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House of Lords Hansard
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Health and Social Care
15 December 2016
Volume 777

Motion to Take Note

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That this House takes note of the case for effective service user representation in health and social care, and of the case for enhancing the independence and capacity of Healthwatch England and of local Healthwatch groups.

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My Lords, I am sure the whole House will want to begin by placing on record again its condolences to the noble Lord, Lord Prior of Brampton, who would under other circumstances have been replying to the debate. We are sorry he is not here because of both the circumstances and what he would have brought to the debate as a former chair of the CQC.

I begin by declaring some personal history. For 12 years I was director of the Association of Community Health Councils for England and Wales, which was then the statutory body representing the interests of NHS users at national level and supported a network of 200 or more member community health councils. That is what I bring to the debate.

I apologise in advance if my remarks are coloured by that experience, but it is good to start by considering why patient involvement matters. It begins with the interaction between patients and clinicians, or service users and those who are caring for them. The Eurobarometer qualitative study on patient involvement, produced by the European Commission in 2012, summarised this well, saying that better communication is the central idea of patient involvement:

“For patients, this meant practitioners explaining to them the diagnosis and treatment. For practitioners, it meant patients describing symptoms and keeping them updated”.

The objective is a partnership between the clinician and the patient. There is evidence that where such partnerships exist they improve the outcomes of treatment because the patient is more committed to the treatment proposed and understands it better.

Patient involvement is also critical to service design and organisation. Those responsible for a service often have little understanding of what it is like to use the service in question—although, I have to say, they think they do. The reality is different. A senior clinician or senior manager inevitably ends up being treated differently if they suddenly become a service user.

At the risk of boring your Lordships, I mention a personal anecdote, which one or two may have heard before. This point of not knowing what the service is really like was brought home to me rather forcefully almost 30 years ago. After speaking at a conference, I began to feel increasingly unwell. To cut a long story short, shortly afterwards I found myself at my local accident and emergency, being prodded by a junior doctor, who was clearly completely baffled—as, indeed was I—as to what might be wrong with me. He then did what a junior doctor always does under those circumstances: he follows the protocol, which is to say, “So tell me, Mr Harris, what do you do for a living?”. I know that I should under those circumstances have lied in the interest of getting the true personal experience, but what I actually did was say, “Well, in fact, I’m the director of the Association of Community Health Councils”. The junior doctor then went behind the curtain. Of course, it is a fallacy that you cannot hear what is going on on the other side of that curtain. I could hear him phoning the consultant: “I think you should come down, sir. He says he’s the director of the Association of Community Health Councils”.

That, of course, is the experience when any senior clinician or senior manager is taken into a casualty department or tries to use a service. The reality is that services are better if they reflect the needs of the users of that service, which is why putting patients first at the centre of the NHS has been the mantra underpinning every government statement on the NHS since it was founded in 1948. The noble Lord, Lord Lansley, who is about to speak, will recall using very similar words during his time as Secretary of State. Incidentally, on the issue of personal experience, I seem to recall seeing all sorts of statements on what various clinicians would like to do to the noble Lord if they ever found him in their care, but fortunately that never happened during his period of brief notoriety in that role.

The most recent iteration of this mantra was probably NHS England’s five-year forward view, which advocated involving communities and citizens,

“directly in decisions about the future of health and care services”.

Since 1974, successive Governments have supported different models of involving the public in shaping services and of representing the voice of service users. First there were community health councils, until they were abolished in 2002 and replaced by patient and public involvement forums, which were in turn replaced by Local Involvements Networks—LINks—in 2008. They in turn bit the dust with the arrival of Healthwatch as part of the Health and Social Care Act 2012.

That Act had a tortuous passage through Parliament. Somewhere along the way, the model intended for Healthwatch at local level was changed. Those changes were given very little parliamentary scrutiny despite my personal best efforts, when I warned that the late changes to the Bill risked weakening the new bodies by starving them of resources and laying them open to conflicts of interest with local councils, which were to be their paymasters. The arrangements for Healthwatch England would inhibit its independence and effectiveness.

I am sorry to say that the concerns I expressed then have been borne out. Healthwatch England remains a sub-committee of a regulator, the CQC, a body that is already overstretched and to which requests for action and, from time to time, criticism may be directed by Healthwatch England or local Healthwatch. For Healthwatch England to be located there compromises its independence and must limit its scope to highlight when the CQC is not being as effective as it should be. Recent changes appear to have made Healthwatch England’s relationship with the CQC even more subservient, with changes to the chair and chief executive being used as an opportunity to make the role even more subordinate to the CQC.

I am grateful to have received in advance of this debate a letter from David Behan, chief executive of CQC, seeking to reassure me of the independence of Healthwatch England from the CQC, but in it he records:

“The National Director for HWE will be line-managed and accountable to myself as the CQC Chief Executive”—

apparently a new distinction. He further states:

“The HWE Chair is already accountable to the CQC Chair”,

and that the strategy of Healthwatch England has to be submitted to the CQC board for endorsement. That hardly sounds like independence.

Healthwatch England is reasonably generously resourced for what it does, with a budget of £4.5 million, but in 2015-16 it could not spend that and used only £3.7 million, a 17.3% underspend. A very small proportion of that goes on developing and supporting local Healthwatch. Nor does local Healthwatch feel that Healthwatch England is there for them and they have little scope to influence it or its work.

Healthwatch England also seems to fail in capturing and articulating the views and concerns of local groups, so much so that a private company, Glenstall IT, has stepped into the void by collating reports and publications of local Healthwatch groups, something you might have expected Healthwatch England to do, and selling the digest back to 2,000 health and social care professionals. The fact that Healthwatch England is not doing the job means that a private company has come in to sell it back to the people funding the system.

What about the resourcing of local Healthwatch groups? In 2013-14, the Department of Health passed over £43.5 million to be included in the local authority block grant to fund local Healthwatch organisations, but the total funding given to local Healthwatch groups in that year amounted to only £33.5 million—£10 million had disappeared along the way. That is before taking into account the cost of the cumbersome arrangements for competitive tendering and commissioning through third parties imposed by those late changes to the Health and Social Care Bill.

While there was £33.5 million in 2013-14, that fell to £31.8 million in 2015-16 and again to £29.9 million in this financial year—a third less in cash terms than the DoH thought was necessary and had handed over three years earlier. I warned the Department of Health that this would happen and that other pressures on local authority budgets would produce this squeeze, yet it acquiesced in allowing the money to go across unring-fenced. Was this a deliberate attempt to hobble patient representation and independent local scrutiny?

There is a big variation in the funding of individual local Healthwatch groups. Bristol provides £400,000, while Manchester only £80,000. Are the needs of the citizens of Manchester for effective patient representation one-fifth of those of the residents of Bristol, whose population is 50,000 less? Some areas have seen big cuts year on year: Barnsley down 25%; Blackpool down 50%; Bradford down 25%; Ealing down 25%; Harrow down 40%; Hounslow down 50%; Leicestershire down 30%. I could go on.

Some of the reductions are of course a consequence of the enormous continuing pressure on local council finances, but how much is it a consequence of local Healthwatch having a role in monitoring local social care provision—the responsibility of the same local authority that fixes their budget and may perhaps not like the criticism that an effective local Healthwatch group might occasionally have to make? Local authorities have a conflict of interest here and I am told of a number of local Healthwatch areas where this has had a deadening effect, particularly on the willingness of paid staff members to criticise those who provide their monthly paycheques.

One example is of a 30% reduction in funding imposed on Oxfordshire Healthwatch by Oxfordshire County Council, which seemed to follow, as night follows day, from criticisms that the local Healthwatch had made of the county council record on social care—precisely the job that Healthwatch was created to do. As one of its board members tells me, “The cut inflicted on us drove us to relinquish our strategically located premises close to the CCG headquarters and move to the cheapest possible accommodation on the edge of a farmyard in remote countryside. We have had to cut back on project work, assistance for voluntary groups and a range of community engagement activities. All this arose because our funding was not independent and ring-fenced, and was routed through a body we had criticised”.

In Manchester, the city council swallowed most of the Healthwatch budget, leaving what has been described to me as, “a puny organisation. They are not very effective and they don’t relate to any of the other patient organisations”. As the King’s Fund put it in its review carried out for the Department of Health:

“Local Healthwatch organisations are very small in comparison to the potential scope of their statutory activities, and the population and services they cover”.

