Health and Social Care

Baroness Watkins of Tavistock Excerpts

Thursday 15th December 2016 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I congratulate the noble Lord, Lord Harris of Haringey, on securing this debate, to which I am pleased to have the opportunity to contribute. I join with other Members of the House in offering my condolences to the noble Lord, Lord Prior. I am sad that he cannot be here today but delighted that the noble Baroness, Lady Chisholm, will respond. Perhaps I may declare my interests as outlined in the register.

The briefing paper from the Library rightly identifies how public and patient involvement often appears to be a nebulous and ill-defined concept that means different things to the multiple stakeholders. We heard recently that some health service commissioners in partnerships with local authorities have spent less than 1% of their total budget on mental health/public health initiatives, yet this House has heard consistently about the growing problem of self-harm among adolescents. Investment in public health initiatives in mental health, for example through school nurses, is chronically underfunded. There are ongoing difficulties in accessing children and adolescent mental health services, and indeed I have heard people say that CAMHS stands for “Can’t Access Mental Health Services”. So where, I must ask the Minister, is the voice for some of the most disadvantaged service users in health and social care? If you cannot access a service, you do not become a user, so what structure do we need in the future to ensure that influencing the health and social care spend will involve the widest range of people in society?

I believe that user representation in health and social care is still biased towards those who speak the loudest and have physical healthcare needs because of cancer, heart disease and diabetes. We are told, for example, that cuts in health visiting of around 20% are likely to be made soon. Again, this will affect a very disadvantaged group, the under-fives. The King’s Fund has observed that putting patients first has become a “mantra” of politicians and senior policymakers with the aim of ensuring,

“a stronger voice in decisions about health and care, and that services should better reflect their needs”.

I will not go over the national structure of Healthwatch which has been so ably described by other speakers, but it is important to note that areas of good practice have emerged. However, it is acknowledged that there has not been systematic progress in the field of Healthwatch and user representation. As outlined by others, the King’s Fund gives three core reasons for this, the first of which is a lack of understanding of what involving people in health decisions means. As outlined by the noble Baroness, Lady Pitkeathley, this is working well at the clinical level but at the strategic level is it often much more problematic. It is difficult, suggests the King’s Fund, because it challenges “vested interests” and current “orthodoxies” about the way funding is controlled, as well as asking whether it really has been a priority. The differences in Healthwatch’s allocations as outlined by the noble Lord, Lord Harris, show that although I was going to argue that Devon is underfunded, when compared with Manchester it is doing well. That reflects the difficulties of prioritising in different places.

In fact, some real advances have been made. User involvement is seen as a real priority in the context of the phrase that other speakers have referred to: “No decision about me without me”. That is a key part of any university healthcare curriculum designed to prepare students for professional registration, whether as a nurse, midwife, doctor or physiotherapist. I assure noble Lords that in my own nursing education 40 years ago, which was not dissimilar to that of the noble Baroness, Lady Chisholm, it was not a key part of our curriculum. User involvement in their own care plans is now an established expectation.

Problems emerge when the healthcare professional and patient—or user—cannot access the right care at the right time because of lack of investment or priority. If I go to my GP with a breast lump that he thinks might be cancer, we will both agree that I should be assessed by a specialist team within two weeks. In most parts of the country, this will be achieved. Hypothetically, if I go to the GP with a 12 year-old daughter who is cutting her arms and losing weight, the GP may agree with her that she should be assessed by a child and adolescent mental health team within two weeks. She may at that point be ready and willing to go for this assessment, but in many areas of the country it is quite likely that it will not be arrangeable within two weeks. Indeed, in some parts of the country, the reported waiting time for such an assessment exceeds six months.

This moves the debate on to the extent to which patients and service users really influence how much is spent on different healthcare services by different bodies. The new strategic development plans are designed to have this debate at a local level, using approved networks to try to get the most appropriate healthcare spend for the vast majority of the population. I believe the SDPs are fundamental to the redesign of health and social care services and that Healthwatch is fundamental to engaging the local communities in this process.

How do I think we are doing where I live in Devon? I asked the chair of Healthwatch Devon to assist me by saying how much she feels they are involved in the SDP process in Devon. I will give your Lordships some idea. There are three Healthwatches in Devon, all of which agree that the definition of patient and public involvement needs clarification, following the numerous NHS documents and references to involvement of patient and public experience in service review, engagement and consultation.

In Devon, the three Healthwatches have come informally together through their chairs to work with the SDP to lobby for engagement and consultation, but they point out to me that the three chairs of Healthwatch are not engaging fully with the community because they have neither the time nor the resources to do so. However, they are also very confident that they are endeavouring to pursue the role of advocate for the community and challenger of the commissioner as independently as they can, but they say that, given they are funded by the LA, they also see the need to work in partnership with strategic players if they are to achieve respect and understanding of the drivers and strategies integral to service review, and therefore lobby at the most senior level for patient and public involvement. These are two roles that many academics have pointed out are to some degree in conflict.

While it is clear that CCGs are required to consult Healthwatch, there is not necessarily a requirement to accept its recommendations. Indeed, the Francis report raised concerns about its flexible framework, suggesting that there needs to be greater consistency.

The health budget is indeed under consistent and prolonged challenge. It is vital that local communities reach sound conclusions about their strategic development plans. As has been pointed out, in many rural areas it is being suggested that community hospital beds should be closed to reinvest the health service pound into rehabilitation services that would more readily reach the population through swift access at home to physiotherapists, occupational therapists and nursing. Yet that changeover will need transitional funding if it is to be conducted safely. Any debate about SDPs will be difficult, but I urge the Minister to ensure that young people are involved in working with Healthwatch and other patient user networks to influence the development of sound mental health and learning disability services as well as the appropriate redistribution of services and resources for physical health provision. To do this, I suggest that Healthwatch, or an equivalent structure, needs to be less nebulous and mandated to include independent scrutiny of the comprehensive health services, including public health and social care. Only in this way will local people have real influence in shaping the degree of services that are needed to meet the challenges in local communities.