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Baroness Pitkeathley: There is one thing of which there can be no doubt and that is this Government's complete commitment to the absolute necessity of putting patients and their families absolutely at the centre of the NHS. We have ample evidence of that in the setting up of the Commission for Patient and Public Involvement in Health, the other arrangements and, indeed, the huge consultation exercise which is going on at the moment in the Department of Health about patient and public involvement. The governance arrangements for foundation trusts offer the opportunity to further this issue. There can be absolutely no question of a withering away as the whole issue of patient and public involvement has now gained such momentum that no provider of health services can ignore it. The absence of specific duties for patients forums within the foundation trust structure is an anomaly. I very much hope that the Minister will be able to reassure us about the Government's continued commitment to ensuring the maximum patient and public involvement in foundation trusts as throughout the rest of the health service.

Baroness Finlay of Llandaff: I should have liked to add my name to these amendments but due to a clerical oversight on my part I did not. Of course the Government have tried to put the needs of patients and their families at the heart of things. Like the noble Baroness, Lady Pitkeathley, who has just spoken, I view this matter as an oversight. I am flabbergasted that these amendments were not incorporated in the Bill before it reached us.

I have a major concern regarding patients who are extremely ill. They will be in-patients in the foundation hospitals. They are quite different from the medically well who will constitute the public who will be consulted and may join a board of governors. They are very different from the medically slightly unwell who will probably express opinions out in the community. When patients are very ill, no one should underestimate how vulnerable they are and how difficult it is for them to express concern or dissatisfaction with any aspect of their care. Attention to detail is absolutely crucial in improving the quality of care that they receive. Without a patients forum right at the heart of the provider who is providing services for these very ill people, I fear that their vulnerability could be overlooked and that they could be subject to a paternalistic and, dare I say, even arrogant approach by the management of a foundation trust who, for whatever benevolent reason, believe that they know best what is right for those patients and do not give them a forum in which to express themselves. I find it astounding that we do not establish a patients forum right at the heart of this measure. I urge the Minister to look very seriously at the proposals before us.

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Baroness Carnegy of Lour: Once again the noble Baroness, Lady Finlay, has reminded us what it feels like to be inside a hospital. We in this House find it easy to conceive how the public will view these hospitals. We can imagine how the members of a trust will view the hospital. We can imagine how they will feel about the board of governors and so on.

In hospitals, where there are vulnerable people—and almost all patients will be vulnerable, especially long-term patients—there must be some mechanism. Most of us who visit people in hospitals have seen the problems there and how difficult it is for families and patients to express their complaints. For example, people may want to complain about the way in which they are fed—about whether it is ensured that they can get the nourishment that they need and reach the cup of tea that has been served up. There are all those small things that people find it very difficult to complain about, on which a person's life may depend.

I hope that the Minister does not simply tell us how the governors will be able to deal with those important matters. I cannot see how a trust can operate properly without a mechanism to deal with them.

Lord Hunt of Kings Heath: I agree with my noble friend Lady Pitkeathley. I am disappointed by some comments made by noble Lords on the matter, because they display a lack of trust in the leadership of foundation trusts in ensuring that there will be proper and effective patient involvement in their activities. I hope that we shall not be prescriptive and that we will allow each foundation trust to make its own arrangements.

I simply ask noble Lords to consider the consultation documents issued by applicant foundation trusts in the first wave. What is so impressive about that documentation is how much effort and focus has been devoted to the arrangements that they want to make to ensure that public and patients are involved and can make their views known. It is very unlikely that any future foundation trust will want to go forward without having robust patient involvement arrangements. I hope that we shall show some trust in those organisations to make their own arrangements, subject to the overriding considerations in the Bill.

I agree with the noble Lord, Lord Clement-Jones, in his reference to the distinction between patient representation and the work of governing bodies. It is very important that the two are kept distinct. Governing bodies are not there to carry out the role of patients forums or organisations like them. I am worried that a number of foundation trusts are referring to the governing bodies as patient councils. They are not patient councils or members' councils but governing bodies. It is very important to keep that distinction.

1.15 p.m.

Lord Warner: The architecture that we have constructed is not quite as shaky as the noble Lord,

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Lord Clement-Jones suggested. I am grateful for the points made by my noble friends Lord Hunt and Lady Pitkeathley.

The Government totally accept the need for independent patient involvement. Patients need to be satisfied that their interests are considered at all stages of patient care. However, independent scrutiny and monitoring of NHS foundation trusts will be carried out by PCT patients forums and overview and scrutiny committees of local authorities. Advice about patient and public involvement will be provided to them by the Commission for Public and Patient Involvement in Health. That is the context in which we are discussing the matter.

