Thursday, 22 March 2012

LINks and the Big Society

I went to a meeting of London LINk last night at City Hall, where there was a heated discussion about how those involved in patient and public involvement will continue to operate under Healthwatch as now laid out in the Health and Social Care Bill, soon to be Act. Listening to the discussion and the difficulties which many of these people already face in dealing with local authorities - Merton has a particularly difficult situation with an uncooperative local authority - the set up for Healthwatch, which will replace LINks in one year, looks even more difficult.

As someone who has been involved in PPI work for some years, listening to the discussion, I asked myself, who would sign up for this in their right mind? For all the talk of the 'Big Society' this demonstrates how difficult the government are making it for volunteering patients and members of the public, who spend vast amounts of time and energy on this, to be treated as part of the current involvement buzzword, 'co-production'. Malcolm Alexander, who has struggled valiantly against the provisions of the Bill on public involvement, was quoted in the debate on the Bill in the Commons on Tuesday. His arguments (contained in Hansard) are below. The key quote for me is:
“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”

From what I heard last night I would not be at all surprised if this happens. And as Malcolm said at the meeting, every time the government reorganises public and patient involvement (and it has happened 3 times over the last 11 years) it takes on average 2 years for the new organisations to bed down. If one were a conspiracy theorist, one would assume that the government's intetion is to wreck public and patient involvement.


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Liz Kendall: I start by sharing with hon. Members a letter to the Prime Minister on 13 March from Malcolm Alexander, who is the chair of the National Association of LINks Members, the national body representing statutory independent local involvement networks that promote the public and patient voice in health and social care. The letter is about the amendments to HealthWatch that were made in the other place and are before us now. He wrote to register his

“strong objections to the government’s major policy change on Healthwatch—specifically your decision to abandon plans to establish statutory Local Healthwatch bodies…Instead of creating independent statutory bodies led by local people who can monitor, influence, involve the public, hold the local authority and NHS to account; the government plan to create weak bodies that will not be independent, but will be funded by and accountable to the local authority they are monitoring. There will be no genuine accountability to the public.”

He then makes this rather perceptive comment:

“Plans for a statutory Healthwatch body were probably the only part of the Health and Social Care Bill that had any public support.”

He continues:

“Your government’s ambition”—

not your Government, Mr Deputy Speaker, but the Prime Minister’s—

“to establish independent, statutory Healthwatch organisations that would help achieve equity and empowerment in relation to access to NHS and social care services, has been diminished to such a degree, that Healthwatch will have little impact…The aspiration to achieve equity and excellence in public involvement in health and social care, especially for the most vulnerable people, has been replaced by a model that has lost its central purpose of building effective patient and user led bodies that can influence the planning of health and social care.”

I will continue reading from this letter because if the Government really want to hear the patient and public voice, Members should do too, and that is what Malcolm Alexander represents. He writes:

“In our discussions with the Earl Howe and”

the Department of Health

“over the past year, we were led to believe that LINks would evolve and go through a transition into Healthwatch. It is incomprehensible to us that the plans that were developing for Healthwatch have been replaced, at very short notice, by a highly confusing set of amendments to the Health and Social Care Bill that are very unlikely to achieve the objectives of the Transition Plan and will be very poor”

value for money. He continues:

“It was the stated policy of the Coalition that patients and users of social care must be at the heart of everything that is done—not just as beneficiaries of care, but as participants, in shared decision-making.”

Malcolm Alexander also writes that the Secretary of State

“has continuously said, ‘there should be no decision about us, without us’. Why has this promise and aspiration been abandoned and why is the government planning to abolish plans for an effective statutory model of local Healthwatch and replacing it with one that will be chaotic, diffuse and weak with no leadership role for patients and the public? Instead of engaged and empowered patients and users of social services taking a leading role—many

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volunteers who have led LINks are feeling disempowered, demoralised and demotivated. We had hoped and believed that at last Healthwatch would genuinely empower”

patients and the public

“through being populated by ordinary people in the community. This hope is now lost.”

