Health and Social Care Bill
(13 years ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, before the House goes into Committee on the Health and Social Care Bill, I should like to take the opportunity to update noble Lords on the latest position with regard to the Department of Health risk registers. The House will recall that my department received a specific request under the Freedom of Information Act to release the transition risk register, which covers risks relating to the development and implementation of our health reforms. There was also a separate request to release the strategic risk register, which covers the most important risks the department faces.
We have taken the view that the information in both registers should be treated as exempt from disclosure under Section 35 of the Act on the grounds that the information contained in the risk registers is integral to government policy-making. Risk registers of this sort are a tool by which information about potential risks—both actual and theoretical—can be recorded in worst-case terms to enable them to be mitigated and managed. The Information Commissioner accepts that the information falls within this category of exemption. Following our decision not to release the registers, the two individuals who made the FOI requests lodged appeals with the Information Commissioner.
In early November, the Information Commissioner published his decision notices in both cases, deciding that the public interest lay, on balance, in full disclosure of both registers. Since then, as is allowed for under the rules, we have been considering whether we should appeal the Information Commissioner’s decisions. As I explained to the House previously, this was not a decision that the Department of Health could make on its own, as the issues which bear upon the decision have significant implications for every government department.
While the principle of openness is one to which we have adhered to the maximum extent through evidence given to the Health Select Committee in another place and the publication of impact assessments, it has been our firm view, and that of other departments, that for risk registers of this type to fulfil their function, civil servants must be free to think the unthinkable and record potential risks and mitigations fully, frankly and with absolute candour, confident in the knowledge that this information will not be publicly disclosed.
The logic of the Information Commissioner’s decision to order the release of information of this nature would entirely undermine the concept of safe space for these sorts of circumstances. The matter has accordingly been the subject of much careful consultation across Government, and a very clear and firm view has emerged that the publication of information in risk registers of this type would be likely, in the future, to undermine the very purpose for which a risk register of this sort is produced, and thus directly threaten the successful implementation of government policy. I can, therefore, tell the House that my department has decided to appeal both decisions by the Information Commissioner.
I would, however, like to respond to the request made on 16 November by the noble Baroness, Lady Thornton, by sharing with the House as much further information as I can about what my department’s transition risk register contains. On that occasion I undertook to examine whether there were any risks covered in the Department of Health transition risk register that are not already in the public domain and on which information could be provided without further ado.
While I cannot share the detailed breakdown of the information recorded in the risk register, or the wording, I am happy to set out for the record the broad issues covered by the transition risk register. They are as follows: how best to manage the parliamentary passage of the Bill and the potential impact of Royal Assent being delayed on the transition in the NHS; how to co-ordinate planning so that changes happen in a co-ordinated fashion while maintaining financial control; how to ensure that the NHS takes appropriate steps during organisational change to maintain and improve quality; how to ensure that lines of accountability are clear in the new system and that different bodies work together effectively, including the risk of replicating what we already have; how to minimise disruption for staff and maintain morale during transition; how best to ensure financial control during transition, to minimise the costs of moving to a new system, and to ensure that the new system delivers future efficiencies; how to ensure that future commissioning plans are robust, and to maximise the capability of the future NHS Commissioning Board; how stakeholders should be engaged in developing and implementing the reforms; and finally, how to properly resource the teams responsible for implementing the changes. I hope that this information will prove useful to noble Lords as the Bill continues its passage in Committee.
Baroness Thornton
I thank the Minister for that statement, of which I did not have more than two minutes’ notice. It is very disappointing indeed. Basically, the noble Earl is saying that the Government are choosing what they do and do not disclose to the Committee on this matter. It is an issue of trust—whether or not we can trust that we will know what we need to know to make judgments about whether this Bill will work.
I thank the noble Earl for the issues that he has decided that the Government can let us know about, but of course I am therefore concerned about what the issues are that the Government have decided that we should not know about. What are the risks that we cannot know about? That is a matter of grave concern to the Committee.
I shall be looking in detail at the Minister’s statement to the House and I reserve the right to return to this matter if I feel that we need to. For example, during the last two days in Committee I put two direct questions to the Minister about whether certain matters—one concerning children—were on the risk register and what the register said about them. I have not received answers to either of those questions. I shall continue to put my questions in that context and I suggest that other noble Lords do the same.
I am very grateful for the Statement as far as it goes but I do not think that this is an end to the matter. I can see why the Government might think that there is a cross-government issue here. However, no other department is in the position in which we find ourselves here—that of discussing a Bill that is going through the House right now. We need full information on this matter in order to be able to make proper decisions but I believe that we still do not have that. Therefore, I thank the noble Earl so far as this goes but I reserve the right to return to the issue in due course.
Lord Campbell-Savours
Perhaps I may ask the Minister a question. He gave us a list of all the areas which he thought it was not possible for Parliament to scrutinise in some detail. Did the Information Commissioner have access to all the document headings to which the Minister has referred, and did he have the opportunity to read all the documentation under those headings? If the Information Commissioner did have access to information on, for example, the handling of the legislation as it goes through Parliament, why did he, throughout the whole report, repeatedly say that these matters should be placed in the public domain? Again, is it not clear that the Government are trying to hide something from Parliament? The Minister’s first reference was to the handling of the legislation by Parliament. Why should not Parliament see what considerations took place within the department concerning how legislation should be handled as it goes through this House?
Earl Howe
My Lords, my clear understanding is that the Information Commissioner had full access to the risk register so that he would be able to see for himself what it contained. I do not believe that anything material was withheld from him. The whole purpose of risk registers of this type is to record all risks, even the unthinkable and the highly unlikely actual risks, as well as potential risks—in other words, risks that may not arise in the future but which could be mitigated with action today. Such risk registers record mitigating actions so that the risks identified do not become a reality. In our clear view, exposing that kind of information could cause needless concern, set hares running and seriously undermine confidence in the programme of work. No Government of any persuasion have routinely made risk registers of this type public for the very reason that to do so would undermine open and frank discussion among policy-makers for fear that the policy would be made public before it was fully developed.
The department has published and discussed its proposals for reform at every stage of this process. It has debated them at length in both Houses. It has even released some detail about the associated risks and what it is doing to address these in impact assessments. Therefore, I firmly believe that the Committee has all the information that it needs to discuss the proposals in detail.
Baroness Williams of Crosby
My Lords, the Department of Health will be aware that with a freedom of information request there are always considerable burdens on those who argue that the information should not be conceded. Has the Minister given any thought to the possibility of a limited redaction of the report rather than not making it available at all, or alternatively whether there are parts of it that he feels could be made available so that the House can consider more deeply the issues that are coming up? I share the view of the noble Lord, Lord Campbell-Savours, that on the issue of how Parliament handles the legislation and the implications for the transition, certain things from the register might be useful, although I recognise that some extreme cases might be picked up by the tabloids and be changed into sensational reporting. Could the Minister possibly consider that qualification more seriously than we have been able to do so far?
Baroness Finlay of Llandaff
My Lords, I would be grateful if the Minister could let us know whether the department considered the BMA resolution in council at the end of last week to now oppose the Bill and campaign against it, when the BMA was coming to its decision to appeal against the release of the information. If not, will it be considered in the next steps the Government take, given that it signals a major loss of confidence in the Bill by the BMA?
Lord Stoddart of Swindon
How long is it likely to take for the appeal and the decision? If the decision disallows the appeal, will the Government accept that?
Lord Butler of Brockwell
My Lords, the problem is not what may be contained in a particular risk register, as the Minister has said, but the precedent that it sets for all other risk registers. There may be nothing in this register that is particularly sensational or has not been released. However, once this case is conceded it will nullify the effect of all risk registers across government. If people think these risk registers are valuable it must be the case, as the Minister has said, that people look at the worst risks and do so frankly, and if they make them anodyne then the purpose of the registers is entirely lost.
Lord Elton
My Lords, I hope that the noble Baroness, Lady Thornton, will remember those words when she is considering her next intervention on this matter. Bear in mind that what she says then will be taken as the yardstick of what any Government of her colour are expected to do when they eventually—one hopes at a great distance of time—take our place.
Lord Campbell-Savours
My Lords, I understand there is a precedent—a Department of Transport one. Therefore, there is a discretion and the Government are in a position on this occasion and not on a further one. I do not really see that that case is relevant.
Earl Howe
My Lords, I am very grateful to the noble Lord, Lord Butler, whose understanding of these matters is one that noble Lords will respect greatly. He is absolutely right—this is not an issue that solely affects the Department of Health: it affects all government departments. That is why the stance taken by the BMA to this Bill was not material in our decision. We regret that stance but it did not come into our thinking in any way.
On the question of precedent, I am aware that during the course of the last Government three separate recent requests were made to the Department of Health to release risk registers. All three requests were declined. I have the letter here that was sent when the right honourable Andy Burnham was Secretary of State, citing exactly the same kinds of reasons I have given.
I was asked how long the appeal would take. I do not know but my understanding is that the process should come to a conclusion reasonably early in the new year. I cannot be more definite than that because it is not up to us—it will be up to the tribunal to order its business as it sees fit. Will the Government accept the result? Clearly, we will have to take a view whatever the result; I cannot pre-empt the decision today. My noble friend Lady Williams asked whether we had considered releasing a redacted version—the decision before us was whether to comply with the Information Commissioner’s decision in full, or not to and appeal. We did not have the option of redaction but I am grateful to my noble friend for her suggestion, which I will take away and consider.
Lord Butler of Brockwell
“(5) In discharging its duty under subsection (1), the Board must publish guidance for clinical commissioning groups that includes the option to opt out and explains the extent of compliance with—
(a) the quality standards prepared by NICE under section 231 of the Health and Social Care Act 2011;(b) indicators included within the NHS Outcomes Framework; and(c) minimum standards set by the Board on patient related outcomes measures.”
The Lord Speaker (Baroness D'Souza)
My Lords, I advise the Committee that if the amendment is agreed to, Amendments 110 and 110ZA cannot be moved by reason of pre-emption.
Lord Butler of Brockwell
My Lords, with the agreement of the noble Lord, Lord Newton, I move Amendment 109A, which stands in my name and his. I can do so briefly, although the amendment is important and, I hope, helpful. I declare an interest as the chair of King's Health Partners, an academic health science centre. Part of the centre's mission is to accelerate the translation of research into patient care—getting a faster process from bench to bedside. It is in that capacity that I move the amendment.
The focus in the Bill on outcomes for patients is very welcome. It is also welcome that Clause 20 gives the Commissioning Board a duty to promote compliance with the quality standards prepared by NICE, as well as guidance published by the Secretary of State. There may be circumstances in which there are good local reasons why NHS providers should not comply with NICE guidelines. One such circumstance may be where there are innovative treatments that have been approved but with which NICE guidance has not yet caught up. We do not want the clause to stifle the introduction of such initiatives, which the creation of AHSCs is designed to promote and which are greatly in the interests of both British industry and patients. For this reason, Amendment 109A introduces an element of flexibility through a comply-or-explain regime. It will give providers the opportunity, in cases where there are good reasons why they should not comply with the NICE guidelines, to depart from them provided they can explain their non-compliance satisfactorily. That is all I need to say about the amendment. I beg to move.
Lord Newton of Braintree
My Lords, I chip in briefly in support of the amendment. I hasten to assure my noble friends on the Front Bench that this is a probing amendment and that I have no intention of pushing my luck. I have been so open and transparent as to share with the Minister every word of the briefing that I received and that led to the amendment. He knows what it is about. Therefore, I am looking for a measured, constructive and well informed response. I have no interests to declare except the public interest. The healthcare industry—the interests of which underlie the amendment—is important. It contains a lot of small and medium-sized enterprises of a potentially and actually very successful kind. We ought to encourage them, and I hope that the Minister will do his best.
Baroness Royall of Blaisdon
My Lords, I speak to Amendment 110ZA. In tabling the amendment and Amendment 343A, I was mindful of information from the Prostate Cancer Charity, which I strongly support, and from members of the Epilepsy Society. Of course I am aware that many other people with different chronic diseases, and those who care for them, are concerned about these issues.
As noble Lords are aware, prostate cancer is the most common cancer in men in the UK. In England, 30,000 men are diagnosed with it every year, and there are 215,000 men living with and beyond the disease. Ten thousand men die from prostate cancer every year. Currently, clinical nurse specialists for men with prostate cancer have to care for a worryingly high number of new patients compared to nurses for people with other common cancers. I am therefore worried that the financial pressures on the NHS and the cost of reform will threaten those already overstretched specialist nurses, who are so vital in driving up the quality of care for people with cancer.
Access to a clinical nurse specialist improves the experience of people with cancer at every stage of their journey and ensures that they have access to the vital support and information they need. This has been evidenced by the results of the 2010 National Cancer Patient Experience Survey. If patients are to have more control over decisions related to their care and report a good experience of care, they need the clinical and emotional support, information and expertise that a clinical nurse specialist can provide.
As the noble Earl will be aware from his association with the epilepsy organisations, NICE guidelines state that epilepsy specialist nurses should be an integral part of the medical team providing care to people with epilepsy. Even with investment made under my Government, 60 per cent of acute trusts and 64 per cent of primary care trusts did not have an epilepsy specialist nurse in 2009. SIGN guideline 70 states that,
“all epilepsy care teams should include an epilepsy specialist nurse”.
There are around 150 epilepsy specialist nurse posts, with a further 250 to 300 nurses who have undertaken training but are not in a role due to the shortage of posts.
As all noble Lords will be aware, specialist nurses save the NHS money by releasing consultants’ time, reducing A&E admissions, enhancing patients’ adherence to treatment and reducing the use of hospital beds. Therefore, I am proposing two amendments that would place duties on the NHS Commissioning Board to have regard to the continued access of patients to clinical specialist nurses. The first would support the board’s existing duty as to the improvement in quality of services and the second would create a new standalone duty. I trust the Minister will be able to accept my amendments.
Lord Walton of Detchant
My Lords, I rise to support Amendment 109A. There is no doubt at all that for many years now the work of the National Institute for Health and Clinical Excellence, NICE, has made a major contribution to the National Health Service. There is a widespread feeling in the public at large that NICE deals with nothing other than whether or not to recommend the approval of certain drugs for the treatment of disease within the NHS. However, NICE’s commitment spreads much more widely than that. It examines procedures; it examines complicated interventions of all kinds; it examines the introduction of new and innovative techniques, new instruments and other procedures in the NHS. Its remit is exceptionally wide.
I know full well that the noble Lord, Lord Newton, says he is not going to pursue this amendment to a vote, but it is important that we have some assurances from the Minister. As my noble friend Lord Butler says, it is clear that, although NICE guidance in general terms is something with which health authorities and health bodies of all kinds will be expected to comply, there are clearly circumstances, particularly at a local level, where, for the reasons he gave, such compliance would be inappropriate. The amendment takes full note of that as being an important issue.
However, we must be sure, in implementing the recommendations of NICE, that we do not overlook the crucial importance of ensuring that the national Commissioning Board will have a duty to promote innovation in its annual report. It is also crucially important, when we come to look at innovation tariffs much later, in Amendment 288H, to see that the tariffs system will not act as a counterincentive to the adoption of innovation and of new technologies. These are issues upon which it is important to seek assurances from the Minister.
Perhaps I may also add to what the noble Baroness, Lady Royall, said. The work of specialist nurses is extraordinarily important to the NHS, and not least in my own field of neurology, where nurses who are specialised in multiple sclerosis, Parkinsonism, epilepsy and many other conditions have made an outstanding contribution to the clinical care of patients. In many instances, their work and advice have prevented unnecessary admissions to acute wards of patients suffering from these conditions. They are invaluable. Unfortunately, over the past five or six years, we have identified instances where cash-strapped health bodies of various kinds have diverted some of these specialist nurses into standard nursing care. I hope that the Minister can give us an assurance that the role of specialist nurses in the NHS is going to be enshrined in the Bill and that the Government will recognise that such nurses are there for a special purpose, not to provide general nursing care in hospital wards and out-patient departments.
Baroness Cumberlege
My Lords, I have tabled three amendments in this grouping: Amendments 110C, 131A and 190C. I am grateful to the noble Lord, Lord Patel, for supporting the amendments because they concern maternity services, and I do not think I could have anyone more distinguished than the past president of the Royal College of Obstetricians and Gynaecologists, although of course the noble Lord is also involved in many other things, not least this Bill. These are probing amendments, the first of which seeks a commitment from my noble friend the Minister that the Government, through commissioning at the national and the local level, will give women and their partners real and informed choice in maternity services. The second amendment would ensure that there is less variation in the quality of services provided, and the third concerns maternity networks, including independent midwives.
