Health: Diabetes

Baroness Masham of Ilton Excerpts

Wednesday 25th July 2012 Lords Chamber

[Earl Howe]

My advice is that type 1 diabetes is not a particular issue in ethnic-minority communities. We are talking about type 2 diabetes, which is five times more common in black and ethnic-minority groups, six times more common in south Asian ethnic groups, and three times more common in areas of social deprivation than in the rest of the population. There are particular clinical risks associated with those from ethnic minority communities who have diabetes. Complications include particularly heart disease—south Asian people are 50% more likely than the general population to die prematurely from coronary heart disease—and the prevalence of stroke is also much higher in African, Caribbean and south Asian men.

[Baroness Masham of Ilton]

My Lords, can genetic problems be a cause? Are not exercise and getting fit an important part of stopping diabetes?

[Earl Howe]

Exercise is recommended under the Change4Life programme and under the advice given by NICE. However, the noble Baroness is absolutely right to mention a possible genetic cause. The cause of diabetes is not fully understood and is multi-factorial. Healthy eating, weight control and exercise can help reduce the risks, but that is not the full picture. It is suspected that there is a genetic component in the case of black and ethnic-minority communities.

NHS: Specialised Services

Baroness Masham of Ilton Excerpts

Wednesday 18th July 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I thank the noble Baroness, Lady Jolly, for this timely debate on AGNSS. There is no doubt in my mind that there are many really concerned and frustrated people who are involved in highly specialised conditions, be they patients, relatives or doctors treating them. With so much insecurity and with PCTs running down and the national Commissioning Board not operational yet, there is a limbo situation.

When a rare disease strikes, it is the individual who matters. The correct treatment is vital, but with rare conditions risks have to be taken if there are to be improvements. The Chief Medical Officer, Dame Sally Davies, has recently endorsed the value of research into rare diseases by the National Institute of Health Research as a significant source of benefit for patients with rare diseases. The role of AGNSS is to advise Ministers. Does the Minister think that the national Commissioning Board members will be infallible so that they will not need advisers? We have come to a shocking situation when staff in St George’s Hospital, a teaching hospital, neglected a patient of 22 who had suffered a rare condition, following a brain tumour, that required daily drugs. He died of thirst because staff failed to read his notes. Patients with rare conditions need extra-special treatment; they should not be neglected and ignored. What has gone wrong? We need transparency and confession and a fool-proof system for all vulnerable patients. When the Government say that everything is fine when it is not, it is a cover-up.

AGNSS is an independent advisory group providing advice to the Secretary of State for Health regarding the commissioning of services for very small populations of patients—fewer than 500 patients in England. Will the Minister make clear what the future of AGNSS is? To cover all specialised services adequately, the Commissioning Board will have a mammoth task.

I must declare an interest as I have a cousin aged six who has relapsed neuroblastoma. The treatment his parents are trying to access is likely to become available on a trial basis in the UK, but not in time for Jamie. It has been internationally recognised as being one of the most promising therapies with encouraging results against neuroblastoma. I think it is available in Germany. There are only about 100 patients a year in England with this aggressive type of child cancer. It desperately needs research. Parents will do anything for their children. This family is appealing to the North Yorkshire PCT.

I am president of the Spinal Injuries Association, which is concerned about tetraplegics and paraplegics who are not being admitted to spinal units. One case is still residing in St Mary’s, Paddington, on a respirator after a ski-ing accident. He has been waiting to go to the spinal unit at Stanmore for months. This is not good. Correct specialised care means good quality for patients. The noble Earl is Minister for Quality. Does he agree that there should be a special fund for very rare cases so that they are not passed over? I, who have every admiration for our hard-working Minister, do not want the system to give him the reputation of being a Pontius Pilate. Even with AGNSS, there are improvements to be made. There is a black cloud hanging over the NHS: the £20 billion that has to be saved. With so many demands on healthcare, this challenge may just be too great.

NHS: Primary Care Trusts

Baroness Masham of Ilton Excerpts

Tuesday 17th July 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, will the noble Earl find out to how many cases the PCT in North Yorkshire has denied treatment in the past year? Is he aware of how distressing it is for very ill patients to have to appeal?

[Earl Howe]

My Lords, I do not have the figures for North Yorkshire in front of me but, as the noble Baroness is aware, there is a process for patients to make an exceptional case application to their primary care trust where the circumstances are deemed to be exceptional. We had a short debate about this matter the other day. However, there will inevitably be variation around the country in the extent to which treatments are seen as a priority for the local population in a given area.