He finishes with an apt comment on the entire Bill:

“This is a betrayal of public trust and an appalling waste of public money.”

The Government have repeatedly claimed that the Bill will put patients and the public at the heart of the NHS and that a crucial core purpose of the Bill is that for patients there will be “no decision about me without me.” Nothing could be further from the truth. Opposition Members have consistently argued, since the first Commons Committee stage, that the Government’s proposals for HealthWatch are weak and ineffective, and will fail to give patients a strong and independent voice to shape local health and council services. [Interruption.] The Minister chunters from a sedentary position. We always saw through the Government’s plans; now everyone else has too.

More than 67 Government amendments about HealthWatch England and local healthwatch bodies were tabled in the other place. These amendments make major changes to the Government’s original proposals, ensuring that they will be even weaker still. The Government’s amendments 181 and 366, tabled in the other place, remove clause 179 and the related schedule 15, which place a requirement on local healthwatch organisations to be statutory bodies. As the NALM rightly says, the Government made this change without any prior mention to the House, or even in Committee in the other place, and more importantly without any consultation with patients’ groups.

Local authorities will now contract social enterprises or voluntary organisations to provide local healthwatch functions. Councils will be able to split these functions if they choose. The small voluntary groups, social enterprises and, indeed, private sector bodies will be expected somehow to provide a strong and critical voice on behalf of patients about local services—services that may be provided by the very local councils contracting and funding them. The joint effect of these amendments is to divide up the functions of HealthWatch, to break down the synergies between the different roles, to require bidding to win tenders for the delivery of various services and to leave local healthwatch bodies with no automatic consistency or authority to speak on behalf of a community.

The Government have repeatedly argued that the Bill is necessary to give clinical commissioning groups statutory status, to guarantee that professionals are in the driving seat. The question is: why are the Government giving organisations that are supposed to empower professionals a statutory status, but now removing that status from the bodies that are supposed to empower patients? The weak status of HealthWatch England nationally remains. It is still a mere committee of the Care Quality Commission. All that the Government have done is say that a majority of members on the committee should not be members of the CQC. HealthWatch England should be the voice of the people in the NHS. Making it a committee of the CQC is a fundamental error. Patients and the public must have confidence that HealthWatch England will speak up for them, including where it believes that the Care Quality Commission has failed to monitor or

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inspect local NHS services or local council services properly, including care homes. How will HealthWatch England do that if it is funded and housed within the CQC, an organisation that has already been criticised for lacking strategic focus and the resources necessary to do its job effectively?

The Government say that HealthWatch must be part of the CQC in order to get access to information and other resources. However, if the duty in the Bill on all NHS organisations to collaborate—a duty that the Government have made much of—is so strong, why would it not also apply to the CQC in collaborating with a separate, independent HealthWatch England? The Government have also completely failed to ensure that HealthWatch will have the ring-fenced funding that it needs to do its job properly. Funding for HealthWatch England and local healthwatch bodies is only £20 million, compared with £492 million for the NHS Commissioning Board and £140 a year for Monitor. HealthWatch would have already struggled to provide an equally strong voice in the NHS for patients and the public on the basis of those resources, but now the Minister in the other place, Baroness Northover, has made it clear that funding for local healthwatch bodies will not be ring-fenced, but instead be part of the formula-based grant to local councils. Failing to ring-fence local healthwatch funding will virtually guarantee that those bodies will fail to provide a strong local voice.

That is not just my view: it is the view of National Voices, the organisation that represents 150 patient groups, which says that giving local healthwatch groups a strong voice will be possible only if

“the funding is ring-fenced. Otherwise local authorities will continue to use the funding for what they regard as higher priorities.”