The effectiveness of the input that local Healthwatch can provide is critical at present, as the sustainability and transformation plan process rolls forward throughout the country. According to NHS England, this process is supposed to be about building and strengthening local relationships, and service users should be at the heart of the process.

How has this worked out? Frankly, it is very variable. In some areas—Sheffield, Staffordshire and Bath—there is good involvement, but not in others. In Berkshire, Devon and County Durham, local Healthwatch was neither involved nor consulted. In Liverpool, local Healthwatch complains that the process has not been open or transparent. Its chair says, “We have not yet had the opportunity to review or scrutinise the detail of the plan”. In the East Riding, there has been no involvement. The MP for Tottenham had to ask a Parliamentary Question to find out who was consulted during the development of the STP for North Central London. None of the local Healthwatch groups was part of the transformation board. As one local Healthwatch rep from elsewhere in the country put it, “The STP thing is a nightmare. They think we patient reps are just a box to tick and the patronising attitude from some is breathtaking”.

Local Healthwatch also has the important power to enter and view services, but the King’s Fund study for the Department of Health found that this power was used in a wide variety of ways, with some of the case study sites doing none because they were unclear about what would justify an enter and view visit. Many local Healthwatch groups only carried out visits on a prearranged basis. Some saw it as a routine part of their intelligence gathering, while others felt it was only justified when “serious or multiple concerns are raised”. Clearly, there is no guidance and local Healthwatch organisations are left time and again to reinvent their own wheels.

As one local Healthwatch activist put it to me, “Too many of us do little E&V. What they do is announced and done by employed staff who have a vested interest in not rocking the boat”, because their salaries are paid by those they are inspecting. All this comes at a time, as the CQC admitted recently to the Health Committee, when it is struggling to manage inspections of establishments every other year. Local Healthwatch could provide an enormous resource to supplement and inform inspections by the CQC, but its potential enthusiasm is simply being stifled.

None of this should be taken to imply that the work done by hundreds, maybe thousands, of local Healthwatch volunteers is not valuable. I am aware, of course, of the many dedicated staff supporting them, but the reality is that the Department of Health has set up a deliberately flawed system. In the name of localism there is allowed to be an enormous variation in how local Healthwatch organisations structure their governance, as highlighted in the King’s Fund review. As a result, there is a lack of clarity in who speaks for local service users. Is it the board, is it its members, is it the host organisation, is it the staff or is it the volunteers? As a result, the authority of that voice is undermined. The King’s Fund criticised the lack of transparency of local Healthwatch and, as one volunteer put it, its structure and governance should follow the same pattern everywhere and not be determined on the whim of a local authority or a private host company.

It could be so different. As the King’s Fund review said:

“Some of the challenges that local Healthwatch face could be addressed through greater support, advice and shared learning on how to operate effectively”.

The tragedy is that Healthwatch has enormous potential. It could be a tremendous force for good in enabling health and social care services to be much more effective and user-centred. It should not be a box-ticking exercise or provide a woolly voice, but provide effective scrutiny with real influence and a real ability to involve the public. That is what the vast majority of those engaged in Healthwatch activities want to do but, alas, their ability to fulfil that role has been hampered by the cack-handed way the system was established, by the department’s failure to prevent the erosion of funds and, just possibly, by the fact that too many local and national service managers would prefer a quiet life, without having to respond to an effective user voice. I beg to move.

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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.

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My Lords, there are very few people who know as much about patient participation as my noble friend Lord Harris, so it is entirely fitting that he should lead this debate. I join others in sending condolences to the noble Lord, Lord Prior, and regret that he is not here—by which I mean no disrespect to the noble Baroness, Lady Chisholm, who I know will have more than an adequate response for this debate.

I have never heard anyone say that patient participation should not be encouraged or that it is in any way undesirable. On the contrary, I have heard the praises of patient participation sung over 40 years or so. Sadly though, its history is not marvellous and we have not made as much progress towards the reality of “nothing about me without me” as the rhetoric might suggest. But being critical of the progress of patient participation as a policy does not mean being critical of individual transactions and relationships between NHS staff and patients. On the contrary, I should point out that my own experience as a patient has always been good. Although I was, at one point in my life, in hospital for six months, I have no complaint to make on that score. In the whole of that time nothing was ever done to me—no procedure was started or undertaken with my consent—without asking my opinion and acting on my opinion when I gave it. Your Lordships might point out that there are not perhaps many Baronesses with an interest in healthcare on NHS public wards, but I always perceived the same care and respect being given to my fellow patients, however frail they were and however poor their English was.

But putting patients first in policy terms is easy to say and hard to do, as the various attempts over the last 20 years have shown. As the King’s Fund has observed, despite pockets of good practice, there has been a lack of systematic progress, and it suggests three reasons for this. The first is a lack of clarity about what involving patients and people in healthcare actually means, so people and staff are confused about what is expected. The second is the power issue. The involvement of patients challenges orthodoxies, vested interests and established ways of doing things. If you share power with patients, which everyone says they want to do, it means that someone—the doctor, the nurse, the administrator—has to give up a bit of their power, and that is hard for them to do. The third reason the King’s Fund opposes this is that it may have been a goal but was never a priority across the healthcare system.

It is important to recognise that patient and public viewpoints and opinions can make a genuine contribution to debate in shaping national policy and enhancing accountability. It can also help you to manage resources better, as what patients actually want may be less than what professionals imagine they want. The previous attempts to set up effective means of harnessing patient and public views have been set out by my noble friend. We all remember CHCs. I do not think PALS has been mentioned thus far. LINks, forums and the Commission for Patient and Public Involvement in Health have all bitten the dust amid a storm of criticism that they were not representative, too bureaucratic, not good value for money and so on. Many would argue that they were never given either adequate time or resources to prove themselves.

I am on record as saying I was not a fan of the Health and Social Care Act 2012, which in my view has had a deleterious effect on health and social care because it put in place a disastrous and unnecessary reorganisation even though a pledge had been given when the Government came to office that no such reorganisation would take place, and which distracted the hardworking staff of the NHS at a critical time. However, in spite of the late changes to the Bill that my noble friend pointed out, the setting up of Healthwatch seemed like a ray of hope, a concerted attempt to bring the voice of the patient and consumer into planning and a means of feeding back the actual patient experience.

The vision for Healthwatch is inspirational. It seeks a society in which people’s health and social care needs are heard, understood and met so that people can shape their own care, influence its delivery and hold services to account. I commend the work of its first chair and CEO, together with its board, in setting up the organisation and beginning to establish public trust. The combination of local organisations, fully linked into local concerns, with a national body to influence public policy could provide the best chance that we have yet seen to establish effective service-user representation. The current state of health and social care can leave no one in your Lordships’ House in any doubt of how much that is needed.

As we have heard, though, there are two big issues facing Healthwatch. First, it is only as strong as the performance of its local organisations. Funding at local and national level is being squeezed, with about half of local bodies reporting reductions, and in the current year the funding is one-third less than the £44 million originally allocated to local Healthwatch organisations for them to carry out their statutory duties. We should remember that their complaints work is just that—a statutory duty. Many local Healthwatch organisations are already reporting that the situation next year will be even more difficult.

It is now widely accepted that a major problem facing health and social care is the need for service redesign—the integration of budgets across health and social care, for example, and more rationalisation of hospital services. Unless we involve patients and families in this debate, we will waste time and money on dealing with the resistances that such changes inevitabily bring about, so it would be a wise investment to support local Healthwatch. That is clearly not happening, as my noble friend has reminded us.

The second major issue facing Healthwatch, as we have heard, is about independence. Healthwatch was conceived as independent at both local and national level. The trust of the public depends on that independence. The closeness to the CQC—its subordination, some would call it—has compromised this, but there is some feeling too that the Government are too sensitive to criticism, and the decision not to renew the contract of the outspoken first chair is perhaps evidence of that. We have heard that this defensiveness is widespread at local level too.

This has been an all-too-frequent result of previous attempts to set up effective patient representation, from CHCs through to the Commission for Patient and Public Involvement in Health and the other organisations we have heard about. What happens is that Governments commit to effective patient representation with a big fanfare. Then, the body starts to act effectively, asking for change and giving patient feedback. Then the Government of the day say, “Hang on a minute, we did not want that kind of feedback”.