The variation in maternity services across the country is quite startling. Sometimes the poor performance is a reflection of a lack of resources or priorities, but one of the reasons for this is that maternity services have been overwhelmed by the rising number of births, including more complex cases. This is partly due to the increase in the number of older women giving birth. Last year the number of women giving birth aged over 40 was the highest since 1948, the post-war period, and we can surmise about that. In the past 10 years in England, the number of births overall has risen by 22 per cent, which means that more than 10,000 extra babies are born every month. There has been a modest increase in midwives, and we should be grateful for that, but they are being run ragged by this record-breaking baby boom.
The Bill seeks to ensure that the quality of NHS services will improve by using new and increasingly much more sophisticated commissioning systems. If this key objective is to be realised, it will require commissioning of a very high quality. Pathfinder clinical commissioning groups are beginning to get a grip and to understand the health needs of their local populations, but inevitably others will lag behind and we will see variations in commissioning. One of the ways to address this is through a NICE quality standard, as already discussed by the noble Lord, Lord Butler, and my noble friend Lord Newton. But as the noble Lord, Lord Walton, said, even when these standards are produced, advice from NICE is not always adhered to, and I understand that the queue for these quality standards to be produced is very long, with maternity services some way down the line.
On quality, proposed new Clause 13E(1) states that the NHS Commissioning Board should improve the quality of services in three areas: prevention, diagnosis and the treatment of illness. On prevention, however powerful the board is, it is going to find it a real task to prevent wanted pregnancies—even Solomon in all his glory failed to do that, and he knew quite a bit about babies. On diagnosis, I do not think there is much problem in diagnosing pregnancy, as it is usually pretty obvious to those concerned. On the treatment of illness, certainly most women who are pregnant are not ill; on the contrary, many take enormous care of themselves and are extremely fit and so will not need treatment for illness.
Looking at those three criteria in that subsection, I think that they do not fit with maternity services. Therefore, we have a lacuna, which I am trying to fill with my first amendment. I suggest that the Commissioning Board keep a watchful eye on the situation in England and use a means—possibly a specification or some other mechanism—which would act as a guide to enable commissioners to buy services from NHS trusts at a set quality, until NICE has produced its quality standards.
My second amendment concerns choice. I apologise because I think it has been positioned rather wrongly in the Bill, but it is another probing amendment.
“Pregnancy is a long and very special journey for a woman. It is a journey of dramatic physical, psychological and social change; of becoming a mother, of redefining family relationships and taking on the long-term responsibility for caring and cherishing a new-born child. Generations of women have travelled the same route, but each journey is unique”.
I wrote that in the foreword for Changing Childbirth, which was a government policy document that I produced many years ago. It is because each journey is unique that women and their partners should have as much choice as possible, because we know choice is empowering. Giving birth can be wonderful, but it is also very traumatic and the start to a new life can have long-term consequences for the baby as it enters childhood and later adult life.
New Clause 13I, places a duty on the board to enable patients to make choices in the services they receive. Pregnant women and their partners have four main choices when considering where to give birth: at home, in a free-standing midwifery unit, in a midwife-led unit situated alongside a hospital or in a hospital led by a team of obstetricians. This is the theory, but it does not actually work in practice. Delivered with Care, a national survey of women’s experiences of maternity care in 2010, undertaken by two very respected researchers in the field, found:
“Many women (80 %) were not aware of the four possible options for … birth”.
Therefore, how can potential parents choose when they are not even aware of the options? Why do health workers, especially GPs, seeing a woman at the first booking, not tell them what is available? The majority only tell them where to go, and that is hospital.
In a joint statement the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, in their introduction to a paper on home births state:
“The rate of home births within the UK remains low at approximately 2%, but it is believed that if women had true choice the rate would be around 8-10%”.
It is part of government policy to give choice, including birth at home, to every pregnant woman. In Somerset 11.4 per cent of births are at home, whereas in Wansbeck the figure is just 0.1 per cent. Of course there may be a range of factors affecting this—I suspect housing and other conditions also play a part—but this discrepancy is so great that I am sure it is partly due to the fact that mothers were not even told what was available. I would like to ask the Minister how he sees the NHS Commissioning Board addressing its duty in new Clause 13I as to patient choice in maternity services. I appreciate this is quite a minority sport so the Minister may like to write to me on this issue.
My third amendment concerns maternity networks. Neonatal and cancer networks, where they work well, have proved to be highly effective. It is a model that those in maternity services wish to adopt. They believe that effective, inclusive and supported maternity networks have the potential to ensure that all women, within the network locality, are able to access the full range of services from pre-conception to early years. The networks would be able to promote choice within these services and work with all providers to ensure that women are offered and are able to exercise informed choice. The existing networks have received funding for their infrastructure, which has enabled them to be effective. Will my noble friend consider a similar commitment from the Government to support the development and sustainability of maternity provider networks and ensure that they are properly resourced?
Part of the network should be the care offered by independent midwives, who give a highly specialised and personalised service, accompanying the family through this wonderful but often stressful time in their lives. There are around 130 independent midwives in the country, but there are about 800 who would choose to work in this way if they could get professional indemnity insurance. Currently that is not the case because of market failure to provide for it.
The EU Council of Ministers has issued a directive on patients’ rights on cross-border healthcare that requires member states to ensure that systems of professional liability insurance are in place for treatment provided on their territory. The Government ratified this directive on 28 February this year, which means that all midwives in independent practice in the UK will need to be able to access this insurance from September 2013 in order to be registered with their regulatory body, the NMC. Without registration, they will not be able to practise midwifery legally; independent midwifery will disappear, unless a solution to the insurance conundrum is found. Can we really afford to let this happen when the maternity services are in such desperate need of experienced, skilled midwives?
The clock is ticking and the issue is urgent. I ask my noble friend, who is well aware of this difficult issue—we have met in the past to discuss it—to tell me when the Government are planning to publish their proposals and when independent midwives and other non-NHS bodies will be able to take up the NHS clinical indemnity arrangements planned for by the Government.
Lord Mawson
My Lords, I rise to support Amendment 131A proposed by the noble Baroness, Lady Cumberlege. My wife and I have three children and have experienced some choice as to whether they were born at home or in hospital. I must admit that this was not a matter to which my wife and I had given a great deal of thought when we had our first child 31 years ago. Then we naively assumed that having a child in hospital was fine and the normal practice. The doctor would look after us. However, the truth is that it was far from normal for a young married couple. We discovered later that everything that was done seemed to be focused not on the well-being of the patient—my wife and child; some would say the customers—but on the interests and timetable of the consultant. Medication was given that was not really needed to ensure that the child was born to fit some preordained hospital schedule, a timetable that I think had more to do with the consultant’s golfing schedule, I discovered later, than the interests of the mother and child. The experience left some scars.
Our second child was born at home in Tower Hamlets, under a new home birth scheme that was quite radical at the time and which was set up by Dr Wendy Savage. I must say that this experience was completely different. We all felt so much more relaxed and in charge of events, as best you can be on such occasions. It all happened rather quickly and in a relaxed atmosphere and was an experience of great joy for us all. The effects of this experience on mother and child, with a competent midwife present, were quite different. I must say that even I felt quite competent in making the tea. The first experience in hospital had all been about a culture of illness at the most important moment of parents’ lives; the latter was about health and well-being.
Baroness Thornton
My Lords, perhaps I may speak to the amendments in this group which are in my name. First, Amendment 110A concerns NICE guidelines and is very much like that tabled by the noble Lords, Lord Newton and Lord Butler. In fact, theirs may be even better than mine so I intend to say no more than that we are interested in the Minister exploring this issue, because those noble Lords both more than adequately covered the points that need to be made in that regard. I am also very pleased to support the amendments in the name of my noble friend Lady Royall and to put my name to those, because the role of specialist nurses is extremely important.
Amendments 118, 119 and 120 concern the duty of the board to reduce inequalities. Proposed new Section 13G of the 2006 Act states that the board must,
“have regard to the need to—
(a) reduce inequalities between patients with respect to their ability to access health services;
(b) reduce inequalities between patients with respect to the outcomes achieved for them by the
provision of health services”.
This seems a rather narrow definition concerned solely with health services, which I assume flows from the continual and overriding responsibility of the Secretary of State for tackling health inequalities. I would be grateful if the noble Earl could confirm to the Committee how the Secretary of State intends to tackle health inequalities—what information he will need, where he will get it from and how those decisions will then be moved through the proposed structures of the National Health Service Commissioning Board, the CCGs and so on.
Surely, the health and well-being boards would want to have some involvement from the NHS on health inequalities, so Amendment 118 seeks to ensure that the board has health inequalities in its remit. I particularly refer the Minister to the letter from the NHS Future Forum to the Secretary of State on 17 November where it devoted much attention to the NHS role in improving public health and made its claim that the NHS must design its services in a way that both promotes good health and prevents poor outcomes. It is thus important that the legislation provides sufficient leeway to allow the NHS Commissioning Board to do this and that legislation relating to health inequalities is not confined solely to the provision and commissioning of services.
What is also important, in coming to my Amendment 119, is that funding to the clinical commissioning group reflects the deprivation levels within its area. Can the Minister tell the Committee whether there has been a risk assessment on the issues of funding? What risks has the department found that go with the levels of funding that might be made available on the basis of deprivation levels within areas?
Of course, the decision of the Secretary of State not to make clinical commissioning groups area-based is a serious problem in ensuring a population base for commissioning, but it will be doubly important to ensure that clinical commissioning groups with large numbers of deprived patients receive financial support. I would be grateful if the Minister could spell out the intended principles behind the funding associated with clinical commissioning groups.
On Amendments 110B, 127ZA and 190AA, which concern maternity services, the noble Baroness, Lady Cumberlege, has adequately covered the major concerns about those services and we would be keen to support her amendments. I am grateful to the Royal College of Midwives for its briefing on these amendments. My only questions are about maternity networks and the recognition of their potential contribution to the type of maternity care and providing clinical commissioners with expert guidance and advice on driving up standards.
The Committee will be very pleased to hear that I do not intend to share any birthing stories. On the other hand, I am concerned. Without a national standard for maternity services, how will the new commissioning arrangements avoid significant variations? We know, for example, that there is a significant variation between trusts in the number of home births that take place. We can explore the reasons for that, but I would like to know how the new structures would deal with such variations and how that would be reflected in the work of the National Health Service Commissioning Board.
Baroness Williams of Crosby
My Lords, I have Amendment 112 and 113 in this group. I have a comment regarding the excellent speech of the noble Baroness, Lady Cumberlege, and would like the Minister to reply to it. NICE has suggested that all women expecting babies could have the right to consider the possibility of a caesarean birth. Before the choice is finally made, will that be associated with advice from doctors indicating that caesarean births are certainly not as straightforward as some people believe them to be, and for cosmetic reasons may be deeply regretted afterwards? I was a little worried that NICE had given this green light, as it were, to caesarean births without associating it with any form of counselling to the mothers concerned, not least because, as many people in this House will know, the outcomes in terms of morbidity and infant mortality are not as good as people imagine them to be in comparison with a normal birth. Perhaps the Minister could say something about that. Perhaps the noble Baroness, Lady Cumberlege, could also say something about it when she responds on her useful and important amendments, to which I hope the House will give an extremely warm welcome.
Amendments 112 and 113 are about strengthening the language about health inequalities. On that issue, we have had a helpful letter from the noble Earl, Lord Howe, dated 24 November, in which he sets out in detail some of the steps that will be taken, not least the creation of the Institute of Health Equity, to deal with health inequalities. My question is rather a big one but it boils down to the old problem of how one ensures that these worthy and excellent intentions are actually carried out.
The House will remember that new Section 13F of the 2006 Act proposed in Clause 20, which deals with the autonomy of clinical commissioning groups from the Commissioning Board and restricts the board’s actions in terms of having to bear that autonomy in mind, was put into a different set of considerations—the consideration of the whole of the responsibility of the Secretary of State and the responsibilities of the boards—under the headings of Clauses 4 and 10.
All of this means that we are still debating these issues without being clear about where responsibility for them ultimately lies. I do not propose to go over that ground again, but it is appropriate for this debate to notice that the whole set of duties that are laid out in detail—and to which this debate will undoubtedly add as it lays down further duties for clinical commissioning groups and the board as a whole—in a sense therefore depends upon the outcome of those discussions about the constitutional structure. That matters because we need to bear it in mind all the way through our consideration of the duties that are laid upon clinical commissioning groups.
What makes me, to be honest, even more concerned is that I recently read the discussion paper The NHS: Developing Commissioning Support, which was quite improperly, no doubt, leaked on the internet. My attention was drawn to it by a couple of doctors who had access to the internet. The paper sets out in detail the ultimate objective of moving towards a commercial market in the health service and sets it out under a considerable number of different headings. For example, there is a specific mention in this report that,
“Clinical commissioning groups will have a statutory freedom to secure the commissioning support from wherever they want”.
It goes on to say that the commissioning support should be given in a vibrant, commercial market. What worries me about all this is that I am not at all clear—and never have been in our long debate on health—about what the ultimate goal is. I suspect that we are discussing two things at the same time. One is the attempt to keep improving the existing NHS, sometimes by an extraordinary degree of micromanagement—from this House, I have to say. The other is the determination of many people in this House to ensure the safety and continuation of the NHS which is free at the point of need and which is available to people regardless of their ability to pay. Somewhere along the line and at some point, we really have to be clear what we are talking about. I do not know whether others taking part in this debate share my sense that we are walking in without knowing the constitutional responsibilities and quite where we are going.
I commend my two amendments. They both strengthen the words on equality of health outcomes. I congratulate the Government very much on establishing the Institute of Health Equity and carrying forward the detailed research we are now doing on lifestyles and many other things, which are important and which I am sure the whole House will applaud. However, I have to raise the big question about destinations. I hope that at some point before we abandon the Committee stage, we will have a clearer view about the Government’s ultimate destination: whether it is to retain an NHS; whether it is to make it more open to innovation and other contributions from the private sector, with which many of us would certainly not disagree; or whether the ultimate outcome is to move towards a commercial market system, this being essentially a transitional stage.
Lord Turnberg
My Lords, this is a disparate group of amendments. I support a number of them. Some seem to be counter to others, but I hope that they will come together at some point. Amendment 110A seeks to strengthen the need to take into account the guidance from NICE. From time to time, NICE faces someone complaining about the way it goes about its business. Sometimes patient groups suggest that it is taking its time or is working against their best interests. The pharmaceutical industry complains from time to time that it takes too long and maybe gets things wrong—perhaps that is a good thing on behalf of NICE. Others complain about the methodology that NICE uses, using QALYs—quality-adjusted life years—as its measure of whether a drug or treatment is effective. Despite all that, I believe that NICE does a marvellous job, as do many who know what it does. It makes sure that the suggestion of treatments is based on clear, independent evidence of their effectiveness. Its approval is something of a kitemark for the standards that GPs and PCTs should follow and the system is envied across the world. There are others trying to emulate NICE.
Baroness Finlay of Llandaff
My Lords, I have put my name to several of the amendments in this group—namely, Amendments 112, 113, 115, 186, 187 and 189—all of which are aimed at reducing inequalities. The noble Baroness, Lady Williams, has spoken about this. I will not repeat her arguments, other than simply to say that my reason for adding my name to these amendments was that it struck me that the words “act with a view to reducing inequalities” were not strong enough. Unless commissioning must have regard to the need to reduce inequalities, we will not improve the health of the nation.
Perhaps I may make a comment on Amendment 109A, which is a probing amendment and refers to NICE. I just want to place on record other areas of standard-establishment, such as the National Prescribing Centre and the audits and independent service reviews that are undertaken by the medical royal colleges. These are available and can be very informative. The service accreditation standards that they have produced are aimed at driving the equality improvement agenda and draw to the attention of the Commissioning Board and clinical commissioning groups the role of audits and the information that they can receive from audits, which are intended to drive up equality and reduce inequalities in service provision.
I also have in my name Amendment 299C, which seems to be almost an orphan amendment in this group but is there. It relates to private work. My reason for tabling it is that for a long time there has been confusion over what is private and what is NHS. The Bill also highlights a complexity about what is private and what is third-sector provision. Until now, third-sector services outside the NHS have generally tended to be lumped together in regulation. We will be facing different models in the non-NHS sector ranging from for-profit, through not-for-profit, to the voluntary sector as we know it today. One of the difficulties is making sure that patients are not recruited into the private practice of an individual who sees them during an NHS consultation. The fine balance between information-giving and recruiting should be clarified in guidance. Patients may ask what the waiting time is and whether they could have their intervention, investigation or whatever done more quickly if they went privately. I am concerned that the way the information is given may skew the patient’s perception of it and the patient can then feel they actually ought to go privately. This may be for the profit of that individual practitioner but not necessarily make a great deal of difference to the clinical outcome of the patient.
