(13 years ago)
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“( ) In subsection (5), for “this section, section 245 and section 246” substitute “this section and section 245”.”
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, unusually, it falls to me to introduce this group of amendments. In moving Amendment 327ZC and speaking to Amendments 327ZD, 327ZE, 327ZF and 327ZG, I confine myself to saying that these are minor technical amendments to Clauses 187 and 188. For the most part, they ensure consistency between the scrutiny provisions in the Bill and in the Localism Act. I hope that they will receive the support of the Committee. I beg to move.
Baroness Massey of Darwen
My Lords, I speak to Amendments 330, 333 and 334 in this group. I draw attention to issues important for strengthening integrated working in children’s health and well-being. Of course, integration is important for all consumers of health, but services for children have often been fragmented and disconnected, sometimes with tragic results, as we all know. I spoke last week about the importance of listening to the voice of the child. If children had a voice, they would say—as they do when we speak to them—that integration of services is not good in many areas. It should be, for effectiveness and efficiency.
My amendments require all health and well-being boards to promote close, integrated working between health, social care, and health-related services in their area. Specifically, Amendment 330 requires that they “must,” rather than “may”, include in their joint health and well-being strategy,
“a statement of their views on how arrangements for the provision of health-related services in the area of the local authority could be more closely integrated with arrangements for the provision of health services and social care services in that area”.
Amendment 333 requires, again, that they “must,” rather than “may”,
“encourage persons who arrange for the provision of any health-related services in its area to work closely with the Health and Wellbeing Board”.
Amendment 334 requires that they “must,” rather than “may”,
“encourage persons who arrange for the provision of any health or social care services in its area … to work closely together”.
As the Bill stands, health and well-being boards’ role in bringing health and social care together with health-related services is optional. The National Children’s Bureau and its Every Disabled Child Matters campaign believe this role must be strengthened so that there is a clear duty on all health and well-being boards to promote joined-up commissioning and delivery of services in their area. This is particularly important for children and young people for three key reasons. One reason is that joint working across local agencies is crucial for children’s and young people’s health and well-being. Integrated planning is particularly important for children and young people, for whom some of the most effective interventions are those delivered through non-health settings and services, such as schools and colleges, children’s centres, and youth services. For example, the national evaluation of Sure Start found that a child with access to a children’s centre—formerly Sure Start local programmes—had more immunisations and fewer accidents than young children living in other areas. School health initiatives can have a positive impact on pupils’ health and behaviour—I am thinking of health-promoting schools, for example.
However, evidence suggests that health, social care, education, early childhood, youth and other services are not always working in partnership to secure good outcomes for children and young people. The Marmot review identified the lack of consistent partnership working between such bodies as the barrier to delivering services that reduce health inequalities. Similarly, the Kennedy review highlighted the fact that the requisite links between the NHS, social care, education and criminal justice services to support juvenile people are not always made. His report recommended that local partnerships covering all services for children should have,
“a duty to ensure that local organisations work together”.
Close working between local partners is particularly vital for children with complex needs, such as disabled children or looked-after children, who need co-ordinated interventions from a range of services. A recent report from the Every Disabled Child Matters campaign found that families of disabled children often report experiences of fragmented service delivery and have been caught between services that do not communicate well. One parent has said:
“As a parent, you just want a service, but it’s like health, education and social care are all separate and they don’t really like working together. What you need as a family is one system—not three”.
The Government have expressed aspirations for better partnership working across a broad range of children’s services. For example, Support and Aspiration, the special educational needs and disability Green Paper, states,
“we want to make it easier for professionals and services to work together, and we want to create the conditions that encourage innovative and collaborative ways of providing better support for children, young people and families”.
I believe that unless the Bill strengthens the framework for local integration, the ability of local areas to implement these aspirations will be undermined.
The Bill contains many key measures promoting joined-up working on health and social care, through relationships between local authorities and NHS commissioners. However, many of the services that promote the health of children and young people, such as schools and colleges, children’s centres and youth services, are or will be provided by bodies which are independent of the local authority or NHS. Health and well-being boards should have a mandatory and not an optional role in promoting the involvement of these health-related services in joined-up commissioning and delivery.
Schools need to be encouraged and enabled to play their part. Schools are key partners in securing the health and well-being of children. The public health White Paper, for example, recognises the role that schools can play, stating that:
“Good schools will be active promoters of health in childhood and adolescence”.
This is crucial for reducing health inequalities. The Marmot review, again, recommends that schools should take a “whole child” approach and they will be unable to do this without routine engagement with partners from other agencies.