If they are really committed to patient and public involvement, governments at local and national level must stop being defensive, be confident about the positive role that the voice of patients can play and use the feedback received to improve services, which is surely the aim not only of patient representatives but of the Government themselves. I hope that the Minister will assure the House that that is indeed the aim of this Government and that they remain committed to a strong, vibrant Healthwatch at both local and national level.

I could not be more delighted by the appointment of Imelda Redmond as the new CEO of Healthwatch nationally, and wish her well. Let us please learn from the history of patient and public involvement, and not make the same mistakes again.

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My Lords, I, too, thank the noble Lord, Lord Harris of Haringey, for instigating this important debate and add my condolences to Lord Prior’s family: his voice will be sadly missed, not just in this House but in the whole of the health and social care sector, to which he devoted much of his political life.

As a patient and service user with rheumatoid arthritis, a life-limiting condition, I have extensive experience of the NHS, but also of the charitable sector, which I suspect is not often mentioned in patient engagement. In particular, I put on record my thanks to the National Rheumatoid Arthritis Society for its advocacy and support, Arthritis Care, which, before I was in my wheelchair, kept me out of one with tai chi for people with disabilities, and Arthritis Research UK, for its medical and practical daily living research.

Over the years, the NHS has launched a number of initiatives to improve patient engagement, and the words are very fine. It is interesting to note from the 2015 report from the think tank Reform entitled Expert Patients that the NHS constitution was established to drive greater patient engagement yet, according to one survey, 76% of patients had not heard of the constitution before receiving any treatment and only just over half were aware of their right to choice of NHS services. According to a survey three years ago, nearly 100% of patients wanted to access their electronic records but 67% did not know where to start to get them.

The 2002 Wanless review of health spending projected that higher levels of public engagement could both improve health outcomes and reduce cost—very important in our society 15 years on, with a significantly ageing population and real pressures on our health and social care sector. Under Wanless’s fully engaged scenario—your Lordships will remember that he had three scenarios about how seriously the NHS could implement engagement—a key component of healthcare expenditure was public behaviour: not how the service responds over the next 20 years but how the public and patients respond. The problem is that public and patients need education on how to respond. It is absolutely clear that costs could be reduced if that were the case, but I think most patients with experience of the NHS would say that their experience was patchy—even expert patients such as myself, who probably have considerably more than the average interaction with the NHS.

Patient awareness is entirely reliant on information and attitude support from every quarter. It was interesting to hear noble Lords contribute their experience of A&E. On an unfortunate visit to A&E when people thought I was coming down with an infection, I was told by the A&E consultant that I knew too much about my disease; whereas my consultant is always keen to ensure that his patients know and understand exactly what is going on, so that they can recognise problems. Continuing my theme of using rheumatoid arthritis as my exemplar of where it can work extremely well, the British Society for Rheumatology service care pathway articulates very clearly how even non-health interactions are vital. Patients’ understanding of the need for an improved diet and making sure that they get out and meet new people, that a life-limiting disease will also affect their emotional life, that they will need to address that and get help when they need it, and that they need self-awareness of both their disease and self-worth, because people often end up having to give up work—all those things, and the informal education you get from that, will increase confidence. It will also improve health and decrease anxiety, provide better sleep, make patients want to try new things and increase their motivation. All those things then have a knock-on effect for every part of the society that they are in, whether it is with family, work, friends or, very importantly, in the healthcare sector.

Just to give noble Lords a picture of what was happening with rheumatoid arthritis 20 years ago, people with my level of disease would spend perhaps three spells in hospital a year—perhaps a week at a time when they had a flare-up—and they had very little access to physiotherapy. Five years ago, in-patient stays were virtually removed, but treatment was being given as with cancer treatment: you would go in for a half-day a month for an infusion. Now most patients with the sort of disease that I have are self-injecting at home and—whisper it carefully—have interaction with the private sector, which delivers my injections and provides support in the early days to make sure that all is going on well. So it is not just about acute hospital times and costs. With this one disease, through the attitude of the consultants working with patients, the entire patient pathway has been completely transformed within five years and is unrecognisable from that of 20 years ago.

NHS RightCare has articulated very well some of the issues about how we increase patient pathways at an earliest possible date. One or two very good examples are offered by Professor Matthew Cripps, of fictional pathways. The first is for someone with diabetes. In our current standard care system, at the age of 45, after two years of a bit of trouble, Paul—this fictitious patient—goes to the GP, who does tests. She is a good GP, but she does not understand about diabetes pathways, so she manages his condition with diet, exercise and pills, but it is not working. Five years on, he has given up smoking and is reducing his drink. He is certainly managing his exercise, but his condition has worsened and, within two years, he is facing amputation of a leg; his condition further deteriorates, with heart problems as well, and within a few years he dies. The alternative patient pathway would mean that from the moment he first went to his GP, the entire health system would have picked up his support. He would be referred to specialist clinics for advice and support, including on stopping smoking, changing his diet and making sure that he got the right exercise. That first journey costs £49,000 to the NHS; the second, where the condition is managed over the same period, costs £9,000. So not only do we have a happy patient with a significantly reduced exposure to his disease but we have a significant cost saving to the NHS.

The other example is of elder care, which is often not talked about with patient experience. Not many people are aware that the time that somebody aged 65-plus who goes in after a fall, say, spends in hospital can equate to a year per week in muscle deterioration, so that you could come out after five weeks in hospital five years older. Or, if you spend, as is currently common with delayed discharge, 10 weeks in hospital, you could have aged 10 years in your body, with all the concomitant problems that go with that.

It is extremely important that every single part of the health and social care system participates in patient involvement. Wanless predicted that we could save a significant amount of money, but the Reform think tank updated his figures and said that by 2021, with real engagement, the NHS could save £1.9 billion, rising to £3 billion by 2063.

Simon Stevens, in his first speech as chief executive of the NHS, said:

“At a time when resources are tight, we’re going to have to find new ways of tapping into … sources of ‘renewable energy’”—

by,

“boosting the critical role that patients play in their own health and care”.

The example that I just gave from RightCare shows that it is not consistent in the NHS, nor indeed is the balance that we have as a society between health and social care working for us. The public health and social care system—which is where, importantly, Healthwatch comes in; I will not repeat the issues about its funding—is absolutely vital.

I spent a day with Healthwatch Stockport just over a year ago. The groups do not perceive themselves as regulators. They understand that it is part of their role but they are absolutely clear that they represent the voice of the people who use services and carers, and that they have responsibility for overseeing those services and reporting concerns back. There is that regulatory role but it is about the community work that they are doing. I saw this with ordinary people, the patients who had developed their own interest, working as the voice back to the NHS to make sure that things were working in Stockport. It was an extremely impressive community operation.

I support Healthwatch and the health and well-being boards as absolutely vital in local development. The noble Lord, Lord Lansley, is right to say that this was a priority for the Lib Dems when they were in government. The problem we face these days is that the funding gap, both for local councils and for social care, is creating a real problem. The King’s Fund said that a £2.4 billion funding gap as a result of the refusal to fund social care in the Autumn Statement is very real. That is one reason why the Liberal Democrats made it absolutely plain that we must prioritise funding immediately—not wait until next year’s local government settlement can come in to start to deliver. We hope the announcement will follow later today; it has been widely leaked. Two per cent per annum over three years of increased council tax to 3% over two years in council tax is not new money. That will not solve the problem, nor will it resolve the issues about patient engagement.

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My Lords, I thank the noble Lord, Lord Harris of Haringey, for having secured this debate, which for some time I have thought needs discussing. I join other noble Lords in sending our thoughts at this time to the noble Lord, Lord Prior. I also congratulate the noble Baroness, Lady Chisholm of Owlpen, for taking on the extra load. As we draw near to Christmas, the ill, disabled, frail elderly people and the vulnerable homeless should be in our thoughts at this time.

We hear a great deal about the patient-centred health service. This should not just be words; patients and patient associations should be part of the system and the patients’ voice should be listened to. They should be part of the team, not just a number to be dealt with. I declare an interest as president and founder of the Spinal Injuries Association. We have a wealth of knowledge collected over the years, which we are only too pleased to share with anyone who may be interested. It is a catastrophic situation if you break your neck and become paralysed. SIA supports members and their families. We have a very complex health system. With so many different bodies it is difficult for even health professionals to know their way around and who is responsible for what.