It is, therefore, a very difficult and fine line, but unless we begin to address it now, we will run into the same problems as we have had, for example, with top-up payments, where we had a lot of debates leading to the establishment of the Cancer Drugs Fund across the UK. We will be facing the same situation, but more so, with many other drugs that come along for non-cancer diseases. The new biologics are very powerful drugs which can be extremely effective but are extremely expensive. I am concerned that a commissioning group might decide that one of these new biologic drugs, even though it goes through all the benchmarking standards required, is something they are just not going to pay for locally. Private sector provision will, therefore, be driving patients who cannot afford to access these treatments, who are not privately insured, and whose quality of life is so severely undermined by their illness—because it is only for severe disease that these drugs are indicated—that they will not be able to work or earn without accessing them. They could therefore find themselves in a double bind.
My amendment is, of course, a probing amendment and I would not intend it to be anything more. If the Minister does not want to respond to these points today, I would nevertheless urge him at least to consider them in the guidance produced for the Commissioning Board and providers on the interface between the public and private sectors.
Lord Newton of Braintree
As this is Committee stage, I hope my noble friends will forgive me if I play Oliver Twist and seek a small second bite. I promise to be brief and make only three points. The first picks up on maternity and the remarks of the noble Lord, Lord Mawson, about consultants versus patients, if I may put it that way. I remember, in the far-off days when I used to sign 18th birthday cards to prospective or actual constituents, noticing a remarkable bunching. If you checked back 18 years you would find a correlation with Fridays and particularly the period in the run-up to a bank holiday. Secondly, nobody else has followed up the amendment of the noble Baroness, Lady Royall, about specialist nurses. I have an interest to declare here as—there are probably other things as well—president of the Braintree Parkinson’s Disease Society and the Braintree Multiple Sclerosis Society. The importance of specialist nurses in some of these areas is both extremely great and underestimated. I hope that we will therefore not lose sight of the point made by the noble Baroness, Lady Royall, in her amendment, supported by the noble Baroness, Lady Thornton.
Thirdly, to assure the noble Lord, Lord Walton—who I thought was at one stage going to accuse me of being a wimp for not pressing this to a vote—I do not rule out returning to the matter on Report, unless the Minister is really nice to me.
Lord Patel
My Lords, I shall speak to several amendments to which I have put my name, but I shall start with the amendment of the noble Baroness, Lady Cumberlege, to which I have also put my name. The noble Baroness is well placed to talk about maternity services. She has championed their cause, particularly regarding choice, for nearly two decades. It is she who should be credited for getting us to where we are now, whereby choice of where to have their babies is available to all would-be mothers.
The noble Baroness covered most points, and I support them all. The one on which I should like to expand relates to maternity networks. It appears that both the Prime Minister and the Department of Health have accepted that maternity networks are the way to improve maternity services, and I agree. Maternity networks have the potential to increase clinician involvement and service-user engagement in the planning, delivery and, where necessary, reorganisation of services. They also have the advantage of being able to scrutinise the performance and outcomes of all maternity providers within the network, thereby helping to drive up standards and reduce unwarranted variations in outcomes. This will help to develop shared services across the network. Thus a home birth service provided by a modern maternity unit could be made available to maternity units in areas where the home birth rate is very low.
I know that a current review of clinical networks is being undertaken for the Commissioning Board, and is due to report soon. Perhaps the noble Earl can tell us more about it. I hope that the review recommends that maternity networks be established to cover all maternity services in England. The concern is that if providers are expected to self-fund networks, there is a risk that some providers, especially foundation trusts, will not engage in networks, thereby reducing their effectiveness. For this reason, I hope that the Government will accept the case for providing some funding and support for maternity networks in the same way as neonatal networks and cancer networks have been able to access central funding and support.
One other issue that will improve the quality of maternity services, no matter where that care is delivered, is the establishment of maternity dashboards. They are a good way of auditing the outcomes on a daily basis and establishing whether the clinical guidelines have been achieved. I therefore strongly support the noble Baroness’s amendment.
The amendment in the name of the noble Lords, Lord Newton of Braintree and Lord Butler of Brockwell, is saying “comply or explain”, whereby if you do not comply with NICE guidelines you must explain why. I agree. Not all standards should be complied with, because there may be reasons why they are not. If you do not comply, you have to explain why. However, you also have to explain why the outcome for patients will be the same or better, because if the outcomes through not complying are not the same or better, you should not be allowed to fail to comply.
I understand that there might be good reasons why certain NHS bodies do not comply. Another way could be the establishment of an alternative compliance system in which organisations and clinicians are required to justify why they have not complied with the standards or, for that matter, innovations that will aid delivery of the best clinical practice. The Commissioning Board, in conjunction with senates and by way of patient pathways, could develop a compliance regime that measures, monitors and incentivises the use of innovation or compliance where these will improve standards of care. So I support the proposal, and I know that we might return later to the issue that my noble friend Lord Walton raised about innovation, tariffs and the innovation tariff. That is the other side of the coin regarding non-compliance and going beyond the standard of care laid down by NICE.
Lord Marks of Henley-on-Thames
My Lords, I start by adding my support for the amendments that change the duty to reduce inequalities by strengthening the wording from having “regard to the need” to reduce such inequalities to “acting with a view” to reducing such inequalities. Those are Amendments 112 and 113, in relation to the board, and Amendments 186 and 187 in relation to clinical commissioning groups. I do not want to add a great deal to what the noble Baroness, Lady Finlay, said in that regard, except merely to observe that the commitment to reducing health inequalities in the Bill is one of its great advantages and will be one of the great advantages and achievements of the legislation, if it is passed. I suggest that saying it loud and clear and imposing the stronger duty on the board and the Secretary of State would be the better way to achieve it.
I want to address the other amendments to which I have put my name, Amendments 153ZZA and 153ZZB, which concern the permitted disclosures of information by the board in proposed new Section 13Z2 on page 24 of the Bill. It is important to observe that the starting point for this clause is proposed new subsection (2):
“This provision has effect notwithstanding any rule of common law which would otherwise prohibit or restrict the disclosure”.
This proposed new subsection is about permitting disclosures by the board of information whose disclosure would otherwise be unlawful, which from the wording I take to include any disclosures that would be actionable either in tort or in contract. My concern is about how far this provision would sanction a breach of confidentiality owed to patients or others.
Most of the examples or circumstances outlined in proposed new subsection (1) are anodyne or obviously called for. The first, for instance, is that the information is already in the public domain; the second is where the disclosure has to be made pursuant to regulations, and so forth. However, the amendments are concerned with two sets of circumstances that are, I would suggest, entirely too wide. The first is under paragraph (d), where the suggestion is that disclosure should be permitted where,
“the disclosure is necessary or expedient for the purposes of protecting the welfare of any individual”.
As drafted, paragraph (d) is without regard to the wishes of the individual concerned or, in the case of an individual suffering from incapacity, to that individual’s care. I would suggest that that smacks of a certain arrogance that ignores the rights of the individual to choose whether information about him or her is released by the board. It is for that reason that our amendment suggests that the words,
“and is made with the agreement of that individual or of a person having legal responsibility for that individual’s care”,
should be placed as a qualification to the unfettered right to disclose based on the board’s view of what is,
“necessary or expedient for the purposes of protecting the welfare of”
that individual.
The second area where we say that the disclosure provision is far too wide is under paragraph (f), which suggests that disclosure should be permitted where,
“the disclosure is made for the purpose of facilitating the exercise of any of the Board’s functions”.
That permissive subsection would give the board an overall right to disclose any information it chose, notwithstanding that it was otherwise unlawful, on the basis that it was,
“made for the purpose of facilitating the exercise of any of the Board’s functions”.
It does not even go so far as to say that it would have to be necessary for the exercise of those functions. In the view of those of us who have put our names to this amendment, those lines should go. They are an unwarranted intrusion into the confidentiality of the individual, and they give far too wide a discretion to disclose information whose disclosure would otherwise be unlawful.
Lord Harris of Haringey
This is an extraordinarily wide group of amendments—I think there are 27 in this group. I sympathise—well, almost sympathise—with the Minister in terms of how he will respond to them.
I wish to comment on just three of the amendments. The first is Amendment 144, which the noble Lord, Lord Patel, has just spoken to, about the importance of sharing information collected on the safety of services provided by the health service. Particularly in the context of what I think we will see as a fragmentation of the service, where a pattern becomes apparent that suggests that particular practices or processes challenge patient safety, it is important that that information is disseminated.
Lord Marks of Henley-on-Thames
If the Minister were inclined to concede our amendment, subject to a proviso dealing with emergencies of the sort that the noble Lord has suggested might be important, would that meet his objection to the amendment?
Lord Harris of Haringey
No, the reason being that it may not be an emergency situation; it may be that an individual is being passed from one agency to another. The point at issue is a risk and the mitigation of that risk. The risk may be that an assessment has been done suggesting that a person is at risk of suicide. They may well not commit suicide; there may well not be an emergency; or there may well be things that the receiving agency can do which will reduce that risk. However, there is no emergency so there would not be circumstances in which you could say it is in response to a particular situation; it is to avoid a situation arising. I am sure that there could be a form of words which would both deal with the concerns the noble Lord has highlighted and permit the sensible passing on of information to safeguard the right to life of that individual. I do not think Amendment 153ZZA quite deals with that point, and the Minister may want to respond to that when we get to that stage.
The final amendment I wish to speak to, very briefly, is Amendment 299C in the name of the noble Baroness, Lady Finlay of Llandaff. I, too, think it is extremely important that NHS services explicitly in the Bill must not use NHS business to recruit private patient business. In a context where again we will see the fragmentation of services, the arrival of all sorts of new providers and the possible blurring of distinctions between NHS provision and that provided privately by NHS practitioners, this needs to be made explicit. It is already an issue. I will cite my personal experience. The last but one time I visited my general practitioner—I think it was the first time for some five years—he declined to make the referral for secondary care I wished to have, saying that I probably had not looked after myself as well as I should have done, but then he pushed across the table a card advertising his Chinese medicine service. I thought that was extremely inappropriate—disregarding whether it was an appropriate treatment; as far as I am concerned it is non-evidence-based medicine.
Under any circumstances for there to be a blurring of the NHS responsibility of a practitioner and their private concerns seems extremely dubious. It is important it is made explicit that this is not permitted. In a previous series of exchanges the noble Earl has said it is quite clear what should happen under those circumstances. However, it does happen and what is permitted becomes increasingly confused. Even if medical practitioners are not abusing their position, or there is no blurring of those lines and everyone has been quite proper, it is perfectly feasible that patients will be confused and will not be clear as to what is happening, and that will colour future relationships they have with people providing medical services to them. It certainly coloured my relationship with that GP because on the last occasion I saw him I was extremely dubious about receiving any advice from him. I confess I referred to him as being patronising. This was perhaps inappropriate; it was certainly unwise as he was about to perform a rectal examination. None the less, it certainly coloured the relationship we had. In the interests of both patients and medical practitioners the amendment of the noble Baroness, Lady Finlay of Llandaff, should be in the Bill.
Lord Warner
My Lords, I do not intend to follow that in a similar style. I support Amendment 144 in the name of the noble Lord, Lord Patel, to which I have added my name. I do not want to go over the ground covered by the noble Lord, Lord Patel, but I just wish to share with the Minister in particular and the House in general my own experience from introducing near-miss reporting in the NHS when the National Patient Safety Agency was established. In those good old days the figure was around 800,000 a year. The current figure, as my noble friend Lord Patel said, is of the order of 3,000 a day; it is on an upward incline.
The issue at stake in those days was not the principle of trying in effect to copy the airline industry and improve safety by having people come clean about near misses—some very serious, some less serious. No one disputed the merits of trying to learn from those experiences. Where everybody got a little concerned was around the making public of the information. I will not delight the House with some of the discussions that took place in Richmond House about whether the first lot of information should be made available, because who knew what the Daily Mail would do with it? Noble Lords will be pleased to know that the Daily Mail behaved in a predictable manner and ran screaming banner headlines about how near to death 800,000 people came each year.
The important point was that one was beginning to change the culture of the NHS, which knew that the information was being put in the public arena. The problem with the Bill is that it leaves to the board the decision about how to disseminate information. We as citizens would be better off putting in the Bill the specific organisations to which the information should be disseminated—which is what the amendment of the noble Lord, Lord Patel, does. I strongly support it and hope that the Minister will give it very careful consideration, and will carry on the publication and dissemination of the information on an agreed basis.
I will make a couple of remarks in response to the concerns expressed by the noble Baroness, Lady Williams, about a market in commissioning skills. I have no particular wish to promote a market in commissioning skills. However, as a former Minister responsible for the performance of primary care trusts, I say that many trusts seriously lacked commissioning skills. These were lacking particularly in areas such as collecting information, analysing it and using it to establish need and to procure services to meet those needs. We should not in the Bill do anything to limit the ability of the new clinical commissioning groups to receive and acquire the skills to enable them to do their job effectively, wherever the skills may be located. That is a very important part of introducing successful new arrangements for clinical commissioning.
I pray in aid of that approach the history of Dr Foster. The dear old NHS had been collecting data for decades but was unable to use them effectively to improve performance. It took an outsider coming in—Dr Foster—to use the information and turn it into something that was useful to the NHS in terms of improving its performance. We should not be too hung up on precisely where clinical commissioning groups get their skills from to do their job.
Baroness Thornton
My Lords, I forgot to speak to my Amendment 137A. I will make three points. The first is not about my amendment. I say how much I agree with the noble Baroness, Lady Williams, on the issues that are the subject of all the amendments to Clause 20, and of the debate and discussions that we are having in the Chamber and outside it about the mandate. I also say to the noble Lord, Lord Marks, and my noble friend Lord Harris that there is clearly an issue about information and confidentiality that must be addressed before the Bill leaves the House.
I will also say how much I agreed with the orphan amendment of the noble Baroness, Lady Finlay. Mine, too, is something of an orphan amendment but is rather important. Amendment 137A states:
“The Board must ensure that in relation to its duties under sections 13C to 13N, those persons in the private sector contracted to provide health services must contribute in the same way as public providers towards the achievements of those duties”.
Those duties are to do with the NHS constitution, effectiveness, quality, reducing inequalities, patient involvement, patient choice, innovation, research, integration, and the impact of those services. It is very important that we have clarification that all providers have a duty to promote those.
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Butler, and my noble friend Lord Newton for prompting this debate, which brings us back to a key theme in this Bill: namely, the extent to which we can reconcile central prescription with local flexibility.
Our White Paper, Liberating the NHS, set out the case for change, and with the help of this Bill we will put patients at the heart of everything the NHS does, focus continuously on improving patient outcomes and empower and liberate clinicians to improve the quality of healthcare services. In doing so, we will build on the successful quality framework pioneered by the noble Lord, Lord Darzi, including the quality standards programme that plays such a central role in providing robust evidence for quality improvement under this Bill.
I am naturally sympathetic to the spirit behind the amendments in the name of my noble friend and the noble Lord, Lord Butler. First, I can reassure them, and indeed the noble Lord, Lord Walton, that the Bill does not impose blanket requirements to implement NICE quality standards or any other NICE guidance, or to comply with indicators in the outcomes framework—nor should it. The board will have to have regard to NICE quality standards, including in relation to those services it will be responsible for commissioning. CCGs will similarly be required to have regard to the board’s commissioning guidance, which will be based on NICE quality standards and other accredited evidence. That is a strong duty. It means that they must consider that guidance and if they do not follow it they have to have a good reason why not. I will be coming on to an explanation of the duty to have regard in a moment. The guidance will explain rather than dictate how to improve quality, efficiency and fairness.
I will just say to the noble Lord, Lord Turnberg, that when it comes to NICE technology appraisals, the Government have undertaken to ensure that the NHS continues to fund drugs that have been recommended in NICE technology appraisal guidance and to maintain the effect of the funding direction in the new arrangements for value-based pricing. So there will be no weakening of NICE’s role here, as the noble Lord suggested.
In this way, the Bill gives us a framework to improve outcomes through recognising and rewarding high-quality care based on evidence of what works best. That comes from encouraging innovation and balancing the independence that is desirable for achieving good outcomes with the responsibility to improve, which I think is the intention behind my noble friend’s amendment.
On this occasion, I am afraid I cannot agree with the noble Lord, Lord Patel, that quality standards should be mandatory for rare diseases. We strongly believe that it should be local areas that lead in setting priorities for their own patient population. Making all quality standards for rare diseases mandatory would essentially cut across that approach. We feel that a more effective way to improve quality is to provide commissioners with all the necessary support and evidence that they need to plan how best to meet the needs of their local population.
