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Lord Peyton of Yeovil: I agree with every word said by my noble friend Lady Cumberlege, who served with distinction in the Department of Health and therefore knows far more than I do about this matter. I hope that the Minister will take note of what she said and will perhaps be influenced by it.
We are in a slightly awkward position. I make no criticism of the noble Lord, Lord Clement-Jones, but we are discussing an amendment which suggests that the community health councils should be given extra powers. Later in the Bill, however, community health councils are to be abolished. I should like to ask the Minister two questions. I hope that his answers will be fairly specific. What have community health councils done wrong? I do not include under the heading of "wrong" becoming a thorn in the flesh of Ministers. Ministers frequently deserve and fully earn the painful injection of a thorn in the flesh. I would not object to that. I want to know what the Government hold against community health councils, apart from the fact that they are a source of inconvenience to themselves. What I am driving at is that I do not believe that causing inconvenience to Ministers is necessarily or indeed at all a cardinal sin.
The Bill is in such a muddle that I do not know the correct order in which to take matters. In dealing with the abolition of community health councils, we have left on one side for a moment the question of scrutiny committees. The very thought of scrutiny committees, directed by Ministers, is a source of horror to me. I very much suspect that, like many such committees, they will consist of a mixture of people whose time would probably be better used elsewhere and people with nothing better to do elsewhere who find themselves on yet another committee.
I do not claim the knowledge of my noble friend, but I am chairman of two charitable trusts. As such, I fairly frequently go to hospitals and universities. In both I hear the same lament--that there is too much bureaucracy and too many committees. I do not see in the Bill any remedy to that. Perhaps I may remind the Minister that not long ago I asked a Question. It was a very unfair question. I asked the noble Lord how many committees were sitting under the aegis of the National Health Service. Very reasonably, the noble Lord said that he did not know. No blame is attached to him for that. My Question was the height of optimism. The only thing that could have been slightly worse would have been to ask him to say how many grains of sand there are on a piece of sea shore. Somewhat naturally, the noble Lord gave the very honest answer that he had not the slightest idea. I urged him then to get out his gun and shoot a few of them.
I have two questions. First, why are the Government displeased with community health councils? Secondly, is it the intention--this is my suspicion--that in future scrutiny committees will be asked to fill the role now carried out by community heath councils? I should be grateful for answers to those two questions.
Lord Rea: With this group of amendments and his introduction to them, the noble Lord, Lord Clement-Jones, has given us an opportunity to canter around all the various successor bodies that it is proposed will follow the CHCs. Grouped together, the amendments begin to provide a rational framework as to how they should relate to each other. I hope that my noble friend has given them serious scrutiny.
I very much commend the linking of the functions of the independent advocacy services with the patients' councils so that the councils can learn the lessons that come from patients' complaints to the advocacy services. Similarly, at a lower level, the patients' forums will be able to pick out from the trusts--even perhaps liaising with the PALS--some of the more local complaints and feed them up to the patients' councils themselves. I hope that that will fulfil many of the functions presently undertaken by the CHCs. As we come to later amendments, we shall be able to examine this in more detail. However, I believe that this general framework provides an extremely good start.
Baroness Masham of Ilton: Great concern has been expressed that the patients' forums and councils will not be independent of the health trusts. To feel comfortable, patients or their representatives need to be totally independent, as should the members of any body representing patients. At the moment, CHCs can delay the closure of hospitals rather in the same way that the House of Lords can delay legislation. I should like to ask the Minister this: can the bodies being proposed by the Government delay hospital closures?
I feel that the Government should build on CHCs to make them more effective. Sometimes patients need easy access to help and advice. They need to know where to go without the risk of confusion. I agree with the noble Earl, Lord Howe, that there should be an overall watchdog for all patients, NHS or private.
The Government's proposals here look very fragmented. That is just what patients do not need. We should seek to avoid confusion and fragmentation. Surely, this is something that, with the goodwill of the Minister, we can get right in your Lordships' House.
Lord Harris of Haringey: The noble Earl, Lord Howe, suggested to my noble friend Lord Hunt that the reason why the Government have proposed the abolition of the CHCs is that they had failed to live up to their early promise in 1974. However, I have to say that I am not clear about exactly what was that early
The reality was that CHCs were created as a hotch-potch of powers and responsibilities, none really worked through. Interestingly, a parallel can be drawn with some of the proposals before us in that it is clear that an incremental approach was then adopted as regards what CHCs should do, just as the proposals before us today have grown considerably from those originally contained in the NHS Plan. However, the result of that difficult beginning for community health councils--here I am conscious that my noble friend Lord Hunt was one of the foundation CHC chief officers at the time--is that a series of problems was inherent in the operation of those bodies.