I support flexibility of care and encouraging health and social services to work in co-operation and communication, which must be the best way. But the fact is, both the National Health Service and social care are in crisis due to pressure and shortage of doctors and other staff, so there are demands on the services and a lack of funds to cover the increasing needs of patients who expect and want a high quality of care.

Growth in the workforce has not kept pace with the growth in patients. The Government ought to do a comparison between the UK and Germany to understand why patients seem to get a better service in Germany. When new life-saving drugs come on stream, German patients get them quickly while our patients have to wait, and sometimes never get them. This debate addresses the effectiveness of the local Healthwatch network and its independence from sponsoring local authorities, and the role of Healthwatch England. Healthwatch England and the local Healthwatch organisations have a number of statutory duties such as promoting and supporting the involvement of local people in the commissioning, provision and scrutiny of local care services.

The health and social care reforms of 2012 set a powerful ambition of putting people at the centre of health and social care. To help realise that ambition the reforms created Healthwatch in every local authority area across England, and Healthwatch England is the national body. Healthwatch is supposed to be unique, in that its sole purpose is to understand the needs, experiences and concerns of people who use services, and to speak out on their behalf. Knowing this debate was to take place, I asked many people if they knew about Healthwatch and what it is supposed to do. Not one of them had heard about it, including my sister-in-law who is Lord Lieutenant of the East Riding of Yorkshire.

North Yorkshire is bigger than the whole of Belgium, and that county has only one local Healthwatch, situated in York. There are many problems at the moment in rural areas, with community hospitals and care homes being closed, but I have never heard a comment from Healthwatch supporting the local communities. If there is an important health issue, it is the Patients Association which is asked to comment by the press. Perhaps this debate will help to expose some of the problems. I feel that Healthwatch bodies do not represent rural areas; they are situated in large towns and cities and are spread too thinly to do the job of helping communities. Last Friday morning, my secretary telephoned the Healthwatch in York to get some information but she got only an answerphone. She left a message but we never got a response.

I want to tell noble Lords about a positive project. Independent Age, a voluntary organisation, has joined with Healthwatch Camden. Independent Age has developed a quality assessment for care homes based on the things that older people and their families want and need. Because Healthwatch Camden has a statutory right to enter care homes on request, it has partnered with Independent Age as part of a pilot programme. This will increase the amount of information available to older people when making decisions about their care, as there is often not enough transparency over which care homes are good and which are not. It is good to hear of bodies working together. So much time and energy is wasted when organisations work in silos.

North Yorkshire’s health watchdog, the county council’s Scrutiny of Health Committee, will hold a high-profile conference on 16 December—tomorrow—in response to NHS England’s plan to reorganise services in the area. The Government are rolling out sustainability and transformation plans—STPs—which cover 44 different areas of the country and are intended to accelerate the implementation of the five-year saving plan. The fear is that plans are being rushed through and modelled around the needs of urban centres, depriving the needs of rural areas.

The county has already seen reductions in health provision, with the closure of the Lambert Memorial Community Hospital in Thirsk and the downgrading of the maternity unit at Northallerton. The distances in rural areas can be immense. People do not mind travelling long distances to specialised expert services, but for respite care and general medical matters they need to be nearer home. Can the Minister give an assurance that the special needs of rural areas will be safeguarded across the country? There is suspicion of STPs, which do not seem to be open and transparent.

Everyone wants a thriving NHS, not a failing service. Many people thought that if they voted for Brexit, the money saved would go to the NHS. They will feel that they were led up the garden path if things do not get better.

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My Lords, I thank my noble friend for introducing this debate and commend him for his continuing interest in this issue. I join with other noble Lords in offering condolences to the noble Lord, Lord Prior. The headlines earlier this week following the Care Quality Commission report sharing the experiences of families seeking information about the death of a relative make this, regrettably, a timely debate. I declare an interest as chair of the National Housing Federation, and in a moment I will say something about the importance of the role of housing associations in supporting users of social care. First, however, I will support my noble friend in his comments about Healthwatch England.

Just over a year ago, NHS England published its Patient and Public Participation Policy, which pledged to,

“work in partnership with patients and the public, to improve patient safety, patient experience and health outcomes; supporting people to live healthier lives”.

Those are laudable aims. The problem in achieving them—as the King’s Fund and others have pointed out—is that it is not entirely clear what involving people in health means; and when you attempt it, difficulties arise because often this challenges vested interests and the established way that people do things. Yet, as the chief executive of the CQC, David Behan, has said, what distinguishes many of the good and outstanding services that exist is the way that they work with others: hospitals working with GPs, GPs working with social care, and all providers working with people who use services.

Those services, we hardly need reminding, are under increasing pressure. This makes the role of Healthwatch England and local Healthwatch groups all the more important. As other noble Lords have said, having a local voice for users of the health service is critical to the development of the service. They are the only organisations with an overall view of an entire local health and well-being system. Their responsibility to use public experience to drive service improvement is a vital one. We now have a network of local Healthwatch organisations across England’s 152 local authorities, supported by more than 6,000 volunteers. Almost four years on, it is certainly right to ask about their effectiveness.

I share the concerns already voiced about Healthwatch England’s independence. When it was established in 2012, it was hosted by the CQC but reported directly to the Department of Health. A restructuring this year means that the national director now reports directly to the chief executive of the CQC and aims to “work more closely” with the CQC. How free will Healthwatch England be to criticise the CQC if it is embedded within it? A too cosy relationship makes it harder to be a critical friend.

I think that the point about relationships is particularly important when it comes to local Healthwatch groups, which are commissioned by local authorities. Large organisations such as local authorities and NHS bodies tend to understand the world through analysis of quantitative data and research evidence. This contrasts with the way that individuals and communities operate, where the emphasis is on personal experiences and the stories that describe them. To be effective, local Healthwatch needs to operate between the two—to bring the public into the discussion in a way that is understood and accepted by these large organisations.

However, I believe that the groups must also be at arm’s length from local authorities. They must be prepared to ask difficult questions and to have enough knowledge to square up to consultants or hospital chief executives, and perhaps tell them that they are not doing a good enough job. We know that this was part of the problem in the tragedy of Mid Staffordshire.

It is easy to forget that local Healthwatch groups are still small and relatively new organisations, still developing their expertise. I wonder to what extent local authorities and health trusts are helping Healthwatch by, for example, including an explanation of the Healthwatch role in inductions for new staff, by briefing managers on the role and activities of their local Healthwatch, or by agreeing what good practice should be when working with the local Healthwatch on an investigation. The effectiveness of a local Healthwatch can be helped by bigger players in the system.

My noble friend also referred to the capacity of Healthwatch England and local Healthwatch. It is a concern to me that the funding for local Healthwatch groups is still not ring-fenced. I have heard the arguments for local autonomy and the rationale for not telling local authorities what to do but, if the end result is that some regions or councils are not using the money for its intended purpose, this can surely only harm the local community and the patients in those areas.

I should like to mention here the work of housing associations. Our social care system is at crisis point for both patient and taxpayer. A recent National Audit Office report, Discharging Older Patients from Hospital, highlights a problem that we are all too aware of but the figures are still startling: £820 million of taxpayers’ money is spent every year on unnecessary acute care and 2.7 million patient days are wasted waiting for transfers from hospital which have been delayed. If we did more to help older people recover at home, rather than in hospital, the estimated savings would be around £640 million every year. Housing associations are helping to make this happen, and I want to give one example.

Curo, a housing association in the south-west of England, has over 13,000 properties and a successful care and support division. Its “step down” service is made up of six homes that have access to a care team round the clock. Patients are discharged from hospital and move into a home in the service for a set period of time, agreed with their clinician when they leave hospital. They receive individually tailored care and support, and are given opportunities to familiarise themselves with telecare options for when they move on from the service. This reduces the likelihood of further readmissions to hospital.

The step down service was commissioned in 2011 by Bath and North East Somerset Council and the local clinical commissioning group with funding from the better care fund. It has enabled emergency discharge from hospital as part of a wider “discharge to assess” pathway, providing a value-for-money route for hospital discharge where assessments can be conducted outside a primary care setting. It has been recommissioned and continues to deliver a cost-effective solution for discharge and reablement, particularly for older people.