I can sympathise with the intention behind Amendments 110ZA and 137B. The Government absolutely acknowledge the important contribution that nurse specialists make to patient care, and the value that patients, their families and indeed other members of the clinical team place on having their specialist expertise and support. I am of course well aware of the value of specialist nurses to people with epilepsy and I also completely understand the close interest of the noble Baroness, Lady Royall, in prostate cancer specialist nurses.
Under our proposals, commissioners will have the freedom to commission pathways of care designed around the patient and delivered by a multiprofessional workforce that includes specialist nurses. Of course, they will have the benefit of commissioning guidance on best practice, but in the end we are committed to empowering clinicians and giving them the freedom to determine how best to meet the needs of their patients. This will include decisions about which member of the healthcare team should deliver which aspects of care. These decisions are complex and we believe that they are best made by local clinicians and commissioners working in partnership, so although I have sympathy with much that the noble Baroness, Lady Royall, said, I do not agree that the board should have the sort of role envisaged in her Amendments 110ZA and 137B. We think that they are too prescriptive.
Turning to Amendments 144 and 145, I would say to the noble Lord, Lord Patel, that safety is a key domain of quality, and I have outlined before our intention to embed a culture of patient safety in the NHS by giving the board responsibility for managing the systems for reporting and learning from patient safety incidents that are currently operated by the National Patient Safety Agency. However, I agree that it is important that information which can inform and enhance patient safety in the NHS should be made available to all those who would benefit from it, as he suggests. The NPSA currently shares information with a number of bodies with a particular role in relation to patient safety, such as the MHRA and the CQC, and this will continue to be the case. Indeed, if it did not make important information available to those who it thought could reasonably benefit from it, the board would be in breach of its duty.
In addition to NHS bodies, the information is currently also used to develop products for use by non-NHS organisations, by the devolved Administrations and by international organisations, for which the board may determine it appropriate to charge a fee. It is for these reasons that we have framed the duty to share information in broad terms, and we would not want it to be more prescriptive or restrictive than that. This is the perennial problem of trying to insert a list in a piece of legislation.
Where the board does disclose information that relates to an individual, it is essential that their confidentiality is respected whenever possible and that information is disclosed only where there are compelling reasons to do so. I can reassure my noble friend Lord Marks that disclosures would be subject to the provisions of the Data Protection Act 1998 and the Human Rights Act 1998, so any disclosures of personal information would need to involve the minimum amount of information necessary to serve the purpose. To ensure that this is clear, it may be helpful to my noble friend to know that we are working with the BMA on issues to do with confidentiality and the application of the common law in relation to the board and other bodies. We intend to bring forward any necessary changes to the Bill on Report.
Lord Walton of Detchant
My Lords, I thank the noble Earl for confirming that the Government are working with the BMA. Is it not also very important, in relation to confidentiality, that they should also work with the General Medical Council which, after all, has provided very detailed advice to doctors about confidentiality issues?
Earl Howe
My Lords, the noble Lord is quite right, and my understanding is that we are doing that as well. Meanwhile, I can tell my noble friend Lord Marks that we will consider the provisions highlighted by Amendments 153ZZA and 153ZZB as part of this process.
My noble friend also raised the issue of inequalities. In earlier debates I highlighted the very significant departure made in the Bill that, for the first time ever in this country, the Secretary of State will be legally obliged to have regard to the specific need to reduce health inequalities, whatever their root cause. The board and the CCGs will also have this duty, which clearly emphasises our commitment to equity and fairness across the health service. We believe that the phrase “have regard to” completely captures the intention of the legislation; that is, that the board and the CCGs must consider the need to reduce inequalities in every decision they take. That, I hope, addresses the essence of Amendment 118. This is consistent, as I think it should be, with the public sector equality duty, which is phrased in exactly the same way. As the board already has a responsibility for all patients in the population, its general duty on inequalities also applies this widely.
Under Amendment 119, the board would have to have regard to the duty on inequalities in allocating resources to CCGs. We recognise fully the importance of ensuring that allocations give CCGs the resources to meet the distinctive needs of their local population. Again, our preference is not to place particular weight on one factor or set of factors in legislation. In fulfilling this duty, the board will also need to work in collaboration with health and well-being boards and local authorities. We have already debated the various duties on the board to participate in certain activities of health and well-being boards.
On Amendment 137A, of course it will be important to ensure that all providers contribute to the fulfilment of these duties. Some public sector duties, such as the duties under the Equality Act, already apply to anyone exercising a public function, which includes private providers who supply NHS services. The specific duties in the Bill are placed on the board and CCGs, and they remain responsible for exercising them even when they contract with another body to provide services. It is, therefore, incumbent on them to ensure that these commissioning arrangements, and the ongoing monitoring of services provided under them, support the fulfilment of their duties.
I am not sure whether the noble Baroness, Lady Royall, spoke to her Amendment 343A, but if I cover it briefly, it may be helpful to her. The amendment probes how long it will take NICE to produce the full range of quality standards. As the noble Baroness probably knows, the ambition is to create a core library of NICE quality standards that covers the majority of NHS activity, and supports the NHS delivering against the outcomes in the outcomes framework. The programme is ideally placed to deliver a steady stream of quality standards over the agreed timescales and this will lead to a comprehensive library of quality standards within, we hope, about five years. Therefore, I am afraid the timescale envisaged in her amendment is too short.
I turn now to the group of amendments introduced by my noble friend Lady Cumberlege on maternity services. I am grateful to her and, indeed, the noble Baroness, Lady Thornton, for giving us the opportunity to consider this question. I hope I can provide some reassurance that the new commissioning arrangements will provide a very secure basis for quality improvement in these services. Women should always expect—and always receive—excellent maternity services that focus on the best outcomes for them and their babies, and which optimise women’s experience of care. Getting maternity care right from the start can help tackle the negative impact of health inequalities and begin to improve the health and well-being of mother and baby.
We are committed to improving outcomes for women and babies, and for women’s experience of care. Three of the improvement areas in the NHS Outcomes Framework for 2011-12 focus on improving maternity services, by reducing perinatal mortality, by reducing admissions of full-term babies to neonatal units and by improving the experience of women and families of maternity services. My noble friend spoke of variation in services and that was the theme of the very powerful speech by the noble Lord, Lord Mawson. We are committed to ensuring consistency in the quality of maternity services. From April 2012, a maternity experience indicator will be introduced as part of the NHS outcomes framework. It will allow us to chart a woman’s experience of care through antenatal care, labour, delivery and postnatal care.
To support the NHS in improving outcomes in pregnancy, labour and immediately after birth, the National Institute for Health and Clinical Excellence is developing new quality standards based on the best available evidence on antenatal care, intrapartum care and postnatal care. It is outcomes and quality that matter, and the NHS Commissioning Board will be publishing a commissioning outcomes framework for clinical commissioning groups. The commissioning outcomes framework will rely on the national outcomes framework set for the board and NICE quality standards. On top of that, the NHS Commissioning Board could decide to include guidance on the matter in the commissioning guidance that it must publish for CCGs and to which CCGs must have regard.
Lord Warner
My Lords, can I ask the noble Earl a couple of questions, on which I would be grateful if he could write to me and to any other noble Lords who are interested? I found two of his answers a bit unconvincing. The first was on Amendment 144, tabled by the noble Lord, Lord Patel. I would really like to know how the Minister will ensure that the board will disseminate this information on patient safety and put it in the public arena to a wide group of people. At the moment, as the Bill is, it is left totally to the discretion of the board as to how it will behave. Secondly, I did not find the Minister’s answer on rare diseases and mandatory guidance very convincing. I would really like to know what discussions have taken place with those such as the Royal College of General Practitioners and clinical commissioning groups, about their appetite for making local decisions on these very rarefied diseases without the kind of mandatory guidance that the noble Lord, Lord Patel, spoke about. I do not expect an answer now but I would like some more written guidance on that.
Baroness Cumberlege
My Lords, I was heartened by a lot of what my noble friend said about maternity services, but it seems that the variations will be reduced through NICE quality standards. I understand that NICE has a very long queue of services to be considered for quality standards and I wonder whether my noble friend and the Government have any influence over which services have priority to have their standards set early and which will have to wait. As maternity involves a tremendous number of women who are giving birth, it is really important to get it in the front of the queue, as far as possible.
Baroness Barker
My Lords, can my noble friend tell me where in the legislation it is made clear, if a CCG were to have a conflict—that is, a disagreement—with the commissioning support organisation, where and how that conflict would be resolved?
Earl Howe
My Lords, in the interests of time I suggest that I write to noble Lords on those questions, and I am happy to do so. However, I say to my noble friend Lady Cumberlege that I recognise the particular importance of the maternity quality standard. I will try to find out for her what stage NICE has reached or is likely to reach within a certain timescale, and if I can provide her with any further information I will be happy to do so.
Lord Butler of Brockwell
My Lords, I am grateful to the Minister for his comments in response to Amendment 109A and I thank the other noble Lords who have supported it. The noble Lord, Lord Newton, said that this is a probing amendment. As the Minister has said, there is a question of balance here: we want the Commissioning Board to be an effective promoter of standards, but on the other hand we do not want the arrangements to put an unnecessary brake on innovation. I am sure that the noble Lord will consider carefully what the Minister has said. In the mean time, I beg leave to withdraw the amendment.
Lord Patel
My Lords, the amendments in my name are about patient and public involvement, and accountability to patients and the public. They would amend new Sections 13H, “Duty to promote involvement of each patient”; 13I, “Duty as to patient choice”; and 13J, “Duty to obtain appropriate advice” by the Commissioning Board, in the 2006 Act. I shall also speak to Amendments 141A and 206A. The latter is in the name of the noble Baroness, Lady Hollins, who unfortunately had to leave for another engagement but will return later.
All these amendments are about the requirement for the NHS Commissioning Board and all clinical commissioning groups to engage in meaningful and substantial consultation with users of services, particularly with regard to ensuring that commissioners commission services and pathways that are navigable and coherent.
The current requirement to be placed on the board and the clinical commissioning groups is that they must make arrangements to secure that individuals to whom the services are being provided are involved. It is not enough for the suggested means of doing this to be quite as open-ended as the Bill suggests. The Bill implies that this consultation is really aimed at representatives of patient groups, and I would like clarification from the Minister that both individuals and groups of patients should be able to make representation. It is quite easy to conceive of a situation in which a patient is consulted or provided with information and yet is none the wiser and no more involved in the services that they receive.
Baroness Finlay of Llandaff
My Lords, I have put my name to several amendments in this group, some of which are in my name only. Initially, I will speak to Amendments 125A, 125B, 195A and 195B. These are designed to ensure that the Commissioning Board considers the potentially destabilising effect of new providers choosing to deliver only simple or profitable services, and the effect on existing providers who provide a wider range of services. Clause 101 includes provision for providers,
“to set transparent eligibility and selection criteria",
in relation to treating NHS patients. This is intended to ensure that risk selection does not take place on the part of providers, whereby they accept for treatment only less complex cases or patients, with a view to maximising profit. The Bill also instructs Monitor and the board to take account of the different types of patients treated by providers, and the range of services offered. The amendments suggest that this must also be considered in the national tariff, when that is used, because in looking at tariff adjustments, the Bill does not adequately safeguard against the potentially destabilising effect on existing providers, where other providers choose to deliver only simple or profitable services.
This could increase the relative burden on those providers who deliver a wide range of services, including ones that are more complex and less profitable; also when they provide support at a tertiary rather than a secondary care level, they are providing support into other secondary care services. The amendments would ensure that when the board and clinical commissioning groups discharge their duties in relation to patient choice, they have regard to the effect on the stability of the local health economy and the providers within it; and that they provide this wide range for their patients.
I have made inquiries about what is already happening around the country and I am grateful to the British Association of Dermatologists for giving me some information. It has reported to me that private providers already appear to have been awarded contracts without the appropriate range of specialist staff in situ when starting a service; and private providers appear to be contracted to deliver services that are not necessarily integrated with the existing local secondary care services. They are also decommissioning in isolation without looking at the impact on other local specialist services. For a subject such as dermatology, that becomes really important, because it has a small but important role when extremely complex conditions are looked after by other secondary care providers, and where sometimes the skin holds a light to the true diagnosis.
The association has also drawn to my attention the problem in which some providers set up outpatient clinics which have no educational component. By doing that, they are setting up clinics which are unsuitable for secondary care training, both to doctors in training and nurses who want to train to become specialist nurses. This is a field in which a rising number of specialist nurses have an increasingly important role. The amendments are also designed to make sure that choice is appropriate and that the Commissioning Board does not have to prioritise patient choice over efficiency and effectiveness; quality of services; or over its duties to reduce inequalities and promote integration. These are important duties in the Bill, which many of us have welcomed. I hope that the priority for those is paramount, because they will affect the population at large and reduce inequalities.
Regarding Amendments 175A and 175B, I want to outline briefly why it would be important to be able to appoint a secondary care clinician from within a clinical commissioning group area, rather than being restricted either to somebody from outside the area or somebody who is retired. As we have already debated, there is a great need to promote integration. The report Teams Without Walls, to which I have already referred, stressed the importance of this integration with clinical leadership across primary and secondary care. The Government’s commitment, in response to the Future Forum’s report, that clinical commissioning boards would include at least one specialist doctor and a nurse was welcomed. I hope there will be some reciprocity by having a general practitioner representation on the board at foundation NHS trust board level, at a governance level, to facilitate such integration.
I was concerned that the Secretary of State for Health stated that a hospital doctor on the Commissioning Board should either be from outside the area or be retired. I was particularly concerned about the latter, because there did not seem to be any statement about how recently that person should have retired. People rapidly become out of date with what is going on in an area. For those doctors who work in a fairly large geographical area, it would mean that the secondary care doctor may have to travel a great distance, and perhaps be represented on the clinical commissioning group of an area where the secondary care services are pretty well unknown to him. In saying that, I draw on my own experience of being previously on a health board simply adjacent to the one in which I worked. There were many times when I felt I could contribute much more at a local level, across different services, because of having an in-depth knowledge, than having to explore the various ramifications of secondary care services in the area of the health board on which I sat before I was able to contribute fully to the debate within the board itself.
I also believe that it would help to drive up standards if somebody came from within the board. In saying that, it is important that we learn lessons from problems that have arisen. No one wants to prejudge what the Francis inquiry will recommend but the transcript of the oral evidence that doctors gave to the inquiry appears to indicate that the doctors and the hospital were isolated; that they did not have good networks with other local doctors who worked in different environments; and that when they complained about standards of care they did not report their concerns outside the trust’s structures. That suggests a degree of geographical isolation. There would be merit in reconsidering the stipulation and the restriction that the doctor must be drawn from outside the area.
I do not believe that appointing a clinician from within the clinical commissioning group area results in an unmanageable conflict of interest. First, the role of the secondary care doctor is to offer expertise to inform commissioning decision-making, not to represent one hospital or one specialty. Secondly, GPs will have the same degree of conflict of interest. Therefore, I suggest that the safeguards against this affecting their decision-making need to apply to other healthcare professionals—whoever they are—who sit on the clinical commissioning boards. That also applies to the nurse who sits on the board.
Since the secondary care doctor would not represent any one provider or specialty, there would be no conflict. The model of having a single representative across specialties is not new and exists within the current system—for example, with medical directors in trusts. Other clinical advice will come from clinical networks and senates, and there will be a degree of co-terminosity in the advice received by the clinical commissioning group. That might allow a degree of consistency, which would support some of the difficult decisions that the group will have to make, particularly about issues such as decommissioning services. Therefore, the secondary care doctor will not be able to overrule or push a personal agenda. They will be bound to governing board decisions in the usual way and should have no right of veto. I hope that the Government will reconsider the position of the person on the clinical commissioning group.
For the involvement of patients, it is important to differentiate between public involvement and the involvement of each individual patient in the management of their care and treatment. Amendments 194 and 195 seem important if the mantra and important principle of “no decision about me without me” is to be made real. That phrase is one of the most important things that this Government have put in place. It is certainly a phrase that I have often used in making presentations about various aspects of healthcare delivery.
The importance of involving patients is made clear when you look at the 17 million patients with long-term conditions, many of whom provide more than 80 per cent of their care themselves or with the help of their relatives. If patients understand what is going on with their illness and how to manage their condition, their demands on the health service will decrease. The Health Foundation is developing ways of embedding techniques for supporting people to manage their care and treatment through its Co-creating Health programme. This has already been shown to have excellent outcomes by empowering individual patients to take a degree of control over their own illness and condition. Therefore, I hope that the amendments in my name will be considered by the Government in revising some of the apparently restrictive aspects of the Bill.
Lord Warner
My Lords, I rise to speak in support of Amendments 124, 125, 126 and 196, which are in my name in this group. These amendments are on slightly different aspects of patient involvement and patient choice in new Sections 13H and 13I in Clause 20.
