How the Health Bill fails patients

The Second Reading debate on the Government’s Health and Social Care Bill has been going on for about thirteen hours with more to come tomorrow.  This was my contribution earlier tonight:

“9.26 pm

Lord Harris of Haringey: My Lords, at this two-thirds point in this debate, I make no apology for focusing my remarks on Part 5 of the Bill, and the quality of the voice for patients that it offers. This Bill is likely to damage irreparably the National Health Service, creating a service that is less accountable and more fragmented; that is increasingly provided by for-profit organisations; and where the relationship of trust between doctors and their patients is undermined. Under such circumstances, an effective structure is essential to support patients in navigating their way through the new arrangements, to ensure that their needs and concerns—both individually and collectively—are not neglected in the brave new world of private suppliers feeding on the remnants of public provision. It is essential to guarantee that, with the democratic deficit that will now open up in health provision in this country, the impact of the changes is catalogued and drawn to the attention of those charged with regulating the new system, of Parliament and ultimately of the public who are paying for it.

I declare a former interest as someone who—for 12 years—was director of the Association of Community Health Councils, then the statutory body representing the interests of the public and the users of the NHS. The Government are now bringing forward another round of proposals to fill the void left by Community Health Councils when they were abolished in 2003. They were succeeded by patient and public involvement forums, which lasted four years before they were replaced by local involvement networks. Again, with a life of four years, LINks are to go, to be replaced by HealthWatch. The sequence of change in consumer organisations is a poor recommendation of the previous Government. I am shocked to see that the current Government are moving forward in a similar vein.

Of course, the Government’s objectives are laudable: “No decision about me without me” is as resonant as previous rhetoric about putting the patient at the heart of the NHS or the mantras about patient empowerment 10 to 15 years ago. Some of your Lordships will even remember John Major’s Patient’s Charter—that daughter of the Citizen’s Charter and that cousin of the Cones Hotline. How does the high-sounding rhetoric match up to the reality of this Bill? How far are patients going to be involved in decisions about managing their own care and treatment? It is simply not clear whether these are adequately safeguarded in the Bill. A duty to promote involvement or a duty to promote choice is not a sufficient guarantee. Who will hold clinical commissioning groups or the NHS Commissioning Board to account for the extent to which they have promoted that involvement or choice? Where will patients go for redress if they find that their family doctor will not refer them for treatment or investigation but insists on managing that treatment or conducting that investigation within the practice, thereby keeping the resource that would otherwise go with that patient? What will be the process for ensuring that key commissioning decisions are in line with the preferences of those affected by them and that those decisions reflect the expertise that patients have in their own conditions and the experience that patients collectively have of their local services?

Presumably we will be told that this is where HealthWatch will come in, but what will HealthWatch mean in practice? The first problem is that it is unclear how local healthwatch groups will be constituted. If individuals are simply going to be self-selected, their views, though valuable, will not necessarily be representative of all service users, and there is a risk that because of that they will not be treated by commissioning groups as having legitimacy. Members of local healthwatch groups need to have their own local accountability and must have the resources to engage with the wider community to be able to assess and represent their views.

Resources will also be necessary to enable local healthwatch groups to provide advice, support and advocacy. This will be an important and potentially substantial role in the brave new world of the NHS that this Bill creates: a world where patients will no longer be clear whether their GPs are acting in their interests or to bolster their practice’s coffers; a world where decisions about what is to be commissioned will be taken with no clear system of public accountability; and a world where for-profit providers will increasingly squeeze out those that are not-for-profit and where profitable treatments will be cherry-picked.

A strong system of patient advocacy and support will be needed, but will it be provided? This will depend on the decisions of hundreds of local councils. The money provided by the Department of Health will not be ring-fenced, and there will be no mandating of local authorities about the nature and quality of HealthWatch services that should be supported. All this is in the name of localism, that same localism that has seen the budgets of LINks drop dramatically this year, in some instances by more than 50 per cent, despite, as the Minister told a number of us last night, the Department of Health saying that it has increased the resources available. The resources went up, but the resources available for local healthwatch went down. It is a localism that means that the Minister can offer us no assurances that those advocacy services that he promises us will be adequate. In future spending rounds who will argue with the Treasury for the moneys for HealthWatch? Will it be the Department of Health, which will have no say in whether the services expected are being delivered, or DCLG, which will have no interest in those services, or will the current commitment be allowed to wither on the vine as no department fights its corner?