NHS: Definition of Exceptional Case

Baroness Masham of Ilton Excerpts

Monday 2nd July 2012 Lords Chamber

Asked by

[Baroness Masham of Ilton]

To ask Her Majesty’s Government what is the definition of an exceptional case needing surgical and medical care through the National Health Service, and who makes the decision.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the department has not issued definitive guidance on this difficult issue. Indeed, there is a paradox in the whole concept of defining an exception. However, good practice in the NHS suggests that a patient can be considered for treatment which is not normally provided locally if the patient has exceptional clinical need or is likely to derive exceptional clinical benefit. The decision is made by the local commissioner.

[Baroness Masham of Ilton]

My Lords, I thank the noble Earl for that reply. However, is he aware that there is a young doctor in Northallerton, North Yorkshire, whose PCT has denied her a vital operation for a genetic pancreatic condition? If she does not have this operation, she will remain in excruciating pain all the time, she will not be able to work, and there will be a risk of cancer.

[Earl Howe]

My Lords, I hasten to reassure the noble Baroness that I have every sympathy with the individual in question, and I was aware of this particular case. The chief executive of the NHS will shortly be writing to her clinical tutor to suggest a possible way forward. However, I should put on record my view that the commissioner is acting reasonably in insisting that its decision on exceptionality should depend solely on the clinical need of the patient, and not on any broader social factors. If there is now good clinical evidence to support the use of this particular treatment, commissioners should be considering whether to make it available to all patients with similar clinical needs, and not just to a few individuals.

NHS: Liverpool Care Pathway

Baroness Masham of Ilton Excerpts

Wednesday 20th June 2012 Lords Chamber

[Earl Howe]

My Lords, I am pleased to hear that the noble Baroness’s mother was well looked after with the benefit of the Liverpool care pathway. I take the point about the name. Indeed, the noble Baroness, Lady Finlay, can probably give us some instructive examples from Wales, where the word “pathway” has not been adopted and the process has, I believe, been refined.

[Baroness Masham of Ilton]

My Lords, is the noble Earl aware that some relatives and loved ones have to fight to stop their loved ones being on the Liverpool care programme? Can he think of anything worse than dying of thirst?

[Earl Howe]

My Lords, no one should be denied basic care at the end of life. However, that is a different question from whether artificial nutrition and hydration should be withheld. Relatives should always be consulted.

Health: Local Healthwatch Organisations

Baroness Masham of Ilton Excerpts

Monday 11th June 2012 Lords Chamber

[Earl Howe]

We are working with the Local Government Association and the Care Quality Commission to provide support for the implementation of local Healthwatch organisations. As I mentioned, the LGA is running a series of master classes for local authority commissioners. It has published 15 case studies taken from the 75 Healthwatch pathfinders, and a small number of Healthwatch experts will be available to help spread learning. As regards making the public aware, it will be very much for local authorities to decide what is appropriate in their particular areas in order to ensure that patients and the public are engaged in the important work of Healthwatch and understand what the statutory remit of local Healthwatch consists of, because that is the only way in which local Healthwatch will make its voice truly heard.

[Baroness Masham of Ilton]

My Lords, will local Healthwatch members be able to support members of the public if they go to a tribunal?

[Earl Howe]

One of the potential functions of local Healthwatch is to act as a support in terms of advocacy for local people and to signpost patients and the public to appropriate services. It is too early to say which local authorities will commission what services from local Healthwatch in an area, but the resources available to local Healthwatch have to be borne in mind in that context.

Health and Social Care Act 2012

Baroness Masham of Ilton Excerpts

Wednesday 25th April 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, does the Minister agree that HealthWatch has been left in limbo? Would he agree to a fast-track legislative scrutiny?

[Earl Howe]

I do not agree that HealthWatch has been left in limbo; in fact, only this morning I was attending a round table of pathfinder local healthwatches and witnessing for myself the tremendous energy and enthusiasm that they were devoting to HealthWatch. So the short answer to the noble Baroness is no, I think the process as regards HealthWatch is very much on track.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Monday 19th March 2012 Lords Chamber

[Baroness Jolly]

My Lords, I have put my name to the amendment. Historically, both parties to the coalition were in agreement that there were too many quangos and that rationalisation was required. This is always difficult when it involves an organisation as well respected as the Health Protection Agency and others.

Its successor organisation, Public Health England, was going to take over the HPA’s and have duties with regard to the new structure of public health at local government level. However, that had no place in the Bill. On these Benches, we welcomed the move to ground public health in local authorities, and we welcome the statements by the Minister about the role, responsibility and duty of this newfound position.