The financial benefits are huge. It is estimated that an excess hospital-bed day costs £303 per day or over £2,000 per week. In contrast, Curo’s step down facility costs £60 a day. In 2015-16, Curo delivered 1,721 days of step down from hospital, equating to a saving to Royal United Hospitals Bath NHS Foundation Trust of over £520,000—or £390,000 once costs are taken into account. Feedback from patients who have benefitted from Curo’s services reflects the value, independence and dignity of care from a housing-led service around hospital discharge.

This is just one example of a housing association scheme that is saving the NHS money and helping people to recover with dignity. Working in partnership with the NHS and local Healthwatch groups, so much more could be done. If the Government wish to ensure that the health and social care system works for everyone, more incentives to work together need to be provided to encourage new and alternative approaches to delayed hospital discharge. The current consultation into the future of supported funding offers the perfect opportunity for the Government to work with the sector to end this crisis in provision.

It is clear to me that now, more than ever, we need independent evidence-based thinking to address key public health concerns. Healthwatch England’s special inquiry last summer into the lack of care for vulnerable people discharged unsafely from hospital made the headlines and highlighted the need to put patients at the centre of health and social care. But reports have real value only if they are listened to and acted on. The case for supporting Healthwatch England and local Healthwatch organisations to grow their expertise and experience in undertaking this sort of work is undeniable.

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My Lords, in listening to the noble Baroness speak about housing concerns, particularly for the elderly with health conditions, I am reminded how important it is for policymakers, senior decision-makers and those who hold the money to visit people in their own home to see for themselves what the circumstances are. I suggest that on top of listening to service users, we need to see them in context if we are to really understand what we need to do.

I will concentrate my comments on the service-user element of the debate in the name of the noble Lord, Lord Harris. I want to ask the Minister this question: will she look at how she can improve continuity of mental health care for young care leavers in transition, after the age of 18 and into their early 20s? In much legislation, we recognise the continuing needs of care leavers, who have rights up to the age of 25. I suggest that we need to see that in the mental health care that they receive. Perhaps the noble Baroness might take this to her colleague and ask him to talk to the expert working group on the mental health of looked-after children.

I also join your Lordships in expressing my condolences to the noble Lord, Lord Prior of Brampton, and his family. I thank the noble Baroness for stepping in in his absence. I am also grateful to the noble Lord, Lord Harris, for calling this important and timely debate.

Noble Lords have expressed concern at the lack of White and Green Papers in various legislation in recent years. It seems to me that, if we want to engage service users, we need to follow the proper process. I welcome the fact that the Government have recognised this and will do it more in the future. The Committee stage of the Children and Social Work Bill is going on in the other place. During the Second Reading debate, the honourable Member Tim Loughton said that this aspect of the Bill is a,

“very radical proposal that warranted at least a Green Paper and a White Paper and proper consultation, but there was none”.—[Official Report, Commons, 5/12/16; col. 52.]

The hon. Member Mrs Emma Lewell-Buck commented:

“In short, it is a Bill about children and social work with negligible input from children and social workers”.—[Official Report, Commons, 5/12/16; col. 73.]

Those are the concerns expressed about a current Bill. I should say that I welcome very much what the Government are trying to achieve in that Bill and so much of their work in that area. However, I think that there has been an omission in the past to consult properly in a way that would allow service users to be fully involved in developing policy and legislation.

I declare my interest as a patron of the Who Cares? Trust, recently rebadged as Become. It was established many years ago to ensure that children in care in different local authorities were fully aware of their rights. It published Who Cares? magazine, so that young people in care would know their rights whichever local authority they were in. Over the past 16 years, the Who Cares? Trust has clerked the All-Party Parliamentary Group for Looked-After Children and Care Leavers. That group brings 40 young people in care and care leavers into Parliament once every two months while the House is sitting. They come from all over the country and are different ages. The honourable Member Edward Timpson MP was our chair for a couple of years and the honourable Member Tim Loughton was our chair at another time. I would be interested to hear what it meant to them to have this contact with their service users. I think that it contributed to them being highly successful Ministers and I note that when Tim Loughton became a Minister he set up various panels of young people in care and leaving care to consult with regularly. As Minister of State, Edward Timpson has sustained those service user groups. Both Ministers took the trouble to visit the parliamentary group each year to present what the Government were doing and to hear the young people’s views.

Many noble Lords have commented on the importance of service user involvement to good policy, and I should add how therapeutic it can be for young people. Some 60% come from families who have experienced serious abuse and many will never have felt that their voices were heard before entering care. To come into Parliament or speak in a Children in Care Council meeting to senior members of the local authority are positive experiences. Of course, they need to feel that action is taken on concerns that they raise.

I point out a few pitfalls that can arise around user involvement. It is important not to assume that because we are listening to a service user we no longer need to listen to the professionals. I have a sense that in the past one would consult service users many times and hear their views without properly consulting the professionals—I refer to experienced practitioners who are still in practice and not too far from the front line—and taking their views about how hard it is to bring about changes that meet the requirements of service users. I emphasise that point.

With regard to young people and children, of course in law the Children Act 1989 makes it clear that it is our duty to listen to the wishes and feelings of children, but adults remain responsible for their interests. Just because a child or young person says they wish to do something does not necessarily mean that we should do it. There is a risk of policymakers sometimes assuming that because young people or perhaps other service users say something, it should be done. It needs to be put into context and we need to think about the professionals nearest to them and consult with them.

Such consultation needs to be properly facilitated. There needs to be a context. It can also be very useful for policymakers and those in high authority to build relationships over time with service users so that they can put into context that service user’s experience and deepen over time their understanding of that particular service user group’s need.

To return to the mental health of looked-after children and care leavers, we had a very important meeting of the parliamentary group last year, which the noble Baroness, Lady Tyler of Enfield, attended and made great use of in the recent Children and Social Work Bill in her successful campaign to push the Government a little further on addressing the mental health needs of looked-after children. We heard at that meeting from a young man who struggled for a long time to access mental health services while in care. Just at the point when he appeared to be gaining the help he needed, he turned 18 and was no longer able to access the help. Similarly, we heard from a care leaver in her early 20s and the mother of two children, about how frustrated she was that she could not access the long-term psychotherapy that she felt she needed to recover from early trauma and thus become a good mother to her children. We also heard about instances of best practice such as at the NHS Tavistock and Portman clinic which provides an all-through service for care leavers up to the age of 21. I look forward to the Minister’s comments on that.

While we need to hear the voices of service users, I would encourage noble Lords to consider how very important it is to listen to the professionals in this area such as social workers who work with children in care and those on the front line who have been around for a long time and therefore have a vast amount of experience to help inform policy. I end with the question I set out at the beginning of my speech but I will not repeat it. I look forward to the Minister’s response.

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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.

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My Lords, I congratulate the noble Lord, Lord Harris of Haringey, on introducing this debate and I add my condolences to those expressed to the noble Lord, Lord Prior, on the loss of his father. I congratulate the noble Baroness, Lady Chisholm of Owlpen, on the way she has stepped into the breach this week. There has been a lot of health business, so she has been kept very busy.

This has been an interesting debate. The main issues to come out of it have been the independence and funding of Healthwatch England and local Healthwatch; what the Government really want out of PPI; and the difficulty of defining what a good system of service user representation should look like.

Like the noble Baroness, Lady Watkins of Tavistock, I was interested in the King’s Fund’s analysis. I shall not repeat them, but it asked three very interesting questions that need to be answered to look at what would make a good service user system. That was a very useful analysis.

Although highly desirable, user representation has a chequered history. Phoebe Dunn, a policy researcher at the King’s Fund, has observed:

“Local Healthwatch organisations represent the latest in a long line of attempts to give patients and wider communities an effective collective voice”.

Since the 1970s, successive Governments have implemented a series of structures, beginning with the community health councils, followed by the patient and public involvement forums in 1973, with the LINks replacing those in 2008. Interestingly, along with health services, they also covered state-funded social care and were,

“designed to reflect a more integrated approach to social care”.

We are still trying to do that eight years later. Dr Pam Carter and Professor Graham Martin, from the University of Leicester’s Department of Health Sciences, have suggested:

“Successive reforms arguably demonstrate political commitment to, and sustained high-level interest in, PPI in its various organisational forms”.