Is it even appropriate that local healthwatch groups should be resourced via local authorities which themselves will have responsibilities for social care provision? Is there not a potential or perceived conflict of interest here? How comfortable will a local healthwatch group be in criticising its paymasters about the quality of that provision?

Finally, there is the relationship with national HealthWatch. A national structure is essential for the views and concerns of local healthwatch groups to be captured and articulated at national level, but that national structure must grow from and be a creature of the local groups, not sit above them as a mere sub-committee of a regulator, moreover a regulator to which requests for action and even criticism may need to be directed by that structure.

The new NHS will need a strong and independent user voice. The Government keep citing the proposals on HealthWatch as evidence not only that such a voice will exist but that the patient will indeed be central to the myriad new structures that they are proposing.

Yet the danger is that what we are being offered is no more than a fig-leaf whose own legitimacy will be flimsy, a fig-leaf whose resources will be plundered as local government itself faces a future with rapidly dwindling money, a fig-leaf whose independence is compromised by its relationship with a paymaster whose provision it is supposed to be monitoring, and, above all, a fig-leaf protecting the nakedness and insufficiency of the protestations that no decisions about the patient will be taken without him or her. My Lords, it is just not good enough.”

Ninety-nine speakers and counting on Health and Social Care Bill

I have put my name down to speak on the Second Reading in the House of Lords on the Health and Social Care Bill next week. So have 98 colleagues.  So far.

This must be some sort of record for any Bill (other than those dealing with House of Lords reform).

The level of interest demonstrates that there is widespread concern across the House about what the Government’s Bill will do to the NHS.  Apart from the Government’s apologists on the Tory benches (and those LibDem coalition loyalists), there is a consensus that what is proposed is unnecessary, reckless, wasteful and bureaucratic.

The Government’s proposals were not in the Conservative Party’s election manifesto.  Nor were they in the LibDem manifesto.  They were not even in the Coalition Agreement.

There is absolutely no mandate for the changes proposed and they go against the promises made that there would be “no more top-down reorganisation of the NHS”.

The interest in the Second Reading debate has meant that the session is to start three and a half hours early on Tuesday and there is now going to be an overspill session on Wednesday morning.

There are not normally votes after Second Reading debates in the House of Lords.  However, the Health Bill is so controversial that there could be a vote to kill the Bill at that stage.

Despite speculation, it is unlikely that an outright move to block the Bill will pass: the Conservative peers and most LibDem peers will vote as a block to prevent that happening and cross-bench peers may feel that it would be unconstitutional for the House of Lords to refuse to consider a Bill coming from the elected House.

However, the role of the House of Lords is to scrutinise legislation and there is a proposal from Lord Owen and Lord Hennessy to refer three sections of the Bill for detailed consideration by a Select Committee of the House that could call for evidence and hear witnesses.  The rationale for this is that these are sections of the Bill that were not properly considered and that the sections concerned also raise fundamental constitutional principles in that they could potential weaken Ministerial accountability to Parliament on the NHS and would also make it more difficult for decisions to be challenged in the Courts.  If passed, this might have the side effect of delaying the Bill into the next session of Parliament.

The vote on this proposition is likely to be much closer, but if it is to be passed at least eighty members of the House form the cross-benches (and Government rebels) will have to join Labour peers in supporting it.

There are signs of nervousness in the Department of Health and all peers have been invited to a meeting with Ministers and the Chief Executive of the NHS to “allow Peers to ask any final questions” at 7pm on Monday (such a late start for an all-peers Ministerial briefing is also pretty unprecedented in my opinion).

As Sir Alex Ferguson might say it’s squeaky bum time for Ministers and the coalition.

Lynne Featherstone to get a Theresa May bollocking?

Talking to your local newspaper is clearly the way members of the Coalition Government have of dissenting from the Number Ten approved line.

First, we had Kenneth Clarke, the Justice Secretary, putting the boot in to Theresa May, the Home Secretary, and her Human Rights Act deportation cat story.

