Health and Social Care

Lord Lansley Excerpts

Thursday 15th December 2016 Lords Chamber

[Lord Lansley (Con)]

My Lords, it is a privilege to follow the noble Lord, Lord Harris, and I pay tribute to him for his commitment over many years to patient and public involvement in health and care. The House is grateful to him for once more bringing these issues forward so that we can debate them, and I am glad to contribute. I join with him, as I know all noble Lords will, in sending our condolences to my noble friend Lord Prior of Brampton, whose father was a most-esteemed Member of both this House and another place and will be much missed.

The noble Lord is quite right about visiting hospitals. As it happens, I think that I visited the great majority of hospitals in this country in the course of being shadow Secretary of State and Secretary of State, but I was admitted to hospitals only when I was the shadow Secretary of State. If the noble Lord thinks that being the director of the Association of Community Health Councils sends a junior doctor into a flap, he should see what happens when the shadow Secretary of State arrives.

I am in completely the same place as the noble Lord on what is at the heart of patient involvement in healthcare. It is the principle of shared decision-making: “No decision about me without me”, as I enunciated it. That was not my original phrase but I adopted it. That should be a driving sentiment and form a cultural shift in how healthcare is delivered in this country. It is often still honoured in the breach rather than the reality but there are mechanisms to make it happen. They are not really structural; they are fundamentally clinical and cultural, and provide for shared decision-making not just in clinical guidance.

I remember, not so long ago, a very promising programme for preparing shared decision-making. The first that I saw was about prostate cancer; those who are familiar with what prostate cancer is, and what it means, will understand that the decisions made about treatment are very personal and important. They are not derived simply from what your clinician tells you should happen but are very much about one’s personal view. We have seen in quite recent scientific evidence that the clinical direction might often take people in a way which they would find less than immediately helpful, from a personal point of view.

Patients having the opportunity to exercise the choices that emerge from shared decision-making—clinical choices and choices on treatment and service provision—is at the heart of it. However, the debate about Healthwatch is not about shared decision-making for patients, and we should not confuse the two. There is nothing in the role of Healthwatch which should take away, or in any way substitute for, the central responsibility of any healthcare or care service provider to involve the public in scrutiny and engagement when designing their own activity. There is nothing which should stop them from ensuring that individual patients and care users are involved in their own care and the decisions relating to it.

In my view, Healthwatch is not about that. It may well look at whether people are doing that and comment upon it, but the responsibility lies with the providers of services, not with some external and independent regulatory function. The noble Lord said that it is a deliberately flawed system. I do not agree that it is flawed nor, certainly, that it is in any sense deliberate. The essence of the system is that there are providers of services, those who commission those services and those who regulate them. As we have seen in many other areas of public life, particularly where the Government are involved, it is in the regulatory function that we are looking for independence and scrutiny and, among the regulatory functions, one that is about being the champion for the consumer, the service user. That is what Healthwatch is about: providing within the independent process of regulation a voice that is dedicated to the consumer. It is not without precedent in other areas. For example, Postwatch, which I am sure many noble Lords will remember, was part of the Postcomm regulator but was also an independent consumer champion on behalf of users of postal services. In a sense, that was exactly the model that was to be used and that the Health and Social Care Act implemented for Healthwatch.

The noble Lord, Lord Harris, rather swiftly glossed over the fact that community health councils were abolished under the last Labour Government. He recited it as if one was followed by another which was followed by another, so there were patient and public involvement forums, then there were LINks and then there was Healthwatch. Let me make it to clear to him—I know he would, in truth, acknowledge this—that my experience of community health councils in my constituency was positive. Many of us were aghast in the early part of the Labour Government at their plan to abolish them. We knew perfectly well why they did it: it was because they said things that were inconvenient and unhelpful. Patient and public involvement forums then led to a significant deterioration in the voluntary effort. They virtually saw the paid staff giving executive support to community health councils abolished and the impact lessened. Under LINks, the impact lessened still more and even more of the immensely valuable volunteer effort that went into PPI was lost as a consequence.

Frankly, we did not create Healthwatch on the basis that we were simply rebadging something that had come before. We were setting out to recreate the independence and impact that we had seen in the best community health councils in the past, and I think that is the measure by which we should judge it. Last year’s King’s Fund report indicated that many in local Healthwatch think that they have made progress. I think Anna Bradley was an excellent chair and that she would probably say that within the structure she was working in, she made progress, but there is still a long way to go. With Imelda Redmond, the new chief executive and new chair in due course, we need Healthwatch England to assert itself much more. My view is very straightforward: it is independent. It is erroneous to suppose that Healthwatch England’s position as part of the Care Quality Commission is not independent. The Care Quality Commission is independent of the commissioners and providers of services, and it is the job of CQC and Healthwatch England to be external, independent, rigorous scrutineers of the performance, and sometimes the design, of the services that are provided to users. Within that, Healthwatch England should use its place within CQC to leverage the power of CQC, which is undeniably great inside the system, to be active on behalf of consumers—patients and care users—in giving them access to the services they want and, especially, to the kind of shared decision-making which is at the heart of this debate.

In my view, it is evident that at the moment the CQC does not see Healthwatch England as giving it that sense of what consumers want for priority-setting and helping to determine CQC’s activity and priorities. Equally, CQC should not be seen, to the extent perhaps that it sometimes is, as trying to put Healthwatch England into any kind of box and saying, “Your job is PPI, and you should not be impacting on what our priority decisions are in relation to scrutinising the service and reporting on it”. That is where it should be, as part of the CQC’s role is about bringing to bear the powers of the overall organisation. But remember that local Healthwatch organisations and Healthwatch England have their own powers, including powers of entry and scrutiny which were not available to their predecessor organisations and not there before. They should use them, although they are not a substitute for the overview and scrutiny of local authorities or for the democratic accountability of those authorities.

The solution reached in 2012 was won in a coalition Government, where the involvement of local government was very much at the heart of the Liberal Democrat participation in decision-making on that Bill. That is why local Healthwatch organisations are, in part, where they are in relation to local government. But we need now to recognise that as you progress inevitably sometimes people lose sight of the powers they have got, the potential they have and the structure that is available. It is not a flawed structure; it is viable structure, but it depends on those who participate in it using their powers to the full and, in particular and most significantly, on local authorities and the CQC recognising that they must use, amplify and assist the voice for the patient and the care user represented by Healthwatch nationally and locally, and not marginalise it.