However, we were anxious about public health at a national level. We were not alone, and I pay huge tribute to my noble friend Lady Cumberlege, who took up this cause at Report stage—probably before then—along with the noble Lords, Lord Patel, Lord Turnberg and Lord Warner. The Secretary of State now sees PHE as carrying out his functions. I am grateful for the time that he gave to meet us to explain his point of view and listen. He felt that to make Public Health England an executive agency of the Department of Health would give it a degree of separation and flexibility. It was argued that PHE needed to have not only an independent chair but a board with a majority of non-executive directors if it were to have credibility with professionals and the public, and for the reputation clearly held by the HPA and others to be maintained in England and abroad. It would need to be able to raise funding to carry out its research on both English and worldwide issues. All this has been ably described by the noble Lord, Lord Warner, and we should be grateful for some clarity from the Minister on the research activities proposed for the organisation. There is clearly intended to be a line of accountability from the Secretary of State through Public Health England to the directors of public health, and it would aid understanding all round if my noble friend could clarify Public Health England’s duties and accountabilities at local, community level with the directors of public health and local authorities. The line right the way down needs looking at.

I hope that the Minister will state that the Secretary of State is convinced that all of this is now a shared vision. However, as I stated earlier, none of this is stated in the Bill. My noble friend said that she will not push that, and I certainly will not, but I regret it, as it would be beneficial and make a really bold statement to the world outside that Public Health England is core to the Bill.

Can the Minister confirm the understanding of the Secretary of State’s letter and, perhaps, agree to the wording of the amendment?

[Baroness Masham of Ilton]

My Lords, the Health Protection Agency is held in high esteem throughout the world. It does the most important work in protecting society from infections and epidemics. The National Blood Service can be the blood of life. It is vital. Can the Minister give an assurance that the HPA will not be downgraded in any way? I support Amendment 14 and hope that the Minister will accept it. If he does, that will give some assurance to some of the people who have concerns about the changes. With so many complicated conditions, research should not be restricted and funding for this must be free and seamless.

Will Public Health England work with other countries? Infections have no boundaries. One never knows what is around the corner. The work of the body should be as independent as possible. Otherwise, we will lose some of our brilliant researchers to countries which will give them more freedom.

[Lord Turnberg]

My Lords, I rise to speak briefly, because much of what I might have said has already been said by the noble Baroness, Lady Cumberlege. I, too, am very grateful for the way that the noble Earl has listened to us and spoken and written to us with helpful comments, which I hope that he will reiterate today. I just want to make one point about the research undertaken by the current HPA. It is directed predominantly to infectious disease and bacterial and viral infections. In that area, it is really world-beating. Recently, two of its members of staff have been elected fellows of the Academy of Medical Sciences, which is quite an achievement. The idea that it should do all this research in academic research partnerships with universities is unhelpful. Although collaboration and co-operation with university departments is enormously valuable, it should not be a precondition that it should be able to do research only in collaboration with universities. I hope that the noble Earl will be able to nail that problem.

--- Later in debate ---

[Lord MacKenzie of Culkein]

My Lords, as a nurse I am always delighted to support the noble Baroness, Lady Emerton, and I particularly support this amendment.

I had hoped that the House might have agreed the need for statutory regulation and registration for healthcare support workers, but the Government should at least accept this amendment. It provides for a code of conduct, for mandatory training, which must be to an agreed standard, and for a requirement to have undertaken an assured training programme before one can enter the voluntary registers that are to be set up. These things should all be in the Bill; they are necessary to protect the patient and the public.

Training, in my view, has to be mandatory; it cannot be left to the whims of employers to decide how much or how little training to give to healthcare support workers. I know from nurses, including my step-daughter, who is a registered nurse, that some of that training is good, some of it is patchy and some of it is shockingly poor. Some of it is supernumerary today, on the team tomorrow; see a procedure today, carry out that procedure tomorrow. That old system of training has no place in the modern delivery of nursing care, but it is what many healthcare support workers have delegated to them.

The Minister knows my views about voluntary registers, but I have no wish to see them fail. If they are to succeed, every effort must be made to ensure that those who are eligible get on to these registers. He will correct me if my memory is playing tricks on me, but I seem to recall him saying at an earlier stage that employers could require someone to be on a voluntary register before appointment or promotion. I have no quarrel with that if we are properly to protect the public, but I want to know whether an employer can do that. If, say, there are two candidates for promotion with very similar training and experience on their CVs, but one is on the voluntary register and one is not, will the employer be able to refuse to see the person who is not on the voluntary register? I wonder what an employment tribunal might make of that.

I hope we can have an assurance that employers will be able to discriminate in this way, because I am concerned that everyone who should be on the register is on it. We know that rogues and rascals and those who are less than suitable are the ones who are not likely to want to be on a voluntary register, which is why I prefer the other course. However, we are where we are and I hope that the Minister can at least reassure us on this point.