But now Lynne Featherstone, a (very) junior Minister in the Home Office, has followed suit in an article for her local paper, saying:

In the Blue Corner, Theresa May (my Home Office boss) launched an attack on the Human Rights Act on the morning of the Conservative conference in the Sunday Telegraph saying that saying she “personally” would like to see it go because of the problems it caused for the Home Office. …

As for the Human Rights Act – there are times when people cynically, lazily or ignorantly quote it in a way that completely perverts its intention (and doesn’t stand up if put to the test in court). In that respect it is very similar to the Data Protection Act – often also called in aid as the supposed justification for bizarre decisions in a way that fuels shock media stories but really says far more about the ignorance of those quoting it than about what it actually says.”

So we now know what she thinks of her Home Office boss and what she said about the Human Rights Act and the cat and the deportation story.

And she goes on to assert that changes to the Human Rights Act are:

just not going to happen”.

My contacts in the Home Office tell me that the Home Secretary “gives a pretty good bollocking”.  Lynne Featherstone has already been the recipient of at least one when Theresa May told her to tone down what she said in her blog.

I would love to be a fly on the wall at Monday’s Ministerial meeting in the Home Office when the Home Secretary has a few words with her LibDem Parliamentary Under Secretary who called her cynical, lazy and ignorant.

The shabby tawdry compromise that replaces Control Orders with Terrorism Prevention and Investigation Measures

Today is the Second Reading in the House of Lords of the Terrorism Prevention and Investigation Measures Bill, which replaces Control Orders with the new TPIMs.  The Bill is a shabby tawdry compromise between the different wings of the Coalition Government and is likely to satisfy no-one.  This is my speech (without the interruptions):

“My Lords, I declare an interest as a member of the Metropolitan Police Authority with particular responsibility for overseeing the Met’s work on security and counter-terrorism.

Earlier this week, I went to a meeting with Carie Lemack.  Her mother was killed on American Airlines Flight 11 that crashed into the World Trade Center ten years ago.  She went on to co-found Families of September 11 and later the Global Survivors Network which brings together the survivors of terrorist attacks across the world and their family members.

Her testimony is an international reminder about why the fight to combat terrorism is so important: families are destroyed, individuals are left bereft and the effects last a lifetime.  I am sure no one in your Lordship’s House wants to see repeated the suffering of those terribly injured in the London transport attacks or the grief felt by those bereaved.

And that is why it is a paramount duty of Governments to protect the security of their citizens, to protect those citizens’ right to life, and to protect all of us against terrorism.

The problem that Government faces is simple to state, but is not easy to resolve. 

In essence, it is this: what does the Home Secretary do about those individuals who pose a serious risk to the lives of British citizens, but against whom there is insufficient evidence to bring them before a court charged with a terrorist offence?  The evidence may not be admissible in British Courts or it may rely on material gathered by UK intelligence agencies that would compromise the safety and security of others if it were publicly disclosed or it is derived from intelligence from overseas agencies that is provided on the basis that it must not be disclosed. 

Yet a responsible Home Secretary cannot ignore that those individuals pose a significant risk, cannot turn a blind eye to the threat that is there and cannot fail to take some action to protect the rest of us.  To do nothing would be a dereliction of that responsibility to protect the public.  Control orders were an attempt to provide us with that protection in those very small number of cases where no other action is possible.  And it is a power that has been rarely used, despite the dire warnings that were issued when the powers were first proposed.

This Bill, however, is nothing more than a shoddy compromise which weakens our security and yet does nothing to satisfy those with concerns about civil liberties. 

It is a compromise that demonstrates the weakness of this Government as it tries to square the circle between the two wings of the coalition, epitomised by a Liberal Democrat Deputy Prime Minister and a Conservative Home Secretary – trying to reconcile the irreconcilable.

The current Control Order regime is not, of course, satisfactory.  No-one has ever seriously tried to pretend that it was.  However, it was an honest attempt by the previous Government to balance the free and liberal tradition of this country with the need for security. 

The present Government was formed with an explicit commitment to replace the Control Order regime.  It was a commitment made in the coalition agreement.  And the Deputy Prime Minister was voluble in his promises about what this would mean, telling us that this would – and I quote – “give people’s freedom back”. 

However, let us be quite clear, the Bill does not do anything like enough to satisfy those who have reservations about the previous control order regime and its implications for the civil liberties of those subject to that regime.  