Amendment 124 adds words to the duty under new Section 13H to promote the involvement of each patient. Nothing seems more likely to promote that involvement than ensuring that patients have easy access to their own medical records and, even better, hold their own medical records. The amendment puts those matters in the Bill as part of the duty of promoting patient involvement in decisions about their treatment and care. If patients are to be involved in decision-making, it is important that they can be confident about the information about them that is being held by clinicians and used by those clinicians in making decisions about them. We have moved a long way from a position in which doctors could say, “Trust me, I’m a doctor”. That is not to say that patients do not place a lot of trust in doctors, but the more examples of systems failure that patients hear about, the more I suspect they will want to be sure about what the system has on record about them. This is particularly true when we are dealing with end-of-life issues. Some of us are very keen to ensure that doctors and nurses observe our advance decisions in living wills that are placed in medical records rather than just make decisions on our behalf.
Amendment 125 literally follows on from Amendment 124 and reflects a number of conversations that several of us have had with National Voices, which speaks on behalf of many charities, especially those representing people with long-term conditions. National Voices, with assistance from the Health Foundation, has drawn on a lot of work to distil what it believes service-users expect from those commissioning care. The noble Baroness, Lady Finlay, referred to the work being done by the Health Foundation. This work with National Voices was born from the huge frustration of patients, service-users and carers about the way that they are often treated by those providing services. National Voices has also set out the results of this work in an excellent document called Principles of Integrated Care. Many Members of this Committee may well have a copy of it. If the Minister has not seen it, I commend it to him. I am certain that it has been sent to Sir David Nicholson. Around 50 chief executives or chairs of voluntary organisations involved with National Voices signed a letter to him, commending this piece of work.
Amendment 125 tries to ensure that there is a clear obligation on clinical commissioning groups to pay heed to patients’ and service-users’ voices in their commissioning of services and that the board issues guidance in this area to clinical commissioning groups. I hope that today the Minister will at least take away this amendment, discuss it in detail with National Voices and those of us who are involved in this area, and agree a version that can be included in the Bill and with which everyone is content. Of course, if he wishes to say “Snap!” to these words, we will be delighted. I emphasise that Amendment 125 does not come from the fertile minds of people in this Committee. It comes from the experience and views of many thousands of people with long-term conditions whose representatives have discussed and researched this very thoroughly within the ambit of the Health Foundation and National Voices.
Amendment 126 is on a different topic altogether. It tries to sharpen the duty of patient choice in new Section 13I in Clause 20, which in my view is pitifully vague. When they are exercising choice, people need to know what the speed of access to diagnosis and treatment is; where the location options and alternative providers of service are; and some information on the different levels of performance by those providers. Choice cannot be exercised in a vacuum. If people are to exercise meaningful choice, they need information that they can draw on to make their decisions about what is best for them. They should not simply be guided to local incumbents, which is too often the case in the system as it works now. Very often, those local incumbents may not be the best option for the patient seeking services for their particular condition at a particular time in their life.
I speak with some confidence on this, having spent two years as a Health Minister trying to advance the cause of patient choice. I have had a fair exposure to clinical views about patients not wanting it and just wanting a good local hospital. I have seen at close quarters commissioners in excessively close relationships with local providers. I have heard the voices of patients frustrated at being denied the information they need to exercise choice. I have experienced, at first hand, consultants declining to place their consultation slots on the Choose and Book system. I know that we need much more than the vague wording of new Section 131 in Clause 20 of the Bill. I hope that the Minister, who I know to be a strong advocate of patient choice, will throw away his brief and say yes, we do need more specific wording of the kind in Amendment 126.
I hope the Minister will do likewise in respect of Amendment 196, which applies the same increased precision to the duty as to patient choice and places it on clinical commissioning groups as well as the board. I will not go over the arguments again, as they are exactly the same as those I have deployed on Amendment 126. It is even more important to disturb the cosiness of provider incumbency when we come to clinical commissioning groups. I have added a little piquancy to the clinical commissioning groups amendment by a specific reference to end-of-life care, where we badly need more options for people to choose from if their preferences are to be delivered.
I have spoken for too long already, but I also wish to add my support to the amendments in the name of the noble Lord, Lord Patel, to which I have added my name.
Lord Clement-Jones
My Lords, I shall speak to Amendments 127B and 197B. As they relate to pharmacy, I declare an interest as the chairman of the Council of the School of Pharmacy, University of London. The intention of these amendments is to ensure that all relevant healthcare providers, including community pharmacists, are consulted when the NHS Commissioning Board and commissioning groups are discharging their functions and developing their business and communications plans. The essence of these amendments is to retain the long-standing arrangement whereby, under the 2006 Act, commissioning bodies have to consult widely and in good time with all relevant stakeholders, including local service providers or their representatives.
Under the current system, primary care trusts are required to consult widely in relation to their commissioning duties. There is concern in the pharmacy profession that the current provisions under Clause 20, new Section 13J, for the board, and Clause 23, new Section 14V, for clinical commissioning groups, to obtain appropriate advice are too vague. It is important that consultation with all local healthcare providers should be done via local representative bodies as well as directly with providers. Clinical commissioning groups should consult pharmacy professionals when making decisions in relation to the commissioning of relevant services in order that the professional skills, knowledge and expertise of pharmacists are used in planning, commissioning, delivering and evaluating NHS services. They should also demonstrate arrangements systematically to seek the views of all appropriate local clinical groups throughout the commissioning process, in general and for particular services. This would include ensuring that all local representative committees are fully engaged in the commissioning process and signed up to the outcomes agreed.
As part of their local leadership role, clinical commissioning groups also need open and transparent processes for reconciling different professional perspectives and contingency arrangements for seeking the agreement of non-GP professional groups in the case of urgent service change. These processes should be clearly set out as part of the CCG’s governance procedures for commissioning decision-making. The above will be of particular importance in the immediate term, given the influx of new commissioners into the market, to ensure commissioners commission services effectively. Without relevant healthcare providers being consulted, the different contributions that such providers, including pharmacy, can make to local healthcare could be lost.
If used effectively, pharmacy has the potential to deliver a great deal more both to patients and commissioners. For example, it is estimated that some 57 million GP consultations each year involve minor ailments which could be dealt with at a pharmacy. If these patients could be moved to a pharmacy, more than £812 million could be saved annually, and GP capacity could be freed up to deal with more complex cases.
In summary, it is critical that there is a duty on commissioning groups, when developing their commissioning plans, to consult primary care providers such as pharmacists as there is a danger under the proposed legislation that some groups may not do so, leading to ineffective commissioning of services. At the Royal Pharmaceutical Society Conference in September, the Minister said that pharmacists are pivotal to every aspect of the Government’s plans to modernise the NHS. I find those words very encouraging and hope that he can give further encouragement in the course of this debate.
Lord Patel
My Lords, I support the amendment of the noble Lord, Lord Warner, on patients holding their own records. Speaking from personal experience, I know that it was not uncommon in maternity services years and years ago for patients to be given their old, shared maternity card. The difference was that that card was extra to the actual notes, so what doctors and midwives wrote in those cards was probably an abbreviation.
For 25 years of my life, I allowed patients to carry their complete set of records, thus avoiding having to write another card. That meant that what you wrote and what you told the patient had to be precise, and clear thought had to be given to the purpose of writing it down. It also taught people not to use abbreviations that do not mean anything, or that might be misconstrued. It is not uncommon for doctors to use abbreviations such as SOB or NAD. They do not mean what you think they might mean. SOB stands for “Shortness of breath”, and NAD stands for “No abnormality discovered”. This also meant that when you were putting the results of diagnostic tests into the notes you were forced to explain to the patient what those results meant. If the results were ambiguous, then you had to explain to the patient what that ambiguity was. That improved the quality of record keeping, communication with the patient and the quality of care given to the patient. In 25 years of allowing thousands of my patients to carry their own notes—and some of the noble Lords sitting today are well aware of my habits—I lost only two notes. One was eaten by a dog in the patient’s house and the other was torn up after being left by the mother-to-be on a bus. Apart from that, there was no loss of notes, while in hospitals usually you can hardly find any notes.
There is a double issue here. How do we make notes that are compatible—easy to write and yet which communicate with the patient. An electronic version is better, but even a hand-written version works. I am convinced that allowing patients to carry notes is not a problem.
Lord Harris of Haringey
My Lords, this is an extremely important group of amendments, but I hope it is, by and large, an uncontroversial one. The Government say they are committed to patient involvement and patient choice. They say they want to see all decisions being taken with the patient rather than simply by professionals. These amendments all contribute to achieving those objectives. It is worth distinguishing between a number of different elements in terms of patient involvement. There is the involvement of the individual; there is the involvement of the specialist group of patients; and there is the collective involvement of patients. I hope that these amendments provide a means of addressing all three groups.
The involvement of the individual patient—specifically included in Amendment 121 and in Amendment 124, to which the noble Lord, Lord Patel, has just spoken, on access to medical records—is an example of where it is vital to write this into the Bill if you are serious about the Government’s mantra of, “No decision about me without me”. The experience is that, where patients are involved in all decisions about their medical care, better decisions are made and compliance with them by patients is far fuller than would otherwise be the case. Therefore, requiring patients to be involved in every decision affecting them is part of delivering a good and effective health system. My experience mirrors that of the noble Lord, Lord Patel, because the experience of patients’ organisations is that, where patients are given charge of their medical records, they look after them extremely carefully—often much more carefully than under the old system of trolley-loads of not dog-eaten but dog-eared files in hospitals—and are much more likely to be protected by the individuals concerned.
I have put my name to Amendments 123, 192 and 205, which talk about the involvement of healthwatch organisations. Amendment 123 places a duty on the board to promote the involvement of local healthwatch, and it is important that the board sets the tone for the NHS in the way in which healthwatch organisations are expected to be involved at every level. It needs to come from that level. Amendments 192 and 205 relate to the duties of clinical commissioning groups. There is a gap in the Bill, because it seems to be implied that commissioning groups will involve patients and healthwatch organisations, but I am not sure that that is stated explicitly, which is why those amendments are so important.
However, the reason why it is helpful to engage healthwatch at every level within the NHS is the support function that local healthwatch organisations and HealthWatch England will provide to the three levels of patient involvement that, as I have stated, are so important. That is because, as local healthwatch organisations and HealthWatch England, they will have an understanding of the way in which the health service is functioning. They will have an understanding of the pressures on the health service, commissioning groups and local providers and they can therefore support specialist groups of patients with a particular knowledge of their condition in how to exercise their influence most effectively within the organisation. It is those specialist groups of patients who will be tremendously valuable in improving the quality of service. They will often have far more knowledge about the way in which their condition operates than even the clinicians who support them—maybe not the specialists but general practitioners and so on—because they have that detailed knowledge and experience, day in and day out, particularly when they have a chronic condition that may continue over many years. That involvement is crucial in terms of the quality of decision-making, but it is important that they are supported by organisations such as healthwatch, which will then be able to put a context to the way that the local NHS is functioning.
Finally, there is the critical issue of the collective involvement of patients in decisions about the disposition and organisation of health services at a local level. That will be best articulated through local healthwatch organisations. This will be about what best serves the local community and what meets the differing needs within a community. The only simple mechanism by which that can be achieved is through something such as local healthwatch organisations. That is why such involvement must be built into the commissioning process, and the board must lay down how crucial this issue is crucial to the determination of services.
Lord Kakkar
I shall speak to Amendment 198 in my name and that of my noble friend Lord Patel. It would impose a duty on clinical commissioning groups to consult relevant academic bodies in their area, including potential future academic health partnerships. I remind noble Lords of the entry in the Register of Lords’ Interests on my involvement in University College London Partners—one of the five academic health science systems currently designated by the Department of Health.
Academic health science partnerships can take a variety of forms but are all based upon a simple principle: the delivery of healthcare should be combined with high-quality teaching, training and research to drive the highest possible clinical standards achievable. Indeed, throughout healthcare systems in the world it is well recognised that alliances between the academic and service-delivery elements of healthcare help us to achieve the best possible clinical outcomes. That view has been recognised by the Department of Health in the designation of the five current academic health science centres in our country.
A number of other initiatives are moving forward at the same time as this Bill and are considering a broader role for academic health service partnerships. These include the ongoing review, conducted under the auspices of the chief executive of the National Health Service, which is looking at innovation in the NHS and how that might best be promoted as we move forward. It is possible that that innovation review could propose a broadening of the current five academic health science centres to a larger number of academic health partnerships that would have responsibility for the promotion of innovation, and would ensure that the results of research and other innovative ways of delivering care are more broadly and rapidly disseminated across the NHS. That dissemination of best practice and innovation could also be used to create an environment in which to stimulate economic growth. That is an important additional opportunity that the NHS and academic medicine have for our country.
There is also the detailed discussion that has taken place in Committee, outside the Chamber, and in the work of the NHS Future Forum with regard to future arrangements for education and training. In those discussions, there is a recognition that academic health partnerships should play an important role, not only in the configuration of Health Education England but in local arrangements, potentially with academic health science partnerships playing an important role in defining the structure and core of local education and training boards.
Therefore, at least two initiatives, in addition to the mechanisms and structures proposed in the Bill, will turn to partnerships between the NHS, academic institutions and other academic elements in the delivery of healthcare in our country. The purpose of my amendment is probing in order to try to understand what view Her Majesty's Government take of the potential future role of academic health partnerships and what relationship the Government foresee with regard to clinical commissioning groups working at a more local level with potential academic bodies and partnerships in their vicinity. This is particularly important because we heard today in Committee about the vital importance of clinical commissioning groups being appropriately informed. One of the important roles that academic health partnerships may play in the future is providing that kind of information to better inform the decisions that local clinical commissioning groups take. With the vast amount of evidence that academic health partnerships will have in their structures, bearing in mind that these partnerships are broad and include not only academic institutions but a variety of different service providers brought together with a common purpose, it would be peculiar if clinical commissioning groups did not at least make themselves informed of their information and expertise. It would also be peculiar if, in creating a framework and structure for education and training based around a partnership between academic elements and service and provider elements at local level in local education and training boards, clinical commissioning groups did not avail themselves of the opportunities from that.
Previously in Committee, I proposed to the Minister that clinical senates may be constituted around these broad partnerships of academic health service alliances. There was some concern that this might represent a conflict of interest. However, the very broad nature of these partnerships, with multiples of potential providers as seen in the current five academic health science systems, potentially overcomes the risk of conflict of interest. They provide a natural structure and environment to serve the function of clinical senates, to serve the function of the core of local education and training boards, to provide a useful source of information to clinical commissioning groups with regard to understanding the best pathways of care available in their regions and to promote clinical outcomes, patient safety and patient experience. They also provide a very important basis to serve the objectives of the current innovation review to promote not only best practice but the benefits of economic growth associated with innovation and implementation with regard to healthcare.
I would like to ask the Minister about Her Majesty’s Government’s view of the future role of academic health partnerships, with specific reference to clinical commissioning groups, to understand whether there is an intention that the current five academic health science centres are more broadly expanded into health academic health partnerships. If they are, how will arrangements be made in future to ensure that clinical commissioning groups avail themselves of the great expertise and knowledge that will be available in such partnerships?
Baroness Pitkeathley
My Lords, I agree with my noble friend Lord Harris that this is an extremely important group of amendments. I rise very briefly to support those emphasising the significance of patient involvement and, in particular, Amendment 191 in the names of the noble Lords, Lord Patel and Lord Warner, which changes “promote” to “pay regard to”.
There is no doubt that we have made progress in recent years in addressing patient interest and hearing the voice of patients and carers, and we should acknowledge that. We still have a long way to go, however. When you work with groups of patients and carers, or with individuals, you always get the same reaction. They say something like, “I feel consulted out. I have been to every meeting, I’ve talked to every clinician, I’ve given my opinion endlessly, I sometimes think they add the words ‘patient’ and ‘carer’ to every paragraph of every document that comes out of any commissioner, but what I do not know is what happens as a result of my involvement”. This is what we must bear in mind. Changing the wording in that amendment would strengthen the ability of the patient, the user and the carer to ensure that something happens as a result of their involvement. That is what we must concentrate on. We should never forget that the involvement of patients is not a tick-box exercise; it is there to ensure we shape services around the needs of patients, not the convenience of commissioners.
Baroness Murphy
My Lords, I rise to add a number of comments to one or two of these amendments. I have my name on Amendment 196, also in the name of the noble Lord, Lord Patel, which is about making choices real for patients. My experience is exactly the same as his—that patients have actually benefited very little from the wide range of choices they could have if they understood the information about accessibility, about the sort of provider, about the range of other services that that provider might have and about the performance of that provider. If you are skilled you can use information available on the internet now to find details on the various providers you have been offered under the “Choose and Book” system used by general practitioners. However, the vast majority of patients simply do not have the skill to negotiate the choices. Making that choice a reality is therefore vital.