[Baroness Masham of Ilton]

My Lords, I have my name to the amendment. During the passage of this Bill, some of us have been trying very hard to improve the care of vulnerable patients in hospital and in the community. I felt healthcare support workers should be registered and regulated, as many vulnerable patients, being frail and elderly or disabled in many diverse ways, have to rely on their carers. Your Lordships have heard that patients have been put at risk or died through neglect or assault in care homes and hospitals up and down the country. Many people wait in anticipation for the result of the review of the Mid Staffordshire Foundation Trust. This must not be covered up; lessons should be learnt in memory of the hundreds of patients who received poor care, were neglected and died. Surely it is our duty to try to help rectify this deplorable situation.

I have every admiration for the Minister, who has worked tirelessly over this Bill, but I do not agree with him that nurses who have been struck off their register can go back to caring for patients as unregistered healthcare assistants. We are exposing the most vulnerable in our society to greater risks and poorer care if we do nothing to prevent struck-off nurses continuing to work in a caring profession. This amendment is a compromise, but even so it has a very important part. Subsection (2) of the proposed new clause in the amendment states:

“The assured training programme shall be mandatory for all new health care support workers from 1 April 2013”.

Not to train people who care for vulnerable patients is deplorable. Last year I was involved in a case of a person living at home and using a respirator. The patient was left brain damaged when the agency nurse turned off the wrong switch. Adequate, appropriate training should be given; in that case, it was a health care worker who was also a nurse.

Many disabled people are living in the community, which is good, but many of them use technical equipment that needs training and understanding, such as hoists, pressure mattresses, peg feeds, catheters, complicated electric wheelchairs, ventilators, nebulisers, diabetic management, colostomies, adapted vehicles and many other complicated devices. An assured training programme should include where to place a patient’s food and drink and to assess whether the patient can feed themselves. If not, the healthcare worker should know how to do this; how to wash and bathe and deal with personal needs such as toileting; how to prevent pressure ulcers; moving and handling; and complications with patients who have problems and may be difficult and have a problem communicating. There are many needs, but kindness and common sense should prevail.

If the Minister and the Government do not agree with this amendment, it will mean they do not understand the needs of vulnerable patients’ care. If training is mandatory, I am sure employers will take notice.

[Lord Cotter]

My Lords, I thank the noble Baroness, Lady Emerton, for introducing this amendment, which I hope the Minister will agree gives an opportunity for a very important issue to be aired. Many noble Lords have aired it in the past; indeed, I raised it on the very first day of the Bill. It is an area that remains of concern, and I have been pleased to hear from the Ministers that they are well aware of this. I recollect at the beginning of the Bill speaking to a nurse who, with an air of concern in her voice, said that when she asked assistants to carry out work the responsibility remained with her if that work was not carried out correctly. I welcome this opportunity for the Minister I hope to give a very strong response to indicate the Bill will cover this issue. As the noble Lord, Lord Patel, said, we are talking about 450,000 healthcare assistants: many people of varying abilities and knowledge.

I will say no more except to thank the noble Baroness for her amendment and, in anticipation, to thank the Minister for his response, which I hope will be robust and clear as to what we are going to do to address this concern.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Tuesday 13th March 2012 Lords Chamber

[Baroness Wall of New Barnet]

My Lords, first, I apologise for missing the first five minutes of the noble Baroness, Lady Emerson, moving the amendment. With the House’s permission, I shall briefly speak to the issues that she raised, to which I have referred in the House on many occasions, as many noble Lords and certainly the Minister will be aware.

I understand the arguments that have been made by my noble friend, but healthcare assistants—and they are mostly in clinical areas—have a strong desire to be recognised and accredited for the work that they do. They take a pride in what they do, as the noble Baroness, Lady Emerton, said, but patients do not understand what they do and therefore cannot have the discussion with them that says, “You are qualified, so I have confidence in you”.

I have had this discussion with the Minister on a number of occasions, and I am not sure why there is hesitancy in this area. I do not think there is an issue for trusts in being able to get healthcare workers who are qualified. We have a sector skills council for health, most of whose work is encouraging healthcare assistants and other people who work in hospitals to reach levels 1 and 2, so there is an equivalent provider out there that can do that, working with the hospitals.

The important thing is that the patient understands exactly what the healthcare worker does. The amendment of the noble Baroness, Lady Emerton, describes a healthcare support worker as an individual whose work is “routinely delegated to them”. That is crucial. It is not someone who does something off their own bat. My hospital employs many hundreds of healthcare workers, most of whom do a very good job. It is very important that the noble Earl knows that they are very conscientious when working with other practitioners, clinical or otherwise, who do not do what they are supposed to do. We have many healthcare workers who check that consultants’ arms are bare to the elbow. They are very conscientious and they want recognition that they are people who care about patients. They want to know that the value that they bring is recognised. It is no threat to the health service; speaking as a provider chair, I can say that it is a total advantage.