Shami Chakrabati, the Director of Liberty, has said that control orders have simply been rebranded, albeit in a slightly “lower-fat” form, or as their briefing puts it:

“the TPIM regime essentially mirrors the control order system in all of its most offensive elements”

Indeed, this Bill must be something of an embarrassment for those Liberal Democrats who spent so long in this House criticising the previous Government for introducing and using Control Orders. 

There is silence today from the noble Lord, Lord Thomas of Gresford, who in 2005 when the control order legislation was going through your Lordships House, said on behalf of the Liberal Democrats that control orders would constitute:

“a blatant abuse of what we have known as the proper processes of justice.”

There is silence today from the noble Lord, Lord Dholakia, who again spoke out unequivocally from the Lib Dem frontbench:

“The first and fundamental issue, which is central to all the arguments advanced in this debate, is who should be responsible for the decision to make control orders. On these Benches, it is clear that the proposals made in the Bill are not acceptable.“

The silence of the LibDem lambs. 

I should say that I absolve from the accusation of silence the noble Lord, Lord Goodhart, who we will be hearing from in a moment.  In 2005, he was equally trenchant, but I have faith that he at least will be consistent when he speaks.

So this Bill cannot satisfy those who feel that the current arrangements are disproportionate, draconian and destructive of our liberties.

Yet, the Bill does water down the control order regime.  It raises the threshold from “reasonable suspicion of involvement in terrorism” to “reasonable belief that the individual is or has been involved” before action can be taken against an individual. 

It limits what conditions can be placed on those individuals and crucially it removes the power to relocate individuals away from those localities where they may mix and conspire with others.

For those of us who believe that sometimes the Government must take unpalatable measures to protect us, those are crucial changes.  They leave us all vulnerable.

Let no-one pretend that the threat has gone away – the recent arrests of seven individuals (now charged) in Birmingham as the Liberal Democrats gathered there for their conference are a reminder that we must continue to be vigilant against that threat.

And the Home Secretary has had to acknowledge how critical all of this.  Within days of taking office, within days of the Coalition Agreement being signed, she was presented with information that persuaded her – a rational and responsible individual – that despite the coalition rhetoric about control orders and the need for them to be abolished – that she should personally approve the imposition on a number of people of precisely the same orders that the Government is now abolishing.

And then, only in February – after the Government had announced its proposals, she agreed a control order on a British-Nigerian terror suspect, who apparently – according to MI5 – is a leading figure in a “close group of Islamic extremists in north London”.  He was banned from living in the capital under the terms of that control order.  In May, according to the Guardian, the high court dismissed an appeal by the man, saying that his removal to an undisclosed address “in a Midlands city” was necessary to protect the public from the “immediate and real” risk of a terrorist related-attack.

So in February, it was necessary to place restrictions on that individual as to where he could live – effectively relocating him from North London to the Midlands – something which under this Bill would not be possible. 

If this Bill becomes law, that individual will be free to move back to London in the New Year – just weeks before the Olympics – to renew the associations that only a few short months ago were deemed by a rational and responsible Home Secretary to be so dangerous that a control order was needed along with the relocation of that individual.

I would like to ask the noble Lord, the Minister, what will have changed between the time when the Home Secretary approved that order and the time when the individual concerned is to be allowed to move back to London.  Are we being told that the fresh air of the West Midlands conurbation and its bucolic atmosphere will have so changed the personality of the individual concerned that he now poses so much less of a threat.

Because just eight months ago that rational and responsible Home Secretary on the information presented to her felt that the individual concerned was so dangerous that not only did he need to be subject to a control order but that he should be relocated miles away from his previous environment. 

And she made that judgement knowing that this Bill would remove that option and would tie her hands in the future. 

That rational and responsible Home Secretary made that judgement knowing that however much of a danger that that person might be thought to be such an outcome was to be taken away.  So the noble Lord, the Minister, needs to reassure us, he needs to tell us why the judgement that the Home Secretary made then will no longer apply to this individual when this Bill becomes law.

Perhaps we should not expect the noble Lord the Minister to go through such contortions: all he needs to concede instead is that, yes, the Home Secretary made that judgement then in the interests of our nation’s security, but that this shabby, tawdry compromise of a Bill would prevent her making that same judgement in the future, and that this shabby, tawdry compromise is not just a compromise between two wings of an uneasy and unhappy coalition but that it is a compromise with this nation’s security.”