I also support the amendments proposing that patients, wherever possible, should carry their own records. To cheer up my noble friend Lord Patel, I say that he will be reassured to know that most maternity units now do have the patient carrying their own records, and that has proved to be of great benefit because they hang on to them when the NHS loses them. It has worked very well in maternity services and I certainly support it. There should be more of that in mental health services, where there has been too much holding on to information—not always accurate information—in patients’ records. It would be much better if the patient held on to those data and was able to carry a great deal of the data with them. Of course, it would be much better if people had access to information on simple records but they do not because we do not have electronic patient records in every place. The more information the patient can carry with them, the better it is for those who are going to encounter them in the future; it is also better for the patient to have accurate data about their condition.
I come now to the question of whom the clinical commissioning groups should consult in the way of secondary providers when commissioning care. I do not support the amendment of the noble Baroness, Lady Finlay, which suggests that the specialist on the clinical commissioning group should be local rather than a person from another area. No doubt when you have too much conflict of interest, specialists on a clinical commissioning board, and a PCT which engages with the local providers and takes account of their desires, local institutions become favoured. We have seen that many times. It is simply the institution the provider belongs to. That is when you are making a decision, so it is very important that the decisions should be made by somebody who can input and hold in their heads all the necessary secondary specialist information. The decision should nevertheless not be made by a local person with an interest in secondary care.
However, when it comes to gathering local information, local institutions and specialists in those institutions should be consulted about what is possible in the area, what has been done before and what could be thought about in the future. That is where primary care trusts in some parts of the country so often, unfortunately, have not appreciated what they could benefit from locally in terms of academic health partnerships and how they could use their academic health science groups to assist them with the commissioning function. They need to take account of what is available locally, and need to understand and get help and consult with local academic institutions and providers, but when the decision is made it should be made by individuals who do not have a conflict of interest locally.
Lord Marks of Henley-on-Thames
My Lords, I shall speak briefly to Amendments 193 and 197, amendments to proposed new Sections 14T, on promotion of involvement of each patient, and 14U on the duty as to patient choice.
The Bill and our debates on it have been characterised by a recognition of the importance of patient involvement and patient choice, and a great deal has been said about those two things in this debate. It is important that we recognise and welcome the new Sections 14T and 14U to the NHS Act, which will enshrine those in statute, but it is also important to note that this is not an entirely new idea. In many areas of medical care, patient choice has been with us for some time. Patients currently have a choice of GP practice; they have a choice of hospital; they have a choice of the GP whom they wish to see within a practice; and they have a right to be informed.
However, there is in practice all too often a gap between the theory and reality. The reality is that although people may theoretically have the choice, they do not know that they have the choice. They do not know despite the excellent section on choice on the NHS website and the literature that is put out about choice at the national level. The amendments are designed to impose on clinical commissioning groups at the local level the duty to take steps to inform patients about their right to be involved and their right to make choices. They state, in certain terms, that each group,
“must take steps to inform patients, their carers and their representatives of the right to be involved in such decisions”,
and, in the other cases,
“to make such choices”.
They are simple amendments, and it may be a matter of regret that they are necessary, but simply having the right in the statute book will not do unless we can also ensure that patients are informed of those rights.
Lord Walton of Detchant
My Lords, I rise briefly to support the principle underlying Amendment 198, so ably proposed by my noble friend Lord Kakkar, relating to the crucial importance of making clear that there must be a relationship between the NHS Commissioning Board, local commissioning groups and academic health partnerships. In using that term, I want to be quite clear in what I mean. I am not referring simply to the five academic health science partnerships which have been created within the past few years specifically in certain areas of the country by the NHS; I am talking about the crucial importance of being involved with everyone who is concerned with the teaching of medical students and the training of young doctors and other healthcare professionals.
There is no doubt that years ago, when the health service began, there was an article of faith to the effect that professors, lecturers and readers in the medical schools and universities employed by the universities, those that had clinical contracts, had a duty to spend half of their time on service to patients. In other words, they had honorary clinical contracts, they saw patients and they carried on in that capacity giving services to the NHS, in return for which there was also an article of faith that consultants employed by the National Health Service in teaching hospitals had a duty to involve themselves in the training of medical students and the supervision and training of young doctors who were being prepared for work in a variety of different professions.
There has been a total transformation of the scene over the course of the past 20 or 30 years, because academic appointments are no longer restricted to a small group of hospitals, which used to be called the teaching hospitals. They also take place and are based, in many instances, in other hospitals, sometimes in old regional hospitals at a distance. In those hospitals, not only do we have academic people employed by the university involved with teaching, but many of those hospitals are now called university hospitals. It is a recognition of the fact that medical students now are trained across a huge number of hospitals in what were the regions. Many of them spend considerable periods away from the centre around the medical school. Therefore, a crucial relationship must arise between the academic doctors working in those other hospitals outside the main centre and the commissioning groups.
We must also not forget the crucial importance to the NHS, as we heard a few days ago in discussion of the amendments of the noble Lord, Lord Willis, relating to research, of not only the academic departments but also the consultants working in general hospitals and others who have significant responsibility for being involved in clinical research. As I said when we discussed those amendments, today's discovery in basic medical science brings tomorrow's practical development in patient care. In particular, these academic relationships are crucial when one begins to consider the importance of clinical trials of new procedures, new drugs, and so on, which may be carried out across not only a wide range of hospitals but in the community. A great deal of teaching is now going on in general practices, which makes the relationship between academic doctors in academic centres and commissioning groups even more important. I therefore support the principle and the purpose underlying Amendment 198.
Lord Neill of Bladen
I make one comment on the amendments, which also goes to the Government’s fundamental philosophy, with which we all agree, that patients should be told about their condition and kept fully informed. My experience in recent years has been visiting hospitals and wards with elderly people in them. You cannot but become aware of the inability of a lot of the patients to understand what it is they are being told or to look after their own notes. There is a danger, if we are not careful, of theory and reality moving apart from each other. There has to be a true awareness of the need to get the relevant knowledge to the right person. Sometimes, it will not be the patient; it will be the patient's spouse, daughter, son or whatever. We should keep that in mind.
Baroness Masham of Ilton
My Lords, I add my support to the patient involvement amendments and the HealthWatch amendments. Whose life is it anyway if it is not the patients?’ Patients can now be very much at risk, if they are not involved with doctors, through drugs available through the internet which are counterfeit medicine. I was at a meeting this afternoon and heard from a Minister that the Government had asked China for help, because it is a problem place, and the Chinese are now going to introduce the death penalty for people selling counterfeit medicine on the internet. That is a serious problem. Patients need to be involved; they need to have a voice; and they need to work together with everybody else concerned. Otherwise, they will feel left out and shunned, and that would not be a good thing.
Baroness Wheeler
My Lords, I am pleased to support the spirit, intention and thrust of all the amendments in this very large and, I hope, uncontroversial group, which are intended to ensure that provisions in the Bill to involve the public, patients, carers and specialist professionals and patient groups in the development and decisions about services, care and treatment are reinforced and strengthened. We recognise that the duties proposed by the Government for the NHS Commissioning Board and clinical commissioning groups—to promote the involvement of each patient and to enable patients to make choices on the services provided to them and obtain advice from specialist professionals—are a significant step forward from the original provisions in the Bill. They build on the foundation work on this issue undertaken by my own Government. However, it is clear from this excellent debate that these general duties do not go far enough to mark the significant step change that we need in getting genuine shared decision-making and participation of patients, carers, and patient groups in decisions about care and treatment, and on how services are planned and developed.
We also now have the added complexity of the reorganisation itself. Senates, networks and health and well-being boards are acting as the system integrators, all alongside our newly enlarged CCGs with their giant private sector support organisations behind them, as we now know from the Government’s recently issued draft guidance on commissioning which was referred to in the previous debate by the noble Baroness, Lady Williams. This will be a highly complex raft of interactions and interconnections with no notable route to accountability. I would be grateful if the Minister could give me some insight into how he envisages the voice of patients being heard among all the clamour and shouting that will go on between these different spheres of interest.
We must try to achieve real involvement. For individuals, that means involvement in care planning and support for patients with their carers, relatives and support groups to manage their conditions and share in the choice of treatment. On collective involvement, this means that knowledgeable patients’ groups should be able to advise commissioners on how to design services, rather than to have token consultation after decisions have already been made, which is the case now in so many situations. We must make sure that we harness fully the collective experience and knowledge of patients and specialist care organisations.
We recognise that this will involve a major cultural change in the behaviours, approaches and attitudes of key professionals from across the specialisms, moving away from seeing patients as units of disease, not as people with rights to information and to participation in discussions and decisions about their care and treatment, as the Health Foundation puts it. We need to change the way that patients and clinicians, in particular, relate to each other, and change the way that the NHS relates to patients in terms of, for example, information provision and the organisation of clinics, and in the style of consultations that professionals have with patients.
In respect of the NHS Commissioning Board, we support Amendment 121, which calls for the board to have the duty to secure rather than promote the involvement of patients, carers and their representatives in decisions about the provision of health services. This is important, and Amendment 150C—which seeks to ensure that the board’s annual report includes accounting for how it has carried out its duties in involvement, choice and advice—complements and underlines the importance of this duty.
Amendments 125 and 126, tabled by my noble friends Lord Warner, Lady Thornton, and Lord Patel, turn the focus on clinical commissioning groups and call for a published guidance to CCGs to ensure that they are clear about what is required of them to meet the duty to promote the involvement of each patient. I also pay tribute to the work of National Voices on the principles of integrated care and on other patient and involvement issues relating to these matters.
We know that many commissioners, both nationally and in CCGs, are unaware of the increasing evidence that involving individual patients in their care and treatment is proven to be more clinically effective, provides better patient experience and makes much better use of healthcare resources. In other words, it is the vital underpinning for the Nicholson challenge and for commissioners’ other duties to improve quality. A far stronger signal is needed in the Bill and in statutory guidance to draw commissioners’ attention to the proven interventions that they require from their providers. I would be grateful to hear from the Minister how he intends to do this.
Clearly, many CCGs will not make the changes that we need without help and support. Amendment 125 is therefore crucial, as it calls on the NHS Commissioning Board to draw up guidance to CCGs which will enable patients, carers and their representatives to make informed decisions. This includes patients having the means to express their views on the quality of services provided, opportunities to consult with service providers, access to appropriate information about their care and treatment, opportunities to consider available treatment options and their risks and benefits, and to participate in decisions about their care and treatment and its managers. The information they receive about these areas must be simple and well presented—not league tables or comparison charts, but clear information about treatment options, how effective they are and what the consequences might be for the patient. As other amendments underline, these rights of patients must be accessible to all patients.
Amendment 126 stresses how important it is to have information on access and location and about the providers of health services and performance if informed decision-making is to become a reality for the majority of patients. We fully support Amendments 127A and 197A, which would give expert patients’ organisations equal status to professionals in providing advice to commissioners. This would help ensure a patient voice in the clinical senates and networks. It is an approach that was supported by the clinical work stream of the Future Forum but overlooked in the Government’s response. We also strongly support Amendments 175A and 175B from the noble Baroness, Lady Finlay, which calls for regulations providing for the governing bodies of CCGs to include individuals who are fully aware of the different aspects of specialist provision in the areas covered by CCGs.
Amendments 140 and 142, tabled by my noble friends Lady Thornton and Lord Hunt, require the Commissioning Board to ensure that patients are involved and consulted in the development and planning of commissioning and in the consideration of how proposals for change in health services are organised and delivered. Most importantly, Amendment 205 secures the involvement of the local healthwatch in these decisions, vital if HealthWatch is to be able to fulfil its key watchdog and patients role. The importance of this role was ably underlined by my noble friend Lord Harris, so I will not expand further on it.
On patient choice, we support Amendment 127, which proposes a definition of patient choice. Research shows that patients care most about being able to exercise choice about the care and treatment they receive, but currently the NHS performs poorly in involving patients in this way. A full definition of patient choice should be included in the Bill to ensure that commissioners provide opportunities for patients to exercise choices that go beyond the choice of provider. Does the Minister accept the need for this definition in the Bill, and if not, how will he seek to achieve the cultural change in systems and attitudes that we all want to see?
All these amendments seek to ensure that the NHS Commissioning Board and CCGs understand fully their responsibility, and that they commission for involvement. These changes would give a clear signal to the system that the Government mean business in wanting meaningful patient participation and involvement, and that real change can be achieved.
Earl Howe
My Lords, this large group of amendments all relate to the different ways in which patients, the public and others will be involved in decision-making, and although I shall be suggesting that noble Lords should not press them, I am very much in listening mode on the themes that they raise. The only thing that I cannot promise to take forward is the suggestion of the noble Baroness, Lady Masham, that I should introduce an amendment on the death penalty, but, no doubt, she can persuade me.
The issues that noble Lords have covered are central to our vision of informed and empowered patients, and responsive commissioning that is clinically led. These are also issues that were considered in great depth as part of the listening exercise, in response to which significant improvements were made. Those improvements created much stronger duties than currently apply to primary care trusts, so it is important to begin by recognising how this Bill takes us forward from the current position. Nevertheless, I recognise that some confusion remains about what we mean when we talk about involvement, and what the different duties in the Bill are intended to achieve. The noble Lord, Lord Warner, has tried to frame an all-embracing definition of involvement through Amendment 125, and I find little to criticise as regards the purpose and intent of that amendment. However, I would argue that much of what the noble Lord intends through this amendment is already provided for in the Bill. Indeed, it is because there can be different elements to involvement that would be appropriate in different situations that I would be cautious about trying to wrap them up in a single definition.
It will be helpful to begin by considering the duties on the board and clinical commissioning groups to involve patients in decisions about their own healthcare. The noble Lord, Lord Harris, made some useful distinctions on this point. These new duties reflect our vision of shared decision-making, referred to by the noble Baroness, Lady Finlay—“no decision about me without me”, and an NHS where patients are involved fully in decisions about their care in partnership with clinicians. This is primarily about the relationship between the individual patient and their clinician; it does not extend to commissioning decisions. Therefore, I do not think that it would be appropriate for HealthWatch or indeed any other body to have a role in what are meant to be sometimes very personal decisions.
There is clearly a role for CCGs as commissioners, as distinct from the role of general practitioners, in supporting and encouraging this personal involvement. However, it is not completely within their control, so I do not think that it can be for them to secure, as the amendment proposes. Nor do I think that there should be any sort of hierarchy, where the board is in the lead with a weaker duty on CCGs. That would run counter to what we are trying to achieve, which is after all a more personalised service. Therefore, I am afraid that I cannot agree with Amendments 121, 123, 124A, 191 and 192. However, such a service might include giving patients greater control over their medical records, as Amendment 124 suggests. The noble Lord, Lord Patel, may know that this was a key theme of our consultation on an information revolution. Responses to that consultation showed a clear desire to enable people to be more in control of their care, supported by greater access to the information held about them in their care records. We are committed to this and our forthcoming information strategy will set out how we propose to achieve it.
These duties are of course closely linked to those relating to enabling choice. As noble Lords will be aware, patient entitlements to choice are set out in the NHS constitution. These are underpinned by directions by the Secretary of State, which will in future be the standing rules and regulations under Clause 17 which we have already discussed.
I reassure noble Lords that, as now, the role for commissioning bodies in respect of enabling choice in the future will include acting with a view to making people aware of their rights and entitlements, giving them the information that they need to make informed decisions and working with providers to ensure that these are delivered. I did, however, listen with considerable care and sympathy to the noble Lord, Lord Neill, regarding patients who need advocates to speak on their behalf. This will be further reinforced by the new duty that the board and clinical commissioning groups will be under in relation to promoting the NHS constitution among both patients and staff. The board will set the choice offer, establishing the parameters for choice and competition, based on the choice mandate that the Secretary of State will set as part of the annual mandate to the board. I remind the Committee that we recently sought views on these issues through the consultation, Liberating the NHS: Greater Choice and Control. This is an important approach because it allows the Secretary of State and the board to manage the rollout of choice in a controlled way—something that I know many noble Lords are anxious to ensure. That is why we have deliberately used broad terms in describing the types of choice that patients can exercise. Indeed, I think that defining them in more detail, as some of the amendments attempt to do, could paradoxically limit their scope. They could also be unsuitable or indeed unfeasible in particular circumstances, and that is why, although I am in sympathy with the spirit behind them, I am unable to agree with Amendments 126, 127, 193, 196, 197 or 197ZA.