Over 1 million children and young people now attend academies, which are independent of local authority oversight and will not be represented by health and well-being boards. According to the Department for Education, more than 40 per cent of all secondary schools are now open or are in the process of opening as academies. The Government have taken a step towards promoting joint working by dropping proposals in the Education Act to remove the duty to co-operate under the Children Act 2004. However, this Bill does not create the structural environment within which co-operation with education providers will be possible. Health and well-being boards have the potential to act as a forum for schools to fulfil this duty to co-operate. A clearer role for health and well-being boards in bringing a broader range of services together beyond health and social care, as provided by these amendments, should help to secure this.
Finally, health commissioners should be supported to meet their new duties on integration. Duties were introduced, following the listening exercise, for the NHS Commissioning Board, clinical commissioning groups and Monitor, whereby they are required to carry out their functions with a view to securing that the provision of health services is integrated with the provision of health-related services. As the Bill stands, the role of health and well-being boards in securing this integration remains an optional part of their remit and the scope of their local strategy. Health and well-being boards are expected to play a role in holding health commissioners to account for securing services that fulfil priorities set out in the joint health and well-being strategy. Furthermore, health commissioners will need a forum through which to drive forward better joint working and integration with health-related services. Without a guarantee that health and well-being boards would prioritise encouraging this close working across health, social care and health-related services, there is a serious risk that health commissioners’ new integration duties will be ineffective.
I hope that, in this Bill, the Government will take note of issues which will affect children. I know that the noble Earl, Lord Howe, is listening and I hope that on Report we can reach some agreement on children’s health and well-being.
Baroness Finlay of Llandaff
My Lords, I speak to the amendment to which I have added my name in relation to children, but also speak to a raft of other amendments related to allied healthcare professions. Last week we had a debate about the need for the voice of children in the Bill to be strengthened. On reflecting on this and the debate that we had over other vulnerable groups, it struck me quite forcefully that children are the only group who do not have an independent voice en masse. In all other vulnerable groups, there will be a spectrum of people, some of whom can be outspoken and some who can be advocates for others, even among groups such as those with dementia, the very elderly and those who have come here to this country as asylum seekers. However, children under the age of 16 are completely dependent for consent and for other issues on those who have a legal parental role to act on their behalf and to consider their best interests.
We discussed last week the fragmented society in which some children are now brought up, and the difficulties that individual children face. We also discussed the need for health and social care services to reflect the needs of children. I urge the Minister, in looking at these amendments and those we debated before, to consider very carefully where our society will be heading if we do not strengthen the voice of children on the face of the Bill.
Amendment 330A, to which the noble Lord, Lord Low, has put his name and, I believe, will be speaking, will try to secure a change so that this Bill parallels the change in the Education Act.
I will now address my remarks to the need for representation and consultation of allied healthcare professionals, and in so doing declare my interest as president of the Chartered Society of Physiotherapy. Physiotherapists are the largest part of the allied health professions’ workforce. The Bill needs to state that allied health professions as a group are consulted, because there is, sadly, great ignorance in medicine and nursing as to the full range of professional services that allied healthcare professionals can contribute. They contribute right across the range; innovative models of service provision now being developed are able to free up medical and nursing time and decrease the number of interventions needed, particularly on aspects such as orthopaedic surgery, where physiotherapists are running clinics and are able to intervene and completely obviate the need for some patients to progress to surgery.
Allied health professionals by and large, and physiotherapists in particular, are focused on re-enablement; on keeping people healthy; working with the parts of them that are healthy and helping them cope with the parts that are not; on preventing absence from work and avoiding unnecessary hospital admissions and unnecessary interventions. We are already hearing of delayed discharges from hospital. The Health Service Journal of 27 October this year had a piece on this. Patients are having to wait for care packages, including physiotherapy services, that could enable them to be cared for in their own homes. Without the allied healthcare professional voice being involved at senior-level commissioning, acute services will not be joined up in the community, and that leads to fragmented care for patients and poorer health outcomes. Care in the community setting is viewed as key to the Government’s efficiency savings in relation to hospital admissions. Allied healthcare professionals enable patients to take control of their own care and resume living in their own homes, empowering them and easing the burden on front-line services. There are a whole group of amendments in my name which list allied healthcare professionals. I hope that the Government will look favourably on these.
Baroness Greengross
My Lords, my Amendment 332A follows well from the previous two speakers. It would ensure that integrated working in health and social care delivery—particularly the latter, which we know from many noble Lords who have spoken, including the noble Lord, Lord Warner, is often very much the junior partner in these discussions—is given an explicit place on the face of the Bill, rather than simply being relegated to regulations and guidelines. In his report on Fairer Care Funding, Andrew Dilnot commented that when someone has a care or support need, they do not really know which part of the range of state funding is going to provide the services that they need. This particularly applies to people with multiple needs and co-morbidities, which is often the majority. We know that there are many different services delivered at national and local level—for example, the NHS, the adult social care system, social security benefits, public health services and housing services. They can all be critical in meeting people’s needs. The problem is that all these elements overlap and interact, sometimes positively but sometimes rather negatively. Dilnot noted forcefully that when services that are shaped around people work well together, outcomes are better; when they do not, people experience very disjointed services and their experiences are poor.
