements need to be able to deal with the

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kind of issues that Mrs Archibald faces; I believe that they will do so in the first place when it comes to patient advocacy and liaison services.

This is an exciting proposal: a new, trust-based, front-of-house customer service for patients and their families. I came across this kind of service in the US some 15 years ago. There are compelling reasons why we need it in the NHS as soon as possible. The record of the NHS is that very often people come into hospital or into our community health services and find that there are problems. However, they feel inhibited from raising them or they raise them only through a formal complaint some weeks later. If we had a mechanism which enabled us to deal with those kinds of issues on the spot as they arise, surely we would have a much more effective healthcare system. That is what PALS is all about and why we are implementing PALS from April this year, starting with the major hospitals and rolling out the service during the year to cover all NHS and primary care trusts. It will be a new core service for trusts. It will guide people through the system, provide information about the services of the trust, and help to resolve problems as they happen rather than after the event.

As part of that service, PALS staff will have direct access to the chief executive of a trust, with the ability to facilitate the swift resolution of problems. I cannot stress too strongly the importance of that. The people who are charged with trying to sort out problems as they arise will have access to the top management of an organisation.

But it will not always be appropriate for PALS to be the body that deals with patient complaints. Clearly, some people--perhaps after dealing with PALS, and others who may not wish to use PALS at all--will feel much more comfortable with independent help. That takes us to Clause 17, which places a new duty on the Secretary of State to arrange the provision of independent advocacy.

We have not been prescriptive about who should provide that advocacy. We want as much flexibility as possible, and we want to build on many of the excellent advocacy arrangements that already exist throughout the country. What is not in doubt is our assurance that this will be an effective, independent service, and one that will be able to deal with the different issues raised by Mrs Archibald.

At trust level, we are also setting up patients' forums. They will be the local route into the decision-making processes for patients and the public. They will be made up of patients, carers and representative organisations through a process that will be agreed by the independent NHS Appointments Commission. In addition, these patient forums will be able to appoint a member to the trust board to which they relate. That will give a voice to patients at the top level of their local national health service.

Again, I make the point that patient forums will be independent. They will be responsible for monitoring and reviewing the services to which they relate. They will also have a duty to seek the views of patients and carers in their area and will report them to the local

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NHS trusts. They will be able to make recommendations to NHS bodies about services, basing these on an inspection of services that they have conducted and what they have heard from people who use those services.

The noble Lord, Lord Clement-Jones, accused me of wanting to proliferate patient forums. But surely this is the whole benefit: for every NHS trust there will be a patient forum which will be able to bring the concerns of patients to the attention of senior managers and the trust board. Because those forums are basing themselves on the services of a particular trust, they will be able to focus very much on the concerns of patients using those services. That will be a great advance. It will enable forums to exercise a great deal of influence over the NHS.

In addition, another key role of the forum will be to report on how the NHS is fulfilling its duty under Clause 11, dealing with arrangements for consultation and the involvement of patients, their carers and representative organisations in the decisions that the NHS makes and in proposals for changes in the way in which services are provided.

I understand and hear the concern that because patients' forums will relate to each individual trust they might become isolated and might not relate to patients' experience across the range of local health services. I certainly accept that there is a need to co-ordinate the work of patients' forums to ensure that they take what might be described in the jargon as a "whole systems" view of services for patients.

That is why we accepted an amendment on patients' councils in another place. These are made up of members from each of the local patients' forums. The council will make reports to the health authority, to trusts, to the local authorities and to their overview scrutiny committees. Their role will help the forums to co-ordinate their work, to share experience and to consider the views of patients across the range of services. They could even provide independent advocacy services and will certainly be consulted on the best arrangements for providing independent advocacy in their local area. To make all this work in a co-ordinated way, the patients' council will share a secretariat with local patients' forums, strengthening their links.

This is a real and useful role for patients' councils. However, I do not believe that it supersedes the role of the patient forum. We see the patients' forum as having the crucial relationship, bringing the NHS and patients together. The patients' council will necessarily have a more distant relationship. It will deal with many trusts and will take an interest particularly in the health authority's strategic decision-making process.

That is why I do not find myself in sympathy with amendments which seek to make the patients' council the pre-eminent body for representing patients, with the forums as sub-committees. I believe that it is much better that the key body in all these arrangements at local level is that of the forums, which are very much based at the patient care level. The patients' council

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can pull together views and can co-ordinate the forums, but the forums themselves should be the key building blocks.

The noble Lord, Lord Peyton, asked me to discuss overview and scrutiny committees, and we shall debate amendments on the subject in due course. They provide another piece of the jigsaw. It has always been a criticism of the NHS that at local level it has had what has sometimes been described as a democratic deficit. It is often proposed, particularly by local authorities, that the NHS should be run by them so that decisions may be made through the ballot box, legitimised by local councils.

Governments of both parties have always rejected that proposal because of the essential national nature of the National Health Service. But there is no doubt that local government has an important role to play, both in putting forward views about the health service and in ensuring good co-operation between the NHS and local government.

The overview and scrutiny committees will be committees of the principal local authority in an area. They are consistent with what is happening in local government generally in the establishment of such committees to monitor the normal local authority provision. I believe that they will be very powerful in ensuring that what happens in the NHS is very much open to public scrutiny and examination by local authority councillors. If one were looking for an example of where the proposals we are placing before the House are much more powerful than those that currently exist, that is surely it.

The test of all these proposals is whether, at the end of the day, there will be more effective patient and user representation within the NHS at local level. I have no hesitation in believing that the answer to that is yes.

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