PCT patients forums will carry out a range of roles with respect to NHS foundation trusts, including monitoring and reviewing services commissioned by the PCT; monitoring how successful NHS foundation trusts are at achieving involvement, including some capacity for inspection; advising NHS foundation trusts on the range and operation of services that they provide, and on encouraging involvement; representing the views of members of the public; and being able to refer relevant matters to relevant bodies—for example, the independent regulator or the overview and scrutiny committee. Those bodies will be engaged in the work of NHS foundation trusts.

Individual NHS foundation trusts may decide to put in place arrangements reflecting many of the functions of patients forums, if they believe that such arrangements are a helpful way in which to discharge their accountability and ensure patient-led monitoring mechanisms. There is nothing in the Bill to prevent trusts from going down that path in the application that they make for foundation trust status.

PCT patients forums will also promote the involvement of members of the public in consultations, decisions and policy development by NHS foundation trusts, and advise on encouraging involvement and on compliance with their Section 11 duties. As I said, they will carry out other roles, too. There is extensive provision for patient involvement in the new world opening up with NHS foundation trusts.

However, I recognise that there are strong feelings and concerns about the issue across the House, and I am prepared to give an assurance that we will consider the issue further. More specifically, we shall certainly consider whether we can give more reassurance to Members of this House and those outside who feel so strongly, by requiring NHS foundation trusts initially to have a patients forum, while retaining the discretion to disband them if, subsequently, they seem unnecessary, given the other arrangements in place locally that I have outlined. We should not dismiss the present architecture quite as quickly as many noble Lords have done, but I am happy to give the assurance that we will carefully consider an alternative to provide

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more comfort for patient interests, and to show that we are really serious about patient involvement on the providers' side.

Baroness Carnegy of Lour: I wonder whether that is the right answer. It is the sort of answer that the Government are inclined to give—that we shall have a temporary arrangement and see what is necessary. It sounds all right, but if one was setting up a foundation trust it would be particularly irritating to have a temporary arrangement and then to have to think of something else.

Would it not be better to put into the Bill a provision that foundation trusts have a duty to have some arrangement for patient consultation? We should change the Bill, leaving foundation trusts to make the arrangement they want. Would that not be a better answer? I do not know what my noble friend Lady Cumberlege or the Liberal Democrats think about that, but it strikes me that that would be a better response from the Government.

Lord Clement-Jones: I welcome some of the Minister's words but, like the noble Baroness, Lady Carnegy, I have my doubts about the rather tentative way in which the Minister rounded off his response. We had a firm, hard assurance from the Government, but then we find that the actual words are very flabby when written down on paper. That is the problem with the measure on these Benches, and, I suspect, on the Conservative Benches as well.

Like the noble Baroness, Lady Finlay—although I am rarely flabbergasted by what the Government do—I am mildly surprised by the fact that they have not included the sort of provision that we have suggested. I should have thought that a way of creating a more acceptable context in creating foundation trusts would have been to bolt them into the patients forum structure.

The noble Lord, Lord Hunt, more or less alleged that we have a lack of trust in trusts. Of course, one can turn on the moral imperative in these circumstances, but it is not that we have a lack of trust in trusts. People tend to do what they are obliged to do, and it always creates a problem if there is an optional extra for which they have to find money out of existing budgets. One sees that in social care and, no doubt, if the amendment is not passed, we shall see it in health care as well. After all, the staffing costs and other costs of patients forums are met in existing NHS trusts through the Commission for Patient and Public Involvement in Health. That will not be the case for foundation trusts.

The noble Lord, Lord Warner, says that he totally accepts the need for patient and public involvement, but everything becomes conditional after that. He says, "If the trust believes", "There is nothing to stop them", and so on. There is no requirement. The PCT patients forum is of course a very different animal, as I explored in my opening remarks. Above all, there is no requirement on the foundation trust to respond to anything that a PCT patients forum says to it. The Government have deliberately omitted amending that

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provision in the 2002 Act. None of this is accidental or co-incidental. It is all utterly deliberate, which is depressing.

When the Minister talks about an alternative, I hope that he is going to consider seriously the alternative contained in the amendment, otherwise I assure him that the issue will come thundering back on Report. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 202 and 203 not moved.]

[Amendment No. 204 had been withdrawn from the Marshalled List.]

Clause 31 agreed to.

Clauses 32 to 34 agreed to.

Schedule 4 agreed to.

Clauses 35 to 37 agreed to.

Schedule 5 [Audit of accounts of NHS foundation trusts]:


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