I am sure we can agree about that, but we do not appear to have achieved it just yet.

Healthwatch’s establishment was part of the coalition Government’s desire to increase public involvement in how the health and social care system worked. The 2010 White Paper, Equity and Excellence: Liberating the NHS, which set out the coalition’s vision for the future of the NHS, stated:

“We will put patients at the heart of the NHS, through an information revolution and greater choice and control”.

I want to comment on what the noble Lord, Lord Lansley, said about that and clarify the situation. The Liberal Democrats indeed wanted local authorities to be involved, but we warned against the funding coming directly from local authorities because, of course, they are commissioners and providers of the services. My noble friend Lady Jolly emphasised that to me a little earlier, because I was not working on health at the time.

Over the years, ways to consult patients and the public have been set up, but they quickly either become subsumed by NHS organisations or are effectively ignored, although their suggestions are always politely listened to. Healthwatch was meant to be far stronger and more influential than those bodies that went before. Part of this intention came in response to the Mid Staffs scandal. The Francis report commented on the shortcomings of the various PPI policies of the past. In the case of Stafford’s main hospital, the report argued that,

“patients and relatives felt excluded from effective participation in the patients’ care”.

It also suggested that the policies that followed the community health councils did not succeed in giving patients a voice. It stated:

“It is now quite clear that what replaced them, two attempts at reorganisation in 10 years, failed to produce an improved voice for patients and the public, but achieved the opposite”.

In the current climate, it is unfortunate that local Healthwatch funding is provided by local authorities because of the drastic funding cuts for local government. It is not surprising, I suppose, that some of the funding provided has not reached local Healthwatch. There is also the cumbersome bureaucracy mentioned by the noble Lord, Lord Harris, which causes some of the money to seep away. Healthwatch is saying all the right things but, without proper funding, even the best policy and the best structure will fail to fulfil its brief.

One good example of the contribution of service users and their carers used to be the Experts by Experience programme, which the CQC uses to augment its independent inspections. These are skilled workers who have personal experience of using health and social care services. They provide the patient perspective to inspectors. Sadly, since three-quarters of this programme was taken over by Remploy, the number of experts used by inspectors has fallen considerably because of serious shortcomings in the way the programme is now run. I know the CQC is looking carefully at that.

A group of Experts by Experience and former experts—some have now given up in disgust—gave evidence to the House of Commons Health Select Committee and this has been published. It makes very sad reading. The contracts in different parts of the country were awarded to two different companies, with the majority going to Remploy. Problems with the Remploy contract have been well documented and I do not have time to go into all of it, but the real victims in this sad saga have been the most vulnerable people in society, whose views are not sought in as expert a way as they should be during inspections, at least in three of the four regions of the country. I am looking forward to the comments of the Commons Health Select Committee on that evidence.

The hot topic in health at the moment is the STPs, the sustainability and transformation plans. There was recently an article in the Consultation Institute magazine which gave the views of Paul Parsons, who is actively working with institute clients, considering how best to implement STPs. He believes that some common themes are emerging from conversations with commissioning leaders since the first STPs started to seep into the public domain. First, commissioners are not yet won over to the principle of an open public dialogue about the principles and objectives contained in the plans they have published; secondly, each appears to be concerned with the extent to which they have met their legal responsibilities on public involvement in developing the plans; and, thirdly, there is a range of acceptance of, or resistance to, the concept of formally giving the public a chance to comment on the plans at this stage.

Each of the 44 commissioning partnerships are at different stages in their change process and have different challenges in their area. NHS England recognises that and is keen that the plans involve a range of stakeholders and are all led locally. So it is understandable that guidance does not provide a paint-by-numbers approach to the public engagement requirements of these exercises. But Parsons feels that a lack of specific guidance can create some inertia in the system that prevents organisations wanting to be one of the first to commit to a course of action, including consultation on the plan itself. He outlines the advantages to commissioners of formally engaging on the plans at an early stage with patients and the public. He says that it would, first, give STP partnerships the chance to fine-tune the content and understand the priorities that key stakeholders would apply; secondly, help identify people and groups who want a say in the plans; and, thirdly, give the partnerships an opportunity to reduce the risks of challenge later in the process by documenting that they have met the requirement for public involvement at an early stage.

The noble Lord, Lord Harris, mentioned the NHS Five Year Forward View, which sets out a vision for the future of the NHS. As we know, it was developed by the partner organisations that deliver and oversee health and care services, including NHS England, NHS Improvement, Health Education England, the National Institute for Health and Care Excellence, Public Health England and the Care Quality Commission. I note that that list does not include any patient-centred organisations. I want to ask the Minister why the Government did not insist that it should do so.

Some experts, such as David Gilbert, co-director of the Centre for Patient Leadership, believe that the basic premise is that in the NHS all patient consultations end up with the professionals saying, “Thanks, but now we will go back and decide what to do”. That is very unfortunate, even if it is only the impression of one person. He explained in a recent lecture why he feels we must move forward to a model of patient-influenced change and away from the current model of “them and us” that exists between professionals and patients. The simple fact is that patient involvement results in better services. Does the Minister agree?

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My Lords, I, too, would like to be associated with the condolences from all parts of the House to the noble Lord, Lord Prior of Brampton, and his family. Nevertheless, I have utter faith that the noble Baroness, Lady Chisholm, will answer all our questions in her normal, thorough fashion.

I, too, congratulate my noble friend Lord Harris on securing this important debate. He has a long and distinguished record of championing involvement of the public, patients and staff in key decisions about the future of health and social care. He speaks with great authority. It is a timely debate, five years on from the introduction of the Health and Social Care Act 2012. This was a huge Bill, as your Lordships will recall, providing an unnecessary, disruptive and costly reorganisation of the NHS that David Cameron had said his party had no intention of doing. Noble Lords will also recall the Government’s unprecedented “pause” in the face of widespread opposition to the Bill while a full-scale consultation exercise was undertaken through the NHS Future Forum.

It is worth reminding ourselves of the Future Forum’s ambition, which led many to hope that it could mark the start of the sea-change in consultation and involvement, independent scrutiny and shared decision-making that was needed. To quote the forum’s report:

“Involvement must extend beyond the decisions about an individual’s care, and apply to decisions that affect the design and provision of care for communities: as part of designing services for a particular group or condition; in strategic decisions about commissioning of services at the local level; and at a national level, in decisions about commissioning and the operation of the health and wellbeing system … commissioners cannot expect to design integrated, efficient pathways to deliver high quality care if they do not involve the people who will be using the services in their design, as well as patient representatives and patient organisations”.

As we know, the Health and Social Care Act created duties to involve patients and the public at all levels of the health and well-being system. Most importantly, this year’s guidance to CCGs states that they must:

“Involve people early on, not as an afterthought”.

Unfortunately, too few CCGs have put this into practice. As we have heard on sustainability and transformation plans, the “afterthought” approach has sadly dominated in many of the 44 footprints.

I have a number of questions for the Minister. On reporting back to NHS England on their participation approach, can the Minister provide any analysis of the information provided by CCGs? Can she confirm whether there is a breakdown of the best and worst- performing CCGs or areas in this respect? What action is being taken by NHS England to address poor performance and to seek improvements in involving and consulting local patients and communities, including local Healthwatch groups? During the passage of the HSC Act, the noble Earl, Lord Howe, spoke at length about how the legislation would lead to,

“a fundamental shift in the balance of power away from politicians and on to patients themselves”.—[Official Report, 9/11/11; col. 269.]

If this was the case, why has NHS England removed patient groups from membership of the patient and public voice assurance group, leaving only individual members of the public to hold NHS England to account?

The noble Earl said that Healthwatch groups will act as the independent eyes, ears and voice of patients and service users in a local area. The Future Forum was ambitious in the key leadership role it wanted national and local Healthwatch organisations to play. As we have been reminded, there was concern across the House about the authority and independence of Healthwatch England in the light of the Government’s insistence on its relationship to the Care Quality Commission. The Labour Benches strongly supported full independence. The Future Forum clearly saw Healthwatch England, with sufficient funding, as,

“one of the key national players in the new system”.

The extent to which it has been able to fulfil this role so far has to be questioned, given the scale of budget cuts to Healthwatch organisations, the overall funding crisis in the NHS and social care, and the fragmented NHS structures which have made integrated working even more difficult to achieve.