National Voices says that HealthWatch is being “set up to fail”. It is right. In its latest briefing on the Bill, it says that the risks the Bill poses include a

“lack of independence at national and local levels…insufficient power…insufficient funding,”

weak support for the transition, and

“reform fatigue among local activists.”

Andrew George: I am listening carefully to the hon. Lady’s arguments about the structure and funding of local healthwatch bodies and HealthWatch England. I ask this question not to be deliberately mischievous, but in view of her comments and criticisms, what is the preferred option of the Labour party for those scrutiny bodies?

Liz Kendall: I would encourage the hon. Gentleman to read the Opposition Front Bench amendment tabled in the House of Lords which set out how we could have a separate independent body with clear lines of accountability to local healthwatch organisations. That is the policy of the Opposition. Unfortunately, however, that amendment was not accepted.

National Voices represents 150 patient groups. I was interested that the Minister said that the Richmond Group of charities somehow supported everything that the Government were doing in this area. However, I should remind the House that National Voices includes groups such as Asthma UK, Arthritis Care, the British Heart Foundation, Breast Cancer Care, Carers UK, Cancer Research UK, Diabetes UK, Dementia UK,

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Mencap, Mind, Macmillan Cancer Support, Rethink Mental Illness, the Stroke Association and many others. Those groups are saying that the Government are setting HealthWatch up to fail, because it will not provide a strong enough voice for patients and the public.

Interestingly, officials within the Government’s own Department are saying the same thing. Hon. Members will know that the Government have refused to publish the transition risk register, but today I have been passed the risk register from the Department of Health’s programme board for HealthWatch. It is marked “Restricted”, and it sets out clearly what the Department’s officials see as the risks involved in the Government’s proposals on HealthWatch. It deals with high risk in terms of impact, as well as with likelihood, so it does involve prediction.

The risk register says that there is a high risk that

“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”

because of “insufficient consultation”. It goes on to say that there is a high risk that local authorities

“will not invest in establishing effective relationships with existing LINks and other community organisations”

because the process has been poorly managed. It states that there is a high risk that there will be a “narrow engagement group” and that HealthWatch

“doesn’t work effectively with providers and commissioners. HW is not fully representative.”

It identifies the cause for that as the engagement process having been “insufficiently inclusive”. It sees a further high risk in relation to HealthWatch England:

“The establishment of the HWE committee within CQC is either too isolated or too prescribed by DH/CQC plans.”

The cause is identified:

“Early design processes for establishing HWE do not engage broad range of partners resulting to ineffective regulations being laid.”

Those ineffective regulations are being laid by this Government, according to the risk register of the Department of Health’s own HealthWatch programme board.

Some of the Lords amendments in this group would make minor improvements to the Bill in relation to the National Institute for Health and Clinical Excellence and to the functioning of the information centre. I want to return to the Minister’s earlier claim that huge improvements would be seen in public health. Some amendments relate to the employment of public health professionals by local authorities. The trouble is that the Faculty of Public Health, the body that represents those people, opposes the Bill and wants it to be dropped. It has stated that the Bill will widen inequalities, increase health care costs and reduce the quality of care. It says that there are significant risks—[ Interruption. ] If hon. Members are making claims that their Bill will improve public health and that the amendments will improve arrangements for public health professionals, perhaps they should listen to the views of those public health professionals. The Faculty of Public Health has identified

“significant risks associated with the NHS structures, the new health system and environment that the Bill will enact.”

The right hon. Member for Bermondsey and Old Southwark (Simon Hughes) was, perhaps courageously, trying to get the Minister to set out what powers local

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authorities would have under the new system. He will know, however, that health and wellbeing boards will not have the final say over GP commissioning plans. They will not be able to stop them. The only course left to them will be to appeal to the NHS Commissioning Board. I would respectfully point out to the right hon. Gentleman that if he thinks that the NHS Commissioning Board will automatically agree to complaints from local authorities, his experience of the NHS is very different from mine. We need to be clear that there will be no sign-off by health and wellbeing boards.

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