[Baroness Masham of Ilton]

My Lords, we are once more discussing the important matter of the power to regulate healthcare support workers in England. I am pleased to have added my name to the amendment. I spoke about this at Second Reading and in Committee. I agree with the Royal College of Nursing that mandatory regulation and registration of these support workers is important in order to safeguard patients’ safety and to ensure standardised training so that there is a skilled and suitable workforce.

I have yet to meet anyone who understands the situation who disagrees about this, except some members of the Government. Nurses who have been struck off their register can then work as care assistants—again, putting patients at risk. The Government are considering a voluntary register, but this will not cover the undesirable people who get jobs as care assistants because they cannot get employment elsewhere. Clinical physiologists have found that self-regulation, which they have had since 2001, is not as effective as statutory regulation. Should we not learn from this?

We know of the tragic cases at the Mid Staffordshire NHS Foundation Trust, where the deaths of hundreds of patients were associated with bad care. It makes one wonder how Mid Staffs was approved for foundation status. We also know of the horrific bullying by care assistants at Winterbourne View care home at Bristol. Since Committee, we have heard of Malcolm Cramp, who was convicted of seven counts of ill treatment and sent to prison for abusing dementia patients at Brockshill Woodlands, a care home in Leicestershire. In another case, Sean Abbott, a caseworker, was jailed for a year for assaulting vulnerable residents at St Michael’s View care home in South Shields. Daphne Joseph, another person at that home, was given a nine-month suspended sentence when she admitted the ill treatment and neglect of a patient, who died. The judge at Newcastle said that she had not had enough training. He also said that she was operating,

“in a regime which was inadequate and not fit for purpose and in which there were too many patients, not enough planning, and too few staff, let alone trained staff”.

This concerning situation is happening up and down the country. Is it not time that better safeguards for patient safety were put in place? Statutory regulation and the registration of healthcare workers could help. Many of them are now undertaking procedures that only doctors and nurses did but they have little training to do it.

[Lord Turnberg]

My name is attached to this amendment, which I believe is an extremely important one. I find myself in the somewhat unusual—indeed, unique—position of, for the first time, not being able to agree with the noble Lord, Lord Newton. We have had many debates in this Chamber in which the standards of care in our hospitals and nursing homes have been examined and, in too many places, found wanting. We have had many other reports showing the same thing. Many institutions and many care workers are outstanding but, as we know, there are too many places where patients are neglected and their basic needs not addressed.

Of course, all these failures cannot be put at the door of healthcare support workers. Where they occur, these failures are systemic and go right across the hospitals and homes. The employers, doctors, nurses and everyone in the institution should bear responsibility. However, all too often it is at the level of the healthcare support worker—who provides the basic care of feeding, washing, toileting and a host of other responsibilities and is often in closest contact with the patient—that we hear complaints from patients and their families. Healthcare support workers are at the end of the line and are too often left to themselves.

I fear that when we lost our SENs—our state-enrolled nurses, who did not need a university degree—in 2000, we lost a group of professionals who were trained and educated to do their job. If we are to regain the sense of professionalism and pride that my noble friend talked about that full registration would bring to a cohort of well trained and regulated young men and women, then we must move to full and proper registration. I do not believe that a voluntary register gives that degree of control. It certainly does not give sufficient recognition to the importance of the job. I hope that the Minister will agree.

--- Later in debate ---

[Baroness Masham of Ilton]

My Lords, I support the amendments in the names of my noble friends and Amendment 254 in the name of the noble Lord, Lord Hunt of Kings Heath. Clinical physiologists have had voluntary self-regulation for years and they say that it is not as effective as statutory regulation. They have been trying to get statutory regulation since 2004. All clinical physiologists work independently, and while the overall standard of practice is high there is a significant level of risk to patients as practitioners provide services that directly affect the diagnosis and management of patients. Most patients are unaware that clinical physiologists are not statutorily regulated when they are undertaking invasive or high-risk procedures. The clinical physiologists say that there are about 10,000, of which only about half are voluntarily registered. This debate for clinical physiologists has been running on for too long. They are getting frustrated. They want better patient safety, which they feel statutory registration will help to provide. They feel that the Government could easily give them this. I ask the Government: why not? They are a significant and important group doing work with a high risk to patients.

[Lord Walton of Detchant]

My Lords, I, too, support these two amendments on the regulation of clinical physiologists, and I think that the case my noble friend Baroness Finlay made about clinical perfusionists is extremely strong.

Clinical physiologists work across a wide range of disciplines. Some work in cardiac investigations, some in respiratory investigations, some in gastrointestinal investigations, but my particular interest relates to clinical neurophysiologists, who carry out a wide range of different investigations involving patients.

Many years ago in my early days as a neurologist, I was involved in the interpretation of electro- encephalograms, and I also introduced into the north-east a technique of electromyography, which is a means of identifying and studying the electrical activity of muscles in health and disease. In all these activities, I was supported by well-trained clinical physiologists. In those early days, those individuals quite often became members of the EEG society, as it was called, of which I was a founder member.