Greater choice means, among other things, patients being able to choose between a greater range of providers. Amendments 125A, 125B, 195A and 195B are particularly concerned with the impact that greater choice and provider plurality might have on the viability of existing services—a matter that we discussed at our last session in relation to amendments tabled by noble Lords opposite about the interdependency of services. That is an issue that I completely understand. In securing healthcare services to meet the needs of their patients and populations, commissioners must have regard to the stability and financial viability of those services, including taking account of the interlinkages between services, where relevant, on an ongoing basis. Commissioners will need to commission high-quality integrated care that will deliver value for money for local communities and promote opportunities for patients to exercise choices in relation to their care. In taking commissioning decisions, they will have to consider what the noble Baroness, Lady Pitkeathley, reminded us of—that is, what will be in the best interests of their patients. This would always be their primary concern, and we would expect the board to ensure sufficient competency over these issues in authorising CCGs to take on their new responsibilities and in holding them to account for doing the job.
Lord Warner
I am sorry to interrupt the noble Earl’s flow but I have been extremely restrained today. Can he clarify for me the point that he has just made concerning clinical commissioning groups’ constitutions? As I understand it—he can correct me if I am wrong— they have a considerable amount of freedom on how they frame the obligations in those constitutions. Is the Minister saying that there would be some requirements on them centrally from the board to cover areas such as patient involvement and patient choice?
Earl Howe
I am. The intention is that no clinical commissioning group will be authorised in the first instance unless it can demonstrate to the board that it can fulfil the legal duties that the Bill places on it. That is key to our thinking. Indeed, as time goes on, it will be under a continuous duty to show it is abiding by those duties. In the first instance, it is very important that clinical commissioning groups demonstrate they are fit for purpose in that sense.
I also appreciate the concern to ensure that the board and CCGs benefit from as wide a range of advice as possible. The Government have been clear that everyone with a role to play in securing the best possible services for local people should be able to do so. The definition used in the duties to obtain advice is that used to define the comprehensive health service. It would encompass the areas covered by Amendment 127C. Indeed, I do not think it would be possible to cast it in broader terms. These duties will apply to every function the board or a clinical commissioning group will exercise. Again, within those broad parameters it is important to retain some discretion for the board and CCGs to determine how best to exercise this duty.
The board and CCGs will certainly have to work closely and effectively with all the providers with which they contract as Amendments 127B and 197B suggest. I would say to my noble friend Lord Clement-Jones that that most certainly would include pharmacists. I also agree as to the expertise and the unique perspective that patients and their representative bodies can bring not just to the commissioning process but also to the way the board and clinical commissioning groups approach many of their functions. The same would apply to many other groups, including academic institutions, as the noble Lords, Lord Kakkar and Lord Walton, have highlighted.
The noble Lord, Lord Kakkar, spoke powerfully in favour of academic health partnerships. Academic health science centres have been successful at developing these partnerships within their local areas but understandably have been less successful in spreading innovation across the NHS. As the noble Lord set out, the NHS chief executive’s innovation review is due to be published next month. That will set out how we can accelerate the adoption and diffusion of innovations across the NHS. It will include a mix of bottom-up, horizontal and top-down incentives and pressures that will drive adoption and diffusion of innovation and behaviour change. The role of academic health partnerships may or may not feature in this review. I hope the noble Lord will forgive me if I do not at this stage anticipate or pre-empt what the report will say by elaborating any further. However, I counsel noble Lords to play close attention to what the noble Lord said in his speech.
While these duties refer to obtaining advice from people with expertise in relation to the health service, that is not confined to clinical expertise. Indeed, in fulfilling these duties we envisage a role for clinical senates, as we have already discussed, in providing not just clinical advice but multidisciplinary advice from professionals in health, public health and social care backgrounds alongside patient and public representation and other groups as appropriate.
I am sure we all share a desire that these duties are effective. However, I am not convinced that imposing specific duties as to where the advice should come from, including through the membership of governing bodies, or how the advice should be acted on is the right way to proceed. If we become too prescriptive we risk overburdening CCGs with so many duties and obligations that they could never be sure whether they were doing enough and in reality we must trust them to build these relationships themselves and judge them on the outcomes they achieve.
The noble Baroness, Lady Finlay, asked me about the secondary-care doctor role on CCGs and whether it had to be somebody from outside the area or retired or whether it could be a local person. We are looking carefully at that question. The secondary-care doctors on CCG governing bodies will not be able to have a conflict of interest in the decision-making process of the CCGs. That is where the noble Baroness, Lady Murphy, was absolutely correct. We will use regulations to set out more detail about this and we will work with stakeholders, including pathfinders, to develop these proposals. The noble Baroness referred to the secondary-care doctor coming from either outside the CCG area or being retired. Those are two ways in which a conflict of interest could be avoided but they are only examples and do not represent an exhaustive list.
I want to finish by returning to a point raised earlier by the noble Lord, Lord Warner. We too are aware of the very good work of National Voices, as well as a range of other organisations, on how patient and public involvement could be strengthened in the Bill. While I have explained why I think these specific amendments are not necessary, I am happy to go on listening. I feel that the Bill is already strong in this area but we are always open to new ideas and I look forward to further discussions on this general topic. It is for those reasons that, while sympathetic to the intention behind the amendments, I am unable to accept them and I hope noble Lords will agree not to press them.
Lord Patel
My Lords, on behalf of all noble Lords who took part in the debate I thank the Minister for his comments. He excited us all by first saying that the only thing he would not be able to accept would be the death penalty. He finished by saying he could not accept most of what we were saying, partly because it was already in the Bill, which most of us did not think was the case. He demonstrates a commitment that patients’ voices and public involvement will be paramount and that all the commissioning boards and commissioners will be expected to demonstrate that they listen to the voices of patients and the public. We will watch and see how they are made accountable.
The Minister referred to innovation. Of course, the next group of amendments focuses on innovation, so we may come back to it and also the involvement of the academic health centres. We have had a good debate and maybe after reading Hansard some of us can decide whether we will come back to some of these issues. In the mean time, reluctantly, I beg leave to withdraw the amendment.
Lord Warner
Lord Warner
My Lords, I listened very carefully to the Minister’s response to my amendment on patients’ access to or holding of their medical records. As I understood what he was saying, it was that we could eagerly look forward to the Government’s long-awaited information strategy which might well be moving this agenda forward. If that is indeed the case I hope we can consider further with the noble Earl and his officials whether we should enshrine that moving forward in the Bill so patients have a clear statutory right to have access to and to hold their medical records. I will not move the amendment.
Lord Warner
“( ) In discharging this duty, the Board must publish guidance for clinical commission groups that ensures that patients and their carers and representatives have—
(a) the means to express their views on the quality of services provided,(b) opportunities to consult with service providers through a variety of means,(c) access to appropriate information about their care and treatment,(d) opportunities to consider available treatment options and their risks and benefits,(e) the opportunity to participate in decisions about their care and treatment and its management, and(f) the means to ensure informed consent is given to care and treatment.”
Lord Warner
My Lords, I am glad to note that the noble Earl is willing to reflect on this and perhaps discuss it further with us. I would very much like to talk to him with National Voices to see whether we can craft some wording which meets people’s concerns in this area. I will not move the amendment.
Lord Warner
Lord Warner
My Lords, this is an important issue about choice. We need more beef in the Bill about what it means. We have not gone as far as we need to go. In the mean time, I will not move the amendment.
Baroness Thornton
Baroness Thornton
My Lords, we move on now to discuss innovation and research. The amendments in this group are very important and were prefigured to an extent by the discussion we have just had. The amendment tabled by the noble Lord, Lord Hunt, and me, is modest in some ways. However, it strengthens the promotion of innovation in the provision and commissioning of health services. Taken together with the amendments tabled by my noble friend Lord Warner and the noble Lord, Lord Patel, it strengthens the Bill significantly and in a very important way.
We have come to what seems an intractable problem: how to encourage innovation in the NHS. This is part of the Minister's area of responsibility and was also part of the area of responsibility of my noble friend Lord Warner when he was a Minister. I look forward to both of their contributions on this matter.
We know that often, the taking up of great innovation is a painfully slow, complex and bureaucratic process. Our amendment strengthens the promotion of innovation through commissioning as well as through the provision of health services. I would like the Minister to explain why that should not be possible—because it would strengthen and help innovation—and also how it could be done, because we are looking for incentives to promote and spread innovation throughout the NHS.
Last week, the noble Lords, Lord Willis and Lord Ribeiro, and I, with others, enjoyed a dinner and an evening with organisations and businesses to discuss how to ensure that innovation is disseminated, promoted, supported and invested in throughout the NHS so that both the NHS and UK plc benefit. The point was made during the evening that often we do not talk about sophisticated issues but about simple changes to nursing practice, such as the way dressings are done, or to information management, that nevertheless can have an important impact on patient care and progress.
I will not speak further on the amendments because I will be very interested to hear what other noble Lords speaking to their amendments in the group will say. I hope that the Minister, with his passion in this area, will give us some comfort on the matter. I beg to move.
Lord Warner
My Lords, I will speak in support of Amendments 129 and 129A in the group. First, I will take up the point made by my noble friend Lady Thornton about the long-standing problem of the slowness of the NHS to take up innovative ideas, and the frustration often felt by people in this country who have invented new approaches and created new innovations, only to find that they have had to go abroad to get them projected, promoted and sold, with the NHS being one of the last to take up the innovation, which was often funded in one form or another with public money by the British taxpayer. It is a long-standing problem and not a party-political issue; it has been a challenge for successive Governments. One of the most embarrassing moments one has as a Minister is when one meets foreign delegations or travels abroad to back Britain and is asked, “Has this innovation been taken up in the NHS?”, whereupon one has to shuffle one’s feet and think of a suitably weaselly form of words to avoid answering the question directly. It is a very long-standing and difficult issue.
Amendment 129 draws attention to the importance of the procurement of goods and services in the promotion of innovation, and to the duty that that places on the national Commissioning Board. There are many reports about the importance of public procurement in advancing innovation and in ensuring the take-up of UK inventions and innovative practices. The latest one was by the Science and Technology Committee of your Lordships' House, of which I was a member. The report brought out some of the dilemmas around using procurement to take forward innovation. Yet again it cast doubt on central government's use of their purchasing power and muscle to drive the take-up of UK innovations in public services.
The NHS is not alone in having this problem, but it is part of the problem and it is a big part of the public sector. A major and long-standing problem is that too many purchasing decisions are taken too far down the organisational food chain, with too little intervention at senior level and too little willingness to use large-scale purchasing to spread the use of innovative approaches. Whatever else the national Commissioning Board has, it has a lot of financial muscle. It must use that, through the NHS’s purchasing capacity, to drive innovation, which often comes from publicly funded research. I hope that the Minister, who is well aware of the issue, will see the sense in putting something like Amendment 129 in the Bill. We cannot say too often that public procurement is a way of helping to establish and drive innovation in the NHS.
Amendment 129A seeks to add the idea of an innovation fund to the board's armoury on innovation in new Section 13K. There is nothing novel in this. The amendment continues and builds on the proposals of my noble friend Lord Darzi, which led to regional innovation funds that strategic health authorities currently manage. Again, we need to strengthen the mechanisms in the Bill for driving innovation in an NHS that historically has been slow to take up innovations and apply them to scale for the benefit of patients. We are not talking about huge sums of money in the innovation fund, but relatively modest amounts in relation to the scale of NHS expenditure. However, an amendment of this kind would ensure the continuance of the useful work that has been started by the strategic health authorities following the promptings of my noble friend Lord Darzi.
It is typical of what we sometimes do in this country. We start an initiative with a fund at strategic health authority level and then shuffle the cards so that somehow, along the way, some of the initiatives and their benefits get lost. I hope that we can get some reassurance from the Minister that some kind of innovation fund will be available so that we can continue the work that my noble friend Lord Darzi so ably started to ensure that patients can secure the benefits of UK innovations.
Lord Patel
My Lords, I support the amendments tabled by the noble Lord, Lord Warner, to which I have added my name.
First, I will speak very briefly about innovation and procurement. I also contributed to the report by the Science and Technology Committee on procurement. The public sector could learn a lot from the private sector about using procurement to drive innovation. Perhaps the Minister can comment on this. The NHS is a huge organisation that uses about £20 billion-worth of procurement a year and if that was done in a co-ordinated way, it could drive an immense amount of innovation within the NHS.
My second point is about how to drive innovation into clinical care. There are lots of examples I could give, but I will give one from my own specialty. It took us 20 years to take the learning from research into the kind of treatment to be given to the mother in premature labour that would considerably reduce the incidence of respiratory distress syndrome, which causes a lot of harm and death in neonates, and embed that into practice. There are lots of examples of such innovations not being embedded into the NHS and we need to look at ways of doing that faster.
My third point is how to use tariffs to drive innovation. If I as a provider will not be given a higher tariff if I drive innovation or innovate a different way of providing the service, and all that will happen is that the tariff for procuring my services as a provider will be less the following year, there is less incentive for me to use innovation in clinical care to improve patient care and also to make it cheaper.
The fourth issue is about an innovation fund, which I support. Together with the Wellcome Trust, the Government have an innovation challenge fund that asks for tenders in particular areas of innovation. The one I know about is in reducing infection rates. Innovation funds of this kind will drive further innovation; for example, in the United States Medicaid and Medicare have a joint innovation fund to drive improvements in healthcare. So I support that amendment.
Baroness Finlay of Llandaff
My Lords, I rise to speak briefly to Amendment 129ZA, which is really a probing amendment. I hope that the Minister will be able to explain what these “prizes” are that are referred to in the Bill. The Explanatory Notes do not really help. They talk about the Bill providing for,
“the NHS Commissioning Board to make payments as prizes in order to promote innovation in the provision of health services”,
and that:
“Innovation will originate primarily from the actions of commissioners and providers but it is intended that the NHS Commissioning Board will take a lead role in promoting it”.
The changes should bring about continuous improvement and innovation often happens outside the main NHS. Indeed, in my own discipline, end-of-life care, the innovations have happened by and large in the third sector, particularly in care in the last 48 hours of life. In some ways, this is where these organisations, the different hospices and those working with them, have felt freed up to pilot different ways of doing things which have subsequently been adopted within the NHS.
There is a huge need for more health services research and for good, qualitative methodology. My only anxiety about the word “prizes” being in the Bill is not that I do not want innovation to happen—I desperately want innovation to improve services for patients—but that I want to make sure that innovations are also properly evaluated; that they are piloted, evaluated and audited in the long term. It is terribly easy for people to have great flashes of inspiration and great ideas but they might not necessarily roll out appropriately across all aspects of the health service. Many of us have seen innovations that seem to be excellent in one setting but when they are rolled out without adequate support and training, mistakes are made and problems arise.
I had the privilege of chairing the commission into medical generalism, and our report noted the shortfall in both funding in primary care and in researching ways of delivering primary care to common conditions. We welcomed the National School of Primary Care Research and the recognition that more funding was needed, but we urged the MRC and other funders to create a dedicated funding stream for clinical research in primary care as it is difficult to secure funding. I hope the Minister will explain what these “prizes” are and say that they will in no way detract from the much needed research funding to really evaluate innovations and innovative ideas, particularly in primary care.
Baroness Morgan of Drefelin
My Lords, I rise to speak to Amendments 130, 131, 147, 150, which are in my name. I have also added my name to Amendments 215 and 218. These are very big groups and the Minister has my sympathy. I am sure he is listening very carefully to all the advice that he is receiving. I would particularly like to add my support to the remarks made about the power of procurement to promote innovation.
I want to speak about research and the research duty. My amendments are designed to add weight to the research duties in the Bill and follow on from the excellent debate on Clause 5 in relation to the Secretary of State’s research duty. I thank the Minister for his letter, which he has circulated to those who took part in that debate, although I fear that it may have raised rather more questions than it has answered. I apologise to the noble Earl for that, and I would like to go through a few of them now. I declare an interest as chief executive of a medical research charity, Breast Cancer Campaign.
In the debate on the research duty in Clause 5, many excellent examples of research were highlighted. It might be useful very briefly to reflect again on the impact that research has on the lives of people in this country, and to mention a report on cancer survival rates by Macmillan Cancer Support that had a great impact in the media last week. It highlighted that people now live nearly six times longer after their cancer diagnosis than was the case 40 years ago. Many noble Lords will be aware that for nine of the 20 cancers studied by Macmillan, median survival time is three years or less, with little improvement since the 1970s. The report highlighted the achievements that research has made but also that there is an awful lot more work to do.
It is also important to remember that there is a lot of research about quality of life. For instance, median survival time for breast cancer has doubled since the 1970s. Investment in research has played a fundamental role in this and yet more than 12,000 women still die from breast cancer every year. As I said, research is not only about improving survival rates. Many women with advanced breast cancer live with complex support requirements that are frequently not met, as evidenced by the research published recently by Breast Cancer Care and funded by my charity, which raises serious questions about pain control, for example. Ensuring that the NHS is committed to supporting research is absolutely key to addressing long-term improvements in survival but also improvements in quality of life for patients today.