The Healthwatch network received 5.9% less funding this year than last year, and 31.3% less than was given to councils for local Healthwatch groups ahead of their first year in operation. The recent Autumn Statement could have addressed this, or addressed some of the wider funding issues in the health service. Sadly, the Chancellor chose not to act. For the record, under its first chair, Anna Bradley, we felt that a good start was made in establishing and developing Healthwatch England. The Government’s failure to reappoint her when her term of office ended is a mystery. She was an excellent ambassador for the organisation, interacting with the health and social care community to explain the watchdog’s work, meeting local Healthwatch groups and listening to the voices of local people. Some excellent work was undertaken.

The Healthwatch report on hospital discharge, Safely Home, with its particular focus on the elderly, people with mental health conditions and the homeless, was just one example of the strategic overview and scrutiny function that Healthwatch must play if it is to be an effective watchdog of care and performance. However, the Government must give Healthwatch England and the local groups additional support if they are to truly fulfil their role. The King’s Fund has identified local groups’ lack of capability and their need for additional advice and resources as they seek to gain legitimacy and credibility in their communities. How do the Government propose to address the patchy and fragmented local system that has emerged thus far?

Finally, I turn to sustainability and transformation plans. Specifically, I record my concern about the huge inconsistency in the roles and treatment of local Healthwatch groups as these “footprints” are created by health and care organisations across the country. Despite the Government’s commitment that STPs would provide a means for communities to shape their local health and care provision, a number of local Healthwatch groups have reported being frozen out of the decision-making process or involved at only a superficial level at the very latest stages. In light of these concerns, and wider concerns that STPs are merely vehicles for cuts to local services, can the Minister confirm what steps the Government are taking to ensure all local Healthwatch groups are properly consulted on the contents of the STP in their area?

The Labour Party took important steps to promote user participation in local health and social care provision. This Government’s stated intentions on user representation are honourable but, as we have heard in this debate, there is a growing body of evidence that patients’ voices are not being heard and, in some cases, not even being sought. Healthwatch England and local Healthwatch groups have the potential to play a significant role in ensuring that health and social care provision reflects the needs of local communities, but they must step up to the mark and speak out forcefully when needed. Almost five years after the passage of the Health and Social Care Act, the Government must act to deliver on the promises they made to patients. It is incumbent on the Government to provide proper resourcing to Healthwatch and to include other specialist user groups in discussions where they have relevant expertise. Only by properly listening to the views of patients can we have a health and social care service that responds to their needs.

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My Lords, I thank the noble Lord, Lord Harris, for securing a debate on this important issue and for his kind words, and those of other noble Lords, towards my noble friend Lord Prior of Brampton. I know that they will be much appreciated. I also wish that my noble friend was here but I will try to answer the questions raised and, if I fail to do so now, I will make sure that I do so in writing. I shall also try to put the department’s view.

Capturing, listening to and acting upon the views, preferences and experiences of individuals, including those mentioned by the noble Earl, Lord Listowel, and the noble Baroness, Lady Watkins, such as young people in care, those with mental health issues and all types of service users, and of communities, is crucial if we are to deliver the first-class services that people not only expect but deserve. Healthwatch England has two principal roles: first, to gather intelligence locally, which it can then feed back into the CQC and its inspections; secondly, to be the strong voice of users of care services at a national level. There is a powerful rationale for its close working relationship with the CQC. The CQC needs to hear the patient voice in the exercise of its responsibilities, while service users benefit significantly from Healthwatch being able to trigger action by the CQC where it finds that things are going wrong.

The recent changes to the accountability arrangements mean that Healthwatch England remains a statutory committee to the CQC, with its chair a CQC non-executive director. Under the new arrangements it retains a line of accountability to the Secretary of State, via the CQC chair, because the Healthwatch England chair is a Secretary of State appointment. The national director of Healthwatch England reports to the CQC chief executive on a regular basis. They continue to remain accountable to the Healthwatch England committee for delivering Healthwatch England plans. The CQC will be responsible to Parliament for the effective delivery of its statutory duties and finances, and for the delivery of the statutory functions of Healthwatch England through its framework agreement with the Department of Health. In future, the CQC will be responsible for allocating sufficient funds to Healthwatch England to deliver its role and statutory duties.

Let me stress that Healthwatch England’s important role is not changing; there is no change to the functions set out in legislation. The Healthwatch England committee will continue to set its own priorities and publish its own business plan and annual report. We expect it to continue to act as a strong, independent voice for patients and share its findings with the system. These new arrangements reflect the changed landscape since Healthwatch England was set up. The Government remain committed to strengthening the role of patients and communities, with greater focus on local leadership of the health and care system, and we have given the Care Quality Commission itself a stronger role in hearing patient views.

A big part of Healthwatch England’s role is to work with the Healthwatch network to provide leadership and support, as each local Healthwatch builds its profile and impact on local services. In answer to the question from the noble Lord, Lord Tunnicliffe, about a patchy and fragmented system, it is a priority for Healthwatch England. In fact its number one priority as set out in its business plan for 2016-17 is:

“To provide leadership, support and advice to local Healthwatch to enable them to deliver their statutory activities and be a powerful advocate for services that work for people”.

Healthwatch will continue to develop its own business plan and priorities. It will also continue to produce an annual report, which will be laid before Parliament.

This Government have a collective ambition that the people of this nation should have their voices heard, and have local health and care services designed and delivered around their local needs. Whether that be helping to set up a new local community provider of domiciliary care services in Cornwall or investigating mental health services in Birmingham, proper involvement and representation is indeed required to amplify this citizen power and to influence change. This is where local Healthwatch organisations fulfil a pivotal role. Their aims can be neatly summarised as: giving citizens greater influence over the commissioning and provision of local services; using people’s experience of services to bring about improvements locally and nationally; and providing local people with information about health and social care services, and their choices in respect of those services. I am very pleased to inform the House that these aims are now a reality for many local Healthwatch organisations up and down the country.

None the less, I am aware that there is some concern about the perceived lack of independence of local Healthwatch organisations which are funded by, and accountable to, their local authority. I do not consider that the funding and accountability arrangements for local Healthwatch organisations undermine their effectiveness or independence. We are not aware of any specific accusations that a local Healthwatch has felt unable to raise issues for fear of repercussions. Local Healthwatch organisations set their own priorities, based upon information and intelligence gathered on issues relating to local health and social care services. Their place on the local authority health and well-being boards helps to promote their independent role in representing the views and experiences of local communities.

Local authorities are well practised in commissioning organisations to deliver services that benefit communities and, at the same time, scrutinise the council. Local Healthwatch organisations also have independence in that they will be able to feed information directly to Healthwatch England, ensuring that a local voice has influence at a national level. Healthwatch England is assisting by providing leadership, support and advice to local Healthwatch organisations to enable them to deliver their statutory activities and be a powerful advocate for services that work for people.

However, the fact needs to be acknowledged that local authorities are facing challenging funding decisions. In such times, it is crucial that in fulfilling their statutory duty to commission local Healthwatch, local authorities have the freedom to ensure that their arrangements meet the needs of their local population and represent value for money. Central control of local funding decisions would diminish the voice of local communities and ignore other voluntary or partnership arrangements that a local authority may already be funding for the benefit of its population. But let me be clear on one important point: local authorities are still accountable for the funding that they allocate to local Healthwatch.

This Government are committed to transparency around local Healthwatch funding. Healthwatch England publishes figures showing how much councils are spending so that local communities can hold their councils to account. Your Lordships may have seen Healthwatch England’s report on 2016-17 local authority funding. I will say up front that the data show that some local Healthwatch organisations have large reductions in their funding. It is in the interests of local authorities and other local care system partners to have a well-performing local Healthwatch that will help to drive up the quality of local services. Those local authorities will need to demonstrate how their local Healthwatch organisations can still carry out their duties effectively. None the less, I am pleased that Healthwatch England reports that local authorities are recognising the overall value of local Healthwatch and, when compared with other council-run services, are continuing to invest. This is encouraging.

I now turn to some of the questions that were raised by noble Lords during the debate. The noble Lord, Lord Harris, talked about local Healthwatch not influencing CQC inspections. CQC actively seeks intelligence from patients, the public and staff prior to its inspections, including from local Healthwatch. The noble Lord and the noble Baroness, Lady Warwick, raised a point that I want to emphasise. Local Healthwatch has an independent voice and its statutory powers to relay patient and user voices at national level remain unchanged and unfettered.