We need a care system that is more consistent, with less variability, and one in which people feel that services are working for them, not against them. In this context, I welcome the Department of Health’s commitment to breaking down the barriers between health and social care to improve the outcomes and experience of users. Having a National Health Service that is free at the point of need, but a shared-responsibility system of social care, means that difficult decisions will continue to be made if this carries on. For example, in response to the Nicholson challenge, how will clinical commissioning groups ensure that the focus stays on the patient and on integration of services and not on contracting and other arrangements? Do we know what type of support managers need to make integrated services a reality? How can staff be encouraged to work collaboratively? Through this process, how can the correct values and ethos concerning the dignity and respect of patients, which we all believe in, be developed and maintained within and across organisations? There are many examples of where the consequences of having different care streams can seem extremely unfair to people. But when streams have been integrated or a more co-ordinated approach is taken, there is evidence of improved outcomes, high-quality services and better value for money, as well as the fostering of innovation. In my view, the powers proposed in Clause 192 for the health and well-being boards to support integrated working should be extended to encourage explicit joint commissioning.
In support for innovation in Part 5, greater regard should be given to the role that service and technology solutions, for example, can have in breaking down traditional boundaries and in encouraging better integration of health and social care services. All generations, including older people, are having their lives transformed by the dramatic changes that we daily witness in communications technology, yet in the UK the adoption of telehealth into health and social care, particularly in prevention and intervention, has sometimes been much slower than in many countries in the industrialised world. In other parts of the world, we have clear evidence of the key role that these systems play in the prevention of ill health, in self-management, in the provision of improved outcomes and in dependence for service users and efficiency savings for the taxpayer. As part of the overall redesign of care, this represents a vital element in the shift towards more preventive care, reducing the imbalance between hospital and primary care spend and making better use of scarce clinical resources. Better integration should facilitate such innovations and would go a long way to making health and social care more self-directed and giving a boost to the personalisation agenda. Integration deserves to be more than a footnote in this Bill. It could be the cornerstone of better quality, value for money and patient-centred care.
Baroness Jolly
I have put my name to Amendments 328B and 330ZAA. I send the apologies of the noble Baroness, Lady Tyler, who is not well. She had hoped to be able to speak to these instead of me. First, I should like to make a few general points about health and well-being boards. It should go without saying that the Liberal Democrats really welcome local democracy in health and the far greater involvement of local authorities than is the case at the moment, as well as the use of scrutiny committees. We are somewhat saddened that in the legislation there is only one elected decision-maker on a health and well-being board. I understand the Government’s unwillingness to prescribe, but they have not quite got the balance right. There may be as many elected councillors as other voting stakeholders, with maybe a casting vote given to the chair. That feels much more like localism in action than what we currently have.
Linked with that is the role of district councils, which is not mentioned terribly clearly. Here I have another apology, because I know that the noble Lord, Lord Greaves, had hoped to speak on this point. What we are losing in his eloquence we are probably making up for in brevity, but I still feel as strongly as I am sure he will. I can almost feel him behind me now, as I speak, but he is not well and is not able to be with us.
Where are district councils in this framework? I know that a lot of local authorities have now become unitary, but there are really key parts of England where strong county councils are well underpinned by district councils. They need to be there, because they provide planning, housing, leisure and environmental health—all these things that have to be well woven into the fabric of this Bill and the delivery of services. They are also part of the solution for the big public health issues. Three examples come to mind without even having to think very hard. Wearing their leisure hat, obesity is a very big issue. Some people prescribe exercise for obesity. On housing, in my neck of the woods, with the warm, wet westerlies, housing gets damp very easily. That brings with it chronic heart and lung problems, particularly if you cannot afford to heat. District councils also play a key role in housing on mental health issues. They are often providers for county councils and PCTs and I know that they would hope for a similar relationship with clinical commissioning groups, when things become established. They should be at the table of the health and well-being boards. I appreciate that you cannot have every district council having one representative. In Kent, where there are 16, or in Devon, where there are eight, you cannot bring those in, but there needs to be some arrangement for working together to ensure that district councils should be there.
Baroness Wilkins
My Lords, I fully support the amendment just spoken to by the noble Baroness, Lady Jolly, in relation to housing. I speak to Amendment 330A, which is down in my name and in those of the noble Baroness, Lady Finlay, and the noble Lord, Lord Low. It is a probing amendment to ask the Minister to ensure that education providers, including academies, schools and colleges, are represented on the health and well-being boards, in order that there should be integrated planning for disabled children. The National Children’s Bureau, through the Every Disabled Child Matters campaign, has raised concerns that the Bill does not provide equivalency with the Education Act, which has retained the duty to co-operate for schools. This Bill does not ensure that schools will be an integral part of the health and well-being boards, so, while education providers will have a clear duty to co-operate, there would be no equivalent duty on health and well-being boards to include education providers.