Later, as the interests and the techniques broadened and became much more extensive and much more sophisticated, that organisation, which included doctors working in the field as well as the people called technicians, who were in a sense clinical physiologists, changed its name to the British Society for Clinical Neurophysiology, and the so-called technicians became part of a body called the Electrophysiological Technicians Association—the EPTA—an organisation that later became the Association of Neurophysiological Scientists. It is now very well trained. It works not only in EEG and EMG but in techniques including evoked potential recording, peripheral nerve studies—the measurement of nerve conduction velocity as an aid to diagnosis in disease—and techniques of magnetoencephalopathy. A whole series of new techniques has been developed in which these clinical scientists or clinical physiologists—technicians as they once were—are very deeply involved. They are sufficiently well organised in their professional bodies, which represent their interests, and in the voluntary registers, of which many of them are already members, that they fully deserve registration under the Health Professions Council. Such a statute is long overdue. For that reason, I strongly support the amendments.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Thursday 8th March 2012 Lords Chamber

I conclude by saying that this is not a party-political issue. The previous Government got this wrong and, sadly, the present Government look as if they are about to get it wrong. This was an opportunity to get it right. Patients need effective representation, particularly in the context of the Bill. Even if you believe that the Bill will deliver to us a better health service—and I am obviously not one of those—patients need to be given confidence that their interests will be properly represented. At the moment, the arrangements proposed by the Government do not do that. That is why an independent HealthWatch England is so important.

[Baroness Masham of Ilton]

My Lords, with so many changes over the years to volunteers supporting patients, it is important that HealthWatch England and local healthwatches should be effective. First, there were community health councils, most of which did a good job—some did not. Then there were health forums, which lasted only two years. Then there were LINks, which have not been very well supported. The way that these volunteers, who were supposed to be a voice for patients and people using social care, have been treated has not been good. Unless healthwatches have a strong voice and enough support to operate, they will not be able to do a worthwhile job. They need to be independent so that when they see something that needs to be improved they can speak out.

In the Mid Staffordshire Hospital, where the culture was wrong and patients suffered, no one spoke out when they should have done—except the relatives. I hope that lessons will be learnt and strong safeguards put in place, including a strong healthwatch. I know that the noble Earl understands the need for a body supporting patients that is fit for purpose. If the House thinks that HealthWatch England and local healthwatches are not fit for purpose, as suggested in the Bill, and if the amendments are not accepted, perhaps with the help of the Minister there is still time before Third Reading to get it right.

I ask him whether children’s services are to be included in healthwatches. If not, they should be. Just think of what happened to Baby P. We must not forget. It will be very disappointing if we do not get it right in your Lordships' House.

[Baroness Cumberlege]

My Lords, I have several amendments in this group and the next one. There are synergies between the two groups, so I shall speak briefly introducing both groups and go on to those in this group.

I have tried hard throughout our debates to ensure that we have a more robust accountability framework. As I see it, the framework is in three parts. First, there is the local authority. Secondly, there is HealthWatch England. Thirdly, there is the local community. I will not go into the independence of HealthWatch England, because I debated it very fully in Committee, but I understand the passion that has been expressed on that issue. For me, those three elements balance each other, and it is important that they do, because that will improve transparency.

To give an example, if HealthWatch England makes recommendations to local authorities on how they commission local healthwatch, local healthwatch and the community can hold the local authority to account for how it commissions. That gives it a yardstick by a third party, HealthWatch England, against which to measure the local authority commissioning arrangements. The policy document produced by the Government on Friday, Local Healthwatch—The Policy Explained, states that the Government are considering how the constitution and governance of local healthwatch needs to ensure that it operates for the benefit of and is accountable principally to its local community.

The third element is local people. They are critical to the accountability framework. As the noble Baroness, Lady Masham, said, in many eyes, they are the most important.

The government amendments, including those laid on Friday, go some way to addressing that, but they also introduce fresh concerns, which I shall refer to later. The loss of statutory structure is a great threat to independence. The value for money and rationale still have to be adequately explained, but I am sure that my noble friends on the Front Bench will do that shortly.

My noble friend Lady Jolly and I tabled Amendment 224, which improves accountability nationally by linking the perspectives of HealthWatch England more closely to the grassroots by electing the members of local healthwatch to the HealthWatch England statutory committee. The noble Lord, Lord Harris, gave that a warmish welcome, although I say to him that that is not a sub-committee, it is a committee. It is not subservient to a committee, it is a committee.