The noble Lord, Lord Harris, also said that there is underspending and that not enough is spent on local Healthwatch. Going forward, much more of Healthwatch England’s resources will be spent on supporting local Healthwatch as this strand is being given a stronger priority by Healthwatch England. Changes to the governance and organisation of Healthwatch England reducing the duplication of, for example, corporate functions mean that Healthwatch England will be able to refocus more of its resources on its essential duties, especially on supporting local Healthwatch. It retains independence of voice and will continue to speak truth unto power, including, where necessary, to the CQC itself.

Several noble Lords, including the noble Lord, Lord Harris, spoke about problems with IT. The IT company concerned, Patient Experience Library, provides an existing service which draws together a range of reports and reviews from organisations across the country. Healthwatch England subscribes to the service rather than going to the expense and duplication of setting up a parallel system. Healthwatch England also undertakes analysis of the reports as part of its national role to understand and relay the user voice and concerns to national decision-makers. The service is a subscription service, and local Healthwatch organisations are free to decide how to spend their funds.

My noble friend Lord Lansley mentioned the independence of Healthwatch England within CQC. I agree with him that Healthwatch England is independent and acts as a rigorous scrutineer to use its place within CQC as leverage to support the voice of users. As my noble friend said, Healthwatch England has powers to challenge at national level which were not available to predecessor organisations, which puts it in a unique place to bring the voice of users to national decision-makers.

The noble Baroness, Lady Pitkeathley, made, as always, an extremely good speech on this subject. She comes with so much knowledge. She mentioned Healthwatch England’s subordination to the CQC, as did several other speakers. Local authorities are accountable for the funds they allocate to local Healthwatch organisations to ensure that they meet their statutory functions. Healthwatch England will be closely monitoring the ability of local Healthwatch organisations to deliver their statutory functions while also continuing to engage with local authorities in order to support the sustainability of local Healthwatch organisations.

The noble Baroness, Lady Masham, asked about the profile in local communities, particularly rural communities. Simon Stevens and Jim Mackey wrote a letter on 12 December to STP leaders saying how important local engagement is and that rural areas must be included in this. It is an ongoing problem which we must keep addressing.

The noble Earl, Lord Listowel, mentioned the important problem of continuity of mental health between young and old. I am going to take that back to my noble friend Lord Nash. This is a problem that keeps cropping up, and it is something we must keep bringing up. It is very important. There is no doubt that there is a problem when you leave children’s services and move on to adult life. People are definitely slipping through that net, so I will take that back.

The noble Baroness, Lady Walmsley, mentioned the experts by experience groups. CQC is strongly committed to the involvement of patients and service users in its inspections. The new contracts for experts by experience provide a more flexible and cost-effective method of engaging service users to carry out this important role. CQC is taking action to improve contract delivery, which has indeed been less than what is required in some areas of the country. Meanwhile, CQC has been very clear that there has been no diminution of the involvement of service users in the inspections programme.

The noble Lord, Lord Tunnicliffe, raised several very important questions. One was about providing analysis of information provided by CCGs. There is no analysis, but each CCG has to publish an annual report, and these reports are taken into account as part of the CCG assurance process with support provided to those not performing to a suitable standard. The noble Lord also asked whether there is a breakdown of the best and worst performances of CCGs or areas in this respect. NHS England does not do this. It focuses on supporting, not naming and shaming.

The noble Lord also asked NHS England to address poor performance in involvement. NHS England offers bespoke support according to local need. It is currently refreshing the statutory guidance for CCGs in partnership with local Healthwatch, voluntary organisations, patients and the public. He also asked about removing patient groups from the membership of the patient and public voice assurance group. I understand that this is not to be the case and that the membership of that group has been reviewed to refresh and strengthen it.

I hope I have answered all the questions, but I shall make sure that I go back and read Hansard to see what else the department needs to consider following this very important debate. Effective representation of the public voice is vital if we are to have a health and care system that meets the needs and preferences of individuals and local communities. Healthwatch England and local Healthwatch are powerful champions for this public voice and, as the noble Baroness, Lady Walmsley, said, the patient voice is vital.

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My Lords, I am enormously grateful to all noble Lords who have contributed to today’s debate. I am particularly grateful to the noble Baroness, Lady Chisholm, for standing in at short notice and speaking from the Front Bench, and to my noble friend Lord Tunnicliffe, who at even shorter notice has stood in for our Front Bench, who are also away for reasons of illness and other matters.

This has been an interesting debate, and lots of important points have been made. I particularly welcome the point made by the noble Lord, Lord Lansley, that shared decision-making in terms of the individual should happen anyway, irrespective of the structures in place. He outlined—and I do not dispute it—that when he was Secretary of State the Government’s objectives in creating Healthwatch were good, and the intention was to improve the system. It is just a question of how well it has worked subsequently. He asked a very valid question about why the Labour Government abolished community health councils. That is a question that I certainly asked at the time. I am sure that, had he been in his place, my noble friend Lord Hunt of Kings Heath, who was the Minister at the time, may well have wanted to comment on those matters. The fact that the arrangements that were then put in place were felt not to be working only a few years later suggests that perhaps the model was not absolutely right.

My noble friend Lady Pitkeathley, along with a number of other contributors, talked about the whole point of the involvement of patients being that it challenges the existing power structures and orthodoxy, which therefore produces a backlash. She also made the point, which I agree with, that in the Bill that ultimately became the Health and Social Care Act, the creation of Healthwatch was potentially a ray of hope in terms of how things would progress.

The noble Baroness, Lady Brinton, quite rightly reminded us of the role of the voluntary sector and the way in which users can shape the different patient pathways that are available. That too is something that often gets neglected. The noble Baroness, Lady Masham of Ilton, talked very pointedly about the lack of local knowledge about Healthwatch and its role, as well as the suspicion that is growing about the STP process—which could be extremely important, because it is intended to be transformational—in terms of the lack of openness and transparency. It is an important process, which is why it was so vital that health service users and social care service users were fully involved in the process.

My noble friend Lady Warwick of Undercliffe talked about how the role of local Healthwatch could be critical and said that it was one of the few organisations that really has an overview across the health and social care divide. She highlighted the concerns about the changed relationship between Healthwatch England and the CQC. She also reminded us, very importantly, of the potential role of housing associations. The noble Earl, Lord Listowel, talked about the value of senior people listening to service users. That is the essence of most of the models that have existed over the years—senior people directly hearing the voices that are there. The noble Baroness, Lady Watkins, also made that point when she talked about challenging the orthodoxy. She made interesting points about how users should influence and shape things.

I was very amused by one element of the speech made by the noble Baroness, Lady Walmsley, because she said it was not the Liberal Democrats who had said that the structure should work through local authorities. In that case, I am beginning to wonder whose idea it was. The noble Lord, Lord Lansley, speaking 10 years ago about the previous system, said that LINks may “struggle to be credible as long as they are funded through local government”. Just a few years later, he felt impelled by something or someone—we now know it was not the Liberal Democrats—to say that the new system should be funded through local government, with the consequences that I have described.

The noble Baroness, Lady Chisholm, in her reply, tried to reassure me about the relationship between Healthwatch England and the CQC, and reiterated what I already see as the accountability lines which render independence slightly more difficult. She then told us that the CQC would in future be deciding the funding of Healthwatch England, which seems to put even more into question the way in which that independence would operate. She also talked about local councils’ accountability for how much they allocate to Healthwatch England. This is very important, but the sanction Healthwatch England has available—which I think we have discussed before in your Lordships’ House—is that it can send a letter to the council lead saying it is not good enough. As a former council leader, I know what response I always gave to letters saying that something that my local authority was doing was simply not good enough.

In conclusion, I am grateful to all noble Lords who contributed to the debate. There is a great warmth around the House about what could be achieved by Healthwatch, both locally and nationally, and the message going back to the Department of Health must be that it is important to build on the Healthwatch network. If it really wants to get this right, and deliver what all your Lordships have said they want to happen, then it needs to resource local Healthwatch organisations properly through a freestanding Healthwatch England. I suspect we might then well find that we have a system which genuinely delivers a user voice and influence into the centre of health and social care in this country.

Motion agreed.