My Lords, I too thank the noble Lord, Lord Harris of Haringey, for giving us this most welcome opportunity to debate what I believe is a very substantial flaw in the NHS plan; namely, a fundamental confusion within the plan about what the patient advocate and liaison service is intended to do.
It may be useful if I were to bring to your Lordships attention a definition of advocacy which was drawn up some years ago by the Institute of Public Policy Research and the members of a number of leading voluntary organisations, including the noble Baroness, Lady Pitkeathley:
"Citizens Advocacy is a one-to-one ongoing partnership between a trained advocate and a person who is not in a strong position to exercise or defend his or her rights, and is at risk of being maltreated or excluded. The citizen advocate must be free of conflicts of interest with those providing services to their partner and should represent the interests of their partner as if they were their own".
I offer that definition because nowhere in the NHS plan is advocacy actually defined. I believe that what has been proposed in the NHS plan is a confusion between three different aspects: information, support and advocacy or representation.
The new PALS system is described variously on pages 91 and 92 in terms of information, facilitation, negotiation and support for complainants. But those are very different matters which require very different skills. There is a significant difference between a service which eases the path of hospital patients through an organisation's structures and services and one which enhances and supports the ability of people--patients, families and carers--to negotiate the wider NHS, an understanding of their rights as users and their ability to obtain redress if things go wrong.
PALS appears to deal only with patients in hospital, not patients in primary or rehabilitative care. Such patients usually need the following things. First, they need practical information about the services of a hospital in easily accessible formats. They need information about aftercare, benefits and adaptations.
If the proposed system is to work, the integrity of the information which is provided must be assured. There must be no conflict of interest by dint of those responsible being employed by the hospital.
Secondly, patients need support. Lots of patients just need a bit of help to get simple things done. Reading the plan, I believe that that is what the Secretary of State really intended this proposal to achieve. But that is not advocacy. I am not being pedantic here. We are talking about a major structural change on a basis which is wholly unclear.
Here is a tremendous need for advocacy. I cite one example--language difficulties. Many patients suffer simply because of language difficulties. In certain boroughs in London, more than 130 languages are spoken. I cannot see how one hospital or one NHS facility can meet that sort of need. And yet there is scant mention in the plan about the organisations which have that expertise; namely, voluntary organisations.
I have two questions for the Minister. First, why is there no mention in the plan about national standards and criteria for evaluation of the PALS system? Secondly, if the Minister accepts the need for independence and the advocacy skills which exist outside the NHS, is there a case for going down a route similar to that of the community legal service and establishing an NHS advocacy standard to which a number of groups, which prove that they are up to the required standard, could bid to provide that service?
The major flaw is that this does not cover general practice or even PCTs. By far the largest number of incidents in the NHS are in the community services. Will the proposals for PALS and patient forums ever reach down to that level, which is the level at which most people experience the NHS?
In conclusion, I do not think that what is on offer is PALS. It is PILS--a patient information liaison service. If the Minister's department really wants advocacy, then the voluntary and statutory sectors will need to be "PALS" together.