The Government have sought broader opinion with their public consultation on that and other topics which closed on Friday. That elected membership would serve two functions: first, as a counterweight to the influence of the Care Quality Commission, making HealthWatch England more independent; and, secondly, as an agent for the accountability of HealthWatch England, keeping it in touch with the patient and user reality. If local healthwatch does not think that HealthWatch England is really speaking out for people, it can say so through its elected representatives. They would be elected against a skill specification to ensure that they were the right people to fulfil that important role. Without that, HealthWatch England is a free-floating organisation with no local connection, a mere national harvester of local data. I hope that the Minister can reassure me again that that accountability gap will be dealt with.

Government Amendment 226 is very much welcomed. I strongly support it, because it responds to my amendment in Committee. It provides for the majority of the members of HealthWatch England to be made up of non-CQC members, making it independent of the CQC, which therefore cannot dominate HealthWatch England. My Amendment 226A stitches the accountability framework together transparently, by providing for local healthwatch to have regard to the standards set by HealthWatch England. I hope that my noble friend can give me some assurances as to how that last element can be covered.

The introduction of the HealthWatch trademark under government Amendment 235C is a very interesting device and may well help. Amendment 228 was also tabled by my noble friend Lady Jolly and me. It enhances independence and transparency nationally by providing for the Secretary of State to issue conflicts guidance to which both the CQC and HealthWatch England must have regard. I hope that the Minister finds that sensible. Amendment 229 is another government amendment which I support. It includes a risk management strategy, so that what may have gone wrong in one place may stimulate vigilance in another. I strongly support that.

I am sure that my noble friend will wish to speak to her amendments, but I have introduced mine and hope that some of them find some favour with those on the Front Bench.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, I added my name to these amendments because I agree with all the comments that the noble Baroness has just made. Children and young people are stakeholders in health. They are also the future of our nation. They may be dependent at the moment while they are children and young people, but they are the leaders of the future. They have specific needs and their own views about the way that they are treated. If they are not listened to and considered in the way that services are planned, they will continue to feel that they are not valued as much as they should be by healthcare itself and that healthcare is not really placing their needs at its heart in provision.

In the Royal College of Paediatrics and Child Health handbook called My Right to the Highest Standard of Health, Professor Terence Stephenson wrote,

“we cannot afford to continue as we are. The health of our children is at stake and we need to address real issues, with real change that brings about real positive impact on the health outcomes for children and young people”.

Children and young people must no longer be treated as passive recipients of services. It is by feeling valued that their well-being will be increased. Particularly in prevention in healthcare, the engagement of young people is critical to ensure that health improvement policies and the whole public health agenda are taken up by the very group of people who will get the most benefit from them and will be most harmed if public health measures fail—that is, those who are in adolescence and about to transition into early adulthood.

Until now, unfortunately, as has already been said, some LINks have not seen fit for their remit to include children. Through these amendments, I seek reassurance from the Minister that healthwatch will be provided with the resources, knowledge and capacity to involve children and young people effectively and will therefore be able to represent their needs and interests on a local and national level. It cannot be viewed as a tokenistic voice.

I shall cite an unfortunate example that the RCPCH has brought to my attention. A large teaching hospital trust was preparing an application for foundation trust status. As part of the process it was asked to show evidence of patient and public participation, including the involvement of children and young people. In response to this, the trust asked for some young people who were in-patients to receive a patient satisfaction questionnaire. A number of young people completed the questionnaire as requested, but the results were not used during the foundation trust application as the opinions voiced by the young people were at odds with the views of the management team. That is a clear example of tokenistic consultation but then doing nothing about the answers that are received.

Children are able to contribute in a very generous way to the shaping of healthcare services because they will comment quite openly, not only on what they need and what would make their journey through health better but on the experience of others that they encounter on the way. Children and young people with chronic conditions will form close friendships and bonds with other patients in their cohort, whom they will meet regularly when they attend different treatment sessions, and will be concerned about the welfare of those other children. In the days when I was working in paediatrics, I recall vividly how children in the leukaemic unit would ask about the welfare of other children. They would want to know what had happened to a child who had died and to talk about where that child had gone. One little boy commented on another, “At least now he’ll be able to do what he always wanted to do. He’ll be playing football, but it’ll be in heaven”.

Children know what they need, where they want to go and how they want to be involved and consulted. The whole tenor of our health services can be greatly improved by actively seeking out their views and acting on them, however difficult and uncomfortable those views might be.

[Baroness Masham of Ilton]

My Lords, I also have my name to the two amendments in this group. Children need protection and the support that my noble friend Lady Finlay has just talked about. So much more should be done for children, but the big problem is that they fall under so many different departments which are far too isolated. I am thinking now of the young people who are at risk from drugs and alcohol. I went to a presentation last week where there were photographs up of young children who had died from a combination of drugs and alcohol. So much should be done.