Amendments 130 and 131 are intended to strengthen the research duty that has been placed on the Commissioning Board. Amendment 39, which we talked about a few days ago, removed the phrase “have regard to the need to” from the research duty on the Secretary of State, thereby strengthening it, and Amendment 130 seeks to do the same for the research duty on the Commissioning Board. During the debate on Clause 5, the noble Lord, Lord Willis, explained eloquently why the words “have regard to the need to” in the clause would be better removed ,and how by doing that we would have greater clarity and a better statement of intent would be established. So it would be helpful if the Minister could explain why we need to see those qualifying words in this clause. It would be particularly useful to be given practical examples of the effect that removing the words would have, because I suspect that they are not necessary and that the Bill might be better off without them.
I was also extremely heartened to hear the Minister say that he sympathised with me and with many other noble Lords when we argued that the research duty should be strengthened and that he would undertake a “closer consideration” of the research duty. I would welcome hearing a little more about his thoughts on that today, particularly whether any amendments to Clause 5 could be in the making, and whether they could be read across into Clause 20.
Moving on to Amendment 131, this seeks further clarity on the meaning of,
“research on matters relevant to the health service”.
I do not want to rehearse the arguments made previously in relation to Clause 5 and the wording of this phrase except to request a further explanation of its definition, including practical examples to aid our understanding which I hope the Minister will be able to provide either today or later in writing. In correspondence, the Minister helpfully clarified that public health was covered by the current definition, which was an important point for the noble Lord, Lord Warner, as I recall. However, the intention of Amendment 131 is to seek further clarification and a definition of the phrase so that we can understand whether it is sufficiently comprehensive. Public health is one issue that we are very clear about. It is covered, but we need to be confident that the duty is comprehensive in that regard. I believe that a more substantial definition is required and I am pleased to have the opportunity to request this today. For example, with this definition in place, what are the implications for NHS staff who are involved in supporting research? Will there, for example, be sufficient research nurses to support research activity, will clinical training incorporate time for research and how will research successes be recognised and encouraged as part of NHS career progression and structures?
In terms of what we know about the Commissioning Board, what will it be doing with respect to research? The Government have attempted to reassure noble Lords that the Commissioning Board is aware of the need to promote research and indeed that one of the board’s most important functions will be to support a culture that promotes research and innovation. I welcome this but I feel that in practice there is still very little detail about how this will happen. It appears that research will not form one of the six key portfolios of the board, but will fall under the commissioning development portfolio. Will this include, as I believe the Minister’s letter suggested, the development of commissioning tools and commissioning guidance ensuring that patient care is commissioned so as to support the conduct of research in the NHS? I note with interest that the Government are committed to ensuring that the systems and processes for commissioning used by the NHS Commissioning Board and clinical commissioning groups will ensure that research is promoted, supported and funded by the NHS, including the tariff, commissioning guidance and processes for authorising and supporting the development of clinical commissioning groups. That is important, but I would be grateful if the Minister were able to provide further detail on the activities of the Commissioning Board in relation to research.
Will the development of commissioning tools and guidance as defined be sufficient to embed a culture of research in the NHS? While we have heard that the tariff for patient care will incorporate the costs of patients who are taking part in research projects, how will infrastructure costs be captured? Obviously I am thinking about the cost, for example, of storing tissue for research purposes. I fear that what we have been provided with so far is a number of ad hoc references to research that do not attempt to embed comprehensively a research culture into the NHS or set out a vision of what the research duties would mean in practice.
That brings me to Amendments 147 and 150. Two clear opportunities to ensure that the board is accountable for its actions with respect to the research duty now present themselves in relation to the business plan and the annual plan. I note with interest—and I believe that many others have noticed this—that the board must publish a business plan setting out how it proposes to exercise its functions in that year and in each of the next two following years, and at the end of the year it must also publish an annual report on how it intends to exercise its functions. There is therefore a great opportunity here. However, I am puzzled as to why Clause 20 establishes that the business plan and the annual plan must report how the board proposes to discharge its duties only under new Sections 13E and 13P, and likewise explain in the annual report its performance under those sections, which cover the duties on the improvement of quality of services and public involvement in consultation by the board. Again that is very important, but there is no comparative requirement with respect to new Section 13L and the duty on research. Again, there is an opportunity here to improve the feedback loop. I would be grateful if the Minister could explain what plans there might be to bring forward government amendments or to accept the amendments now before the Committee.
Lord Willis of Knaresborough
My Lords, I am delighted to follow the noble Baroness, Lady Morgan, and particularly to support her comments about the duties in respect of research. But perhaps I may also say that the noble Baroness, Lady Thornton, raised a very important issue in her opening remarks, which is the definition of the difference between a duty to provide and a duty to commission. There is a subtle but important difference between the two. Commissioning, as the noble Lord, Lord Warner, clearly stated, is something for which there is a huge budget, so it is very important indeed that it is used effectively. I was particularly interested in Amendment 129A tabled by the noble Lord, Lord Warner. We are all puzzled about the Government’s intentions in terms of prizes and incentives to encourage innovation and to bring research out of the labs, if you like, to the bedside.
There are some extremely good examples of this. The noble Lord, Lord Warner, mentioned the work of his noble friend Lord Darzi, particularly the Health Innovation Challenge Fund. I have just finished chairing the fund’s three-year review, and it is interesting to note that three years into the five-year programme, new devices, technologies and procedures are being brought forward from research to clinical outcome. Some 13 of these are now up and running, and some are quite remarkable. We have seen the groundbreaking research to deal with the onset of blindness being undertaken at Oxford. Within five years we will have gene therapies that will make a huge difference to patients suffering from a whole range of conditions, including macular degeneration. That will have a massive effect not only on patients’ lives, but also on the health service budget itself. It is important work and there are other good examples on which we need to move forward.
I want to speak specifically to Amendments 215 and 218 tabled in my name and those of the noble Baroness, Lady Morgan, and the noble Lords, Lord Patel and Lord Turnberg. I should also declare an interest as chair of the Association of Medical Research Charities. Amendment 215 concerns the role and responsibilities of clinical commissioning groups towards research and includes, within their commissioning plans, how they intend to execute their duty as defined in new Section 14X. That commissioning groups should have a duty to promote research was recommended by Professor Steve Field, the chair of the NHS Future Forum, when he said in his report:
“Support for research and innovation is also important for evidence-based commissioning and practice, so the report recommends that commissioning consortia should have a duty to promote research and innovation and the use of research evidence in the NHS”—
a recommendation which was immediately taken by the Government, to their credit, and, indeed, was welcomed by the medical research community.
Lord Turnberg
I wish to speak to some of the amendments that are in my name. I would also like to comment briefly on Amendments 128A and 129, dealing with innovation. We know that we are quite slow in taking up innovations in the UK. It is not simply that there is a bit of sluggishness in the system—there are hurdles in the system. I want to mention two examples of very simple innovations that would not cost any money to the health service, but which have been blocked by the systems under which we operate.
One example is a consultant colleague of mine, a gastroenterologist—my own field—who set up a clinic in which he took phone calls from GPs and patients and was able to answer many questions without actually having to see the patients. It had a rapid turnover. It was considered to be innovative but was blocked because it did not earn any money for the hospital trust which found that it was not getting the patients referred. The second example concerns a similar situation in which the same consultant saw new patients from 8 am until 9.30 am. He sent them away for tests, scans, endoscopies and so on, and saw them again at about 11 am with the results of the tests and gave them the treatment that was necessary. This, too, was considered not to be earning money for the PCT, because it was paid for items of service, and it would have got twice the money with the normal system. This is a hurdle to innovation which we should surely be able to overcome. We have discussed that with the Minister. He expressed sympathy for the idea so I hope that it can be acted upon. It is not simply that we are slow; we have hurdles.
I come to Amendments 130, 131 and a number of others in my name. I have no doubt that the Government have firm intentions to promote research and innovation. It is mentioned in several places in the Bill and I know that the noble Earl’s heart is in the right place on all this. The amendments in my name are simply there to help the Government in their own aspirations by emphasising and reiterating the need to keep research and innovation at the forefront. I simply emphasise the points made so eloquently by the noble Baroness, Lady Morgan, and the noble Lord, Lord Willis. The amendments make it clear that innovation and research are of such central importance that they should be explicit in the board’s business plans, in reporting its activities and in clarifying how it is going about achieving these aspirations. The amendments make sure that the board actively promotes research as against simply having regard to it. I hope that the Minister will find the amendments helpful in the light of the Government’s intentions.
Amendment 131 returns to the issue of research that protects the public’s health. Here I make two particular points that the Minister might consider answering in one way or another. First, how will it be possible to ensure that the local authorities taking over the directors of public health also promote research? What levers will there be with the local authorities? Secondly, I ask a question that has been posed before. How will we ensure that the Health Protection Agency, which engages in much important research, will have access to external funds? We have discussed this before, but it would be nice to know whether it is clear that the HPA will have access to grants from external funding bodies.
Earl Howe
My Lords, the NHS has a long and proud track record of innovating and delivering better care for patients. That must continue—we all agree about that. That is why new Section 13K of the 2006 Act places a duty on the board to promote innovation when exercising its functions, including innovation in the provision of services and the,
“arrangements made for their provision”.
That last phrase means the commissioning of services. As a result, although we completely sympathise with the principle behind Amendment 128A, it is not necessary. The duty is intended to support the delivery of quality and productivity improvements across the NHS to help transform healthcare for patients and the public. In response to the noble Lord, Lord Warner, I say that I expect that innovation in procurement of goods and services will be an essential part of this. The duty certainly allows for it as it stands. It is an important part of the QIPP programme at the moment, and I am sure that it will continue to be. If we were to specify one area of activity in which the duty should be exercised, as Amendment 129 suggests, we would face the perennial problem of listing those areas where the duty should be exercised to the detriment—
Baroness Thornton
I am sorry to interrupt, but it strikes me that if none of us understood that that was what those words meant—that was what led us to table the first two amendments in this group—maybe the Minister should look at those amendments, because they offer more clarity.
Earl Howe
I am always keen to accept the wise suggestions of the noble Baroness, and I will of course go away and consider the words that she has proposed.
I was just referring to the amendment proposed by the noble Lord, Lord Warner, on procurement, and saying that we would face the perennial problem of listing those areas where the duty should be exercised to the detriment of those not listed.
Lord Warner
I have an uneasy feeling that we are going to hear a lot about lists today. On lists, some things are more important than others, and I think that the argument about lists does not hold a lot of water unless the Minister can show us some other items that will be missed out that are as powerful as procurement of goods and services in further research and innovation. If there are others, I would be happy to consider the matter, but the reason why the amendment has been tabled is because it is a very powerful way in which to promote something that the Government want. Many of the other things may not be as powerful in delivering that.
Earl Howe
I recognise that and, after what I said a moment ago, we know that procurement can be an important lever in the innovation agenda. Indeed, that will be recognised in the innovation review, which is due to be published next month. Furthermore, we are planning to launch a procurement strategy by April 2012. I will not go into huge detail about it, although I have it here, but it will consist of three elements—system levers, standards for procurement and system level support. We can look to take forward some of the ideas that the noble Lord, Lord Warner, put forward in his speech.
All this goes to show that there is a substantial amount of work already under way to create the right conditions for innovation to flourish. These include dedicated regional innovation funds to support front-line innovation and innovation challenge prizes to recognise and reward ideas that tackle some of the biggest health and social care challenges facing the NHS and in future. I have named only two from a long list of current initiatives.
I will just say to the noble Baroness, Lady Finlay, that the Secretary of State already has a power to awards prizes. New Section 13K of the 2006 Act, inserted by Clause 20, simply gives the board the same power. Should it choose to use the power to make payments as prizes—and it is a power rather than a duty—this is one way in which it might decide to promote innovation in the provision of health services. Recently I presented the very first group of innovation challenge prizes, and it was a very heart-warming and exciting occasion.
The noble Lord, Lord Warner, rightly made the point that the NHS was slow to take up innovation and that people were forced to go elsewhere to take their new ideas forward. Again, this is an issue that we are tackling with considerable energy in the NHS chief executive’s review of adoption and diffusion of innovation, which will be published next month. I look forward to talking more to the noble Lord about what is in that review in due course.
I say to the noble Baroness, Lady Morgan, in particular that the main way in which the board will collaborate with research funding bodies is to fund the treatment costs of patients who are taking part in research funded by government and research charity partner organisations.
The existing innovation funds were not put in primary legislation; there is no need to put a specific power in the Bill, as Amendment 129A seeks to do, to enable the board to establish an innovation fund. As with prizes, establishing innovation funds is only one way in which the board might seek to exercise its duty to promote innovation; innovation funding is being considered as part of the chief executive’s innovation review.
Amendments 130 and 131 reflect the similar and previously debated Amendments 39 and 41 on the equivalent duty on the Secretary of State in Clause 5. I agreed to undertake a closer consideration of that duty and I shall do that. I reassure noble Lords that our discussions will include the board’s duty. Work is under way to look at these duties ahead of future stages of the Bill. Indeed, I undertake to reflect carefully on the points raised by the noble Baroness, Lady Morgan of Drefelin, and to write to her with answers to her questions. I have also written to all noble Lords who spoke in that earlier debate, picking up points that I was not able to cover at the time. I explain in that letter how public health falls within the definition of the health service, which was one of the points touched on by the noble Baroness. It will therefore be covered by the existing duty on the board to promote research in proposed new Section 13L of the 2006 Act.
The noble Lord, Lord Patel, spoke about the role of the tariff in promoting innovation. He is absolutely right to do so; the new tariff could indeed play a key role in encouraging innovation. The Bill introduces a new, independent, transparent and fair pricing system where the board and Monitor would collaborate to set prices for NHS services. That would create a more stable and predictable environment, allowing providers and commissioners to invest in technology and innovative service models to improve patient care. We are actively looking at the way in which the tariff could drive that.
My noble friend Lord Willis and, indeed, the noble Baroness, Lady Morgan, asked how exactly the board will go about promoting research. As previously set out, we will make sure that the systems and processes for commissioning used by the board and clinical commissioning groups ensure that research is promoted, supported and funded by the NHS. That will include the tariff, the commissioning guidance and the processes for authorising and supporting development of clinical commissioning groups. However, noble Lords will be aware that a great deal of the practical detail of the board's role is still under development. Further detail will be published in due course and we must respect the autonomy of the board in devising for itself how exactly it will undertake this function.
I turn to Amendments 147, 149A, 150, 215 and 218. Given the wide range of statutory duties placed on the board and CCGs, the approach we have taken in the Bill is to emphasise a few key duties that the board must look at—in particular, in its business plan, annual report and its performance assessments—and that CCGs must, in particular, look at in their commissioning plan and annual report. We feel we have chosen the right duties to emphasise, not because they are the most important but because they are duties about which any annual report, business plan, commissioning plan or assessment should provide explicit evidence, specifically linked to the exercise of the board’s or CCGs’ functions.
That said, with respect to clinical commissioning groups I say to my noble friend Lord Willis that the department has published Developing Clinical Commissioning Groups: Towards Authorisation and that, to be authorised, a CCG will need to demonstrate that it has in place the systems and processes both to promote patients’ recruitment to and participation in research, and for funding the treatment costs of patients taking part in research, so this will not be overlooked. However, we are clear that an annual report, business plan, commissioning plan or annual assessment should provide an assessment of all the body's functions, including the exercise of its innovation and research duties. There is also nothing to prevent the documents going into significant detail about the exercise of a specific duty. I add that the board has the power to issue guidance to CCGs on the contents of commissioning plans and directions as to the form and content of the annual report. I hope that those remarks are helpful in answer to the questions and points from noble Lords, and that they will be sufficiently reassured by what I have said not to press their amendments.
Baroness Thornton
I thank the Minister for those remarks and all other noble Lords for theirs. This has been a very high-quality, expert debate. I do not want to delay noble Lords from their supper and, indeed, on this side, from an opportunity to defrost—we have hypothermia on this side. The Committee has again shown its great expertise, commitment and enthusiasm to innovation and research and there is great consensus across the Committee about this. This suite of amendments would have given practical action and voice, and would have strengthened this part of the Bill on innovation and research. We need to look at what the Minister has said. I am grateful for those areas where he said that he would reflect upon these issues and let us know. However, it is safe to say that because of the consensus in the Committee on these issues, we would all be keen to make sure that the issues of innovation and research are, indeed, put beyond doubt in this Bill. I beg leave to withdraw the amendment.