First, although CHCs were more independent than the proposed PALS might be, they were not truly independent of the local health authority structure. I hope that, during the course of our debates in your Lordships' House, it will be possible to ensure that whatever is brought forward to replace CHCs is given genuine independence from the local NHS structure.
Secondly, concerns were expressed about resources. I can recall reading a report on CHCs which described them as bodies comprising one man and a dog. The expression was decried at the time for being rather sexist. Perhaps more pejoratively, they were described in terms of, "How many times can you re-use a teabag?". That indicates the extent to which resources were limited. Over time, successive governments have made available rather more resources to CHCs, but in reality an enormous expectation has been placed on what CHCs could achieve without necessarily providing the resources to ensure that such expectations could be met.
However, the biggest weakness here, and perhaps the reason why successive governments have considered this problem--we should be clear that over the past 20 years, successive governments have considered the abolition of CHCs--is the fact that no proper mechanism was built into the legislation concerning the quality control and performance management of CHCs. As a consequence, a wide variation has grown up in the way in which CHCs interpret their role and the quality of the work they undertake. That is a strong reason why a number of people, including myself when I was the director of the Association of Community Health Councils, acknowledged that it was important to reform the CHCs and to develop their role in addressing relevant issues.
It is clear that widespread dissatisfaction was felt both in your Lordships' House and elsewhere with the initial proposals that emerged from the NHS Plan. However, major developments have taken place and the Bill now before noble Lords is nearly there in terms
Nevertheless, the noble Lord made certain key points, one of which was that it is essential that the principle of independent advocacy, properly made available to the public, should be enshrined in the Bill. That is entirely consistent with the general objectives set out in the NHS Plan. But the manner in which the proposals are presently contained in the Bill, following amendments made in another place, does not make it absolutely certain that such independent advocacy arrangements will, in practice, be independent of the local trust or the local service. That must be remedied, whichever of the a la carte amendments is favoured or in terms of whatever response to the debate will be made in due course by my noble friend.
I believe that it would make sense for those independent advocacy arrangements to fall within the ambit of the new patients' councils. That is important because one of the main strengths of CHCs has been their ability to draw from their experience, based on the wide range of functions they perform, and to learn the lessons. They have learnt both from their advocacy work and from their complaints work. For that reason, it would be extremely sad if the independent advocacy arrangements to be put in place do not permit the learning of lessons from cases being pursued, so that those results can be applied elsewhere in the health service.
We need to address one other point: the question of independence. During the debate on Second Reading, I referred to the strange position of the staff of CHCs. We have an opportunity, during our discussions on these amendments and other amendments later this evening, to address precisely that question. We must ensure that we do not put in place the strange situation where staff are seen as accountable at a local level to the local health service. Furthermore, the question of resources needs to be taken away from the local decision-making process. It needs to be seen as something that will not be dependent on whether the CHC or patients' council--or whatever body is finally agreed on--has offended local NHS managers.
Major changes were made to the Government's proposals in another place. First came the specific proposal to set up a patients' council in all areas. That clearly signals the need to build a structure which is at least as good as, if not better than, the existing arrangements. The second change was the introduction of the clause about independent advocacy, which, as I said earlier, is nearly there but not quite enshrined. There is a lack of clarity, and that is why changes need to be made.
The noble Baroness, Lady Cumberlege, who spoke about the worthy Mrs Archibald and her problems, suggested that what we have before us today was not thought through initially and is still not thought through. We have the opportunity in this debate and in considering the amendments to make sure that the system is integrated; that it works better than the existing arrangements through CHCs; that it is genuinely independent; and that it provides a seamless service for members of the public who wish to make complaints.
The noble Baroness, Lady Cumberlege, is wrong to suggest that Mrs Archibald's family would have to pursue these matters through a number of patients' forums, through the independent scrutiny committee on the local authority and through the patients' council. We need to make sure that the arrangements for individuals who have complaints and concerns that they want to pursue are seamless. We must make sure that the final proposals which emerge from the Committee address all of those questions and that the arrangements are seen to be independent and properly resourced and enable members of the public to be satisfied that they will get a seamless service.
Ultimately, we must make sure that the lessons learnt from those cases and the lessons learnt by members of the patients' forums and the patients' council are properly utilised so that we end up with an NHS which is better because of the interventions of those bodies. That is a prize we can achieve. In going through these amendments--it is unfortunate that they are grouped together in this way--we can pick out the various elements and ensure that they are addressed.
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