I hope that the Minister will answer my question from the previous debate about children and the risks that they face, taking Baby P as an example. Again, many departments came in and he fell through the net: health, the police, child protection and local authorities. They should be working together for children. We really need to protect them.

[Lord Warner]

My Lords, I speak from a background of having been a director of social services and being involved in reforming youth justice. Collectively, the adult world is very bad at representing the needs of children to service providers. It would be a modest but important change in this legislation if we brought out that the term “people” does include adults and children. A lot of people in the adult world simply assume that “people” means “adults” and does not mean “children”. We see in the NHS, for example, particularly for the teenage years, that services are often provided in a way which is almost bound to deter engagement and involvement by young people in receiving those services and in dealing with some of the problems that they have.

We need to change the culture. We must ensure that in the new healthwatch system—whether it is the one that some of us would have liked or the one that there will actually be—people are sensitive to the needs of children, particularly at the local healthwatch level, and that those needs are not overlooked. It is not just a matter of making children feel better and that they are being listened to. It is actually about how we can get the services shaped to head off at a much earlier stage some of the trouble that is looming for many of these children, in terms of obesity, drugs, sexual health and unwanted pregnancy. I hope that the Government will listen sympathetically to this and move the kind of amendment that my noble friend Lady Massey has moved so ably.

--- Later in debate ---

[Baroness Masham of Ilton]

My Lords, perhaps I may ask a question following the speech of the noble Baroness, Lady Barker. Does healthwatch not cover health and social care? If it does, the noble Baroness, Lady Bakewell, has a strong point.

[Earl Howe]

My Lords, while, for reasons which I shall explain later, I do not feel able to accept this amendment, I say immediately to the noble Baroness that she has raised a very important issue with which the Government are in complete sympathy.

It is important for older people to have a strong voice to champion their interests and to ensure that their needs are addressed in public services. Both I and my honourable friend the Minister of State for Care Services have met the noble Baroness over recent months to discuss this issue and have been struck forcefully by the powerful case that she has made. As she is aware, my honourable friend would like to continue these discussions with her, as we are particularly grateful for the expertise that she brings to this area.

I am sure noble Lords will agree that older people are affected by a wide range of issues—not only health and social care but areas of policy such as housing and pensions. The Government recognise this. The UK Advisory Forum on Ageing, co-chaired by the Minister of State for Care Services and the Minister of State for Pensions, provides advice across government on the additional steps that they and their partners need to take to improve well-being and independence in later life.

In health, a range of functions in relation to older people are already carried out in this country. That should not surprise us because we all know that a very large proportion of the NHS budget is accounted for by healthcare delivered to the elderly. The Department of Health is pursuing a number of initiatives to improve the care of older people in hospitals, care homes and other settings. These initiatives cover all stages of the care pathway—from helping individuals to stay healthy and to stay in the community all the way through to end-of-life care. For example, the department already has a National Clinical Director for Older People, Professor David Oliver, whose remit is to promote the better care of older people across the NHS and social services, and to provide clinical leadership for cross-government work on older people.

My noble friend Lady Barker rightly stressed the key role of social care in relation to older people. Looking across the spectrum of health and social care, each health and well-being board will be required to develop a joint strategic needs assessment, identifying the current and future needs of the local population, and a joint health and well-being strategy to set out how those needs will be met. I can say to the noble Baroness, Lady Bakewell, that it is intended that health and well-being boards will bring together the key local commissioners to enable them, first, to consider the total resource available to improve their population’s health and well-being, and then to come to a joint understanding about how those resources can best be invested. This will undoubtedly help to encourage a more integrated local service which is better able to meet the needs of older people by joining up NHS and social care services. I hope that that offers some reassurance to the noble Baroness that the voice and needs of older people in health is absolutely a priority for this Government.

Amendment 231A proposes that the role of commissioner for older people should fall on a member of HealthWatch England. I am afraid that I cannot agree that that would be an effective approach. The first reason is the one that I mentioned earlier: the role of an old people's champion goes wider than health and social care. Equally importantly, the job of HealthWatch England will be to carry out functions in relation to people. The word “people” is a deliberately broad term and its ordinary meaning would include older people of course, so we do not feel that it would be appropriate to give a member of HealthWatch England a remit for older people, which would give additional weight to one group of people over another. It could also lead to calls for a commissioner for other groups like those with learning disabilities and it would be difficult to see where the list would stop.

Although I completely understand the concern that older people have often lacked a voice within the system, and the need to ensure that they are not overlooked, we do not agree that the singling out of this group over others, within the context of healthwatch, would be the best way to achieve that. We want to address the concerns of the noble Baroness but not in this way. In the light of that and on the basis that she will continue to have discussions with my honourable friend on the issue in a wider sense, I hope that she will feel sufficiently reassured to withdraw her amendment.