Integrated planning and commissioning is particularly vital for children with complex needs, such as disabled and looked-after children, who need co-ordinated interventions from a range of services. Many disabled children require health-related services at school, including physiotherapy, occupational therapy and speech and language therapy, as well as specific medical interventions. There are often problems with providing such services on the school site, or it is not properly co-ordinated with other activities at the school. As Adam, one young disabled person, said,
“I went to a mainstream secondary school. I did not get to see a physio or OT regularly. This is because I didn’t go to a special school for disabled people. I think health, education and social services need to work more closely together”.
This lack of co-ordination of support presents disabled children and young people with barriers to participation in education that their peers would take for granted. As Sir Ian Kennedy’s recent report, Getting it Right for Children and Young People, recognised:
“If children do not receive appropriate support from the school, at worst those with severe health problems receive a ‘double whammy’ as their ill-health damages their education by disrupting their schooling, either through being forced to stay at home or by long stays in hospital. Children with severe or long-term conditions receive enormous benefit from continuing their education during their treatment. And there are social as well as educational benefits. Continuing in education is a signal, to the child themselves, the parents or carers and the peer group, that a child with a severe or complex health condition continues to belong to the ‘community of children’ and does not become defined by their condition”.
When education providers and health services do not collaborate to meet the needs of children and young people, it also has a significant impact on their families. A study by Diabetes UK found, for example, that half—46 per cent—of primary school pupils with type 1 diabetes and one-third—29 per cent—of their secondary school counterparts report that their parents have had to reduce hours or give up work to help them administer life-saving insulin injections. It is clear that when children need such support during school hours, local services should work together to ensure that it is available.
As the Minister will know, the Department for Education’s recent Green Paper, Support and Aspiration: A New Approach to Special Educational Needs and Disability, proposed a more co-ordinated approach to the delivery of education, health and social care. These proposals included the delivery of a single assessment process, a joint education, health and care plan, and a local offer, which sets out all services available to disabled children in the area. EDCM is concerned that these proposals will not be deliverable if education providers, including academy schools and colleges, are not given a presence and a voice at health and well-being board level, which this amendment would provide.
Lord Ramsbotham
My Lords, I rise to speak to my amendment, Amendment 330C, which relates to the fact that offender health is a public health—particularly prison health—issue. Since almost every prisoner will be released, their mental and physical state when they are is therefore a matter of public interest. I wish to speak to something related to imprisonment, rather than to imprisonment itself. There are two other activities associated with this part of the Bill which also affect activities of other ministries, the Ministry of Justice and of course the Home Office, to which I would like to draw attention.
As we all know, prisons are wells of psychiatric morbidity. At one end of the spectrum, some 500 prisoners have to be transferred to special hospitals each year. At the other end, some 70 per cent are suffering from at least two personality disorders which are bound to impact upon their behaviour. Prisons are also the unfortunate recipients of people who were in asylums, until these were abolished. To prevent that happening the previous Government initiated a report, conducted by the noble Lord, Lord Bradley, on diverting people with mental health problems away from prison. This was a very, very comprehensive report, with recommendations which affected the courts and the police in particular. This Government, as I understand, have accepted the recommendations and are working towards them. However, they of course depend on there being proper mental health assessment and treatment available at the point where a person comes into contact with the criminal justice system. This is usually at a police station, to start with, and then at a court. I have been to see one of the pilot schemes in Brighton, where an extremely able psychiatric nurse in the court was able to divert people away from imprisonment, not least because they had taken enormous trouble to ensure that the necessary support for people with mental health problems was available from that moment on. Without that support being available, the scheme becomes worthless. However, before that, the first time that people come into contact with the system is in police stations. What worries me about progress in the future is that unless there is a police representative on health and well-being boards able to represent the needs of the people who make those assessments at the police station, the diversion scheme could fail at its start. The purpose of my amendment, therefore, is to ask the Minister to consider very seriously the addition of a police representative on health and well-being boards, to make certain that the needs of police stations are represented at source, in every area of the country where diversion schemes will start.
I say this because when I started inspecting prisons, I discovered that prisons, alone in this country, were not part of the National Health Service. Indeed, they did not become part of the National Health Service until 2003. The result of that was that the needs of people from prisons were not built into National Health Service estimates, and so they were always competing for other requirements. To avoid that error being repeated, I therefore believe that it is essential to have police representation at the place where planning is carried out.
My second area is to do with probation. With regard to the plans—“Breaking the Cycle”, the rehabilitation revolution and all the noise that has come from the Ministry of Justice about reducing the prison population and providing alternatives to custody—most of that comes down to the probation service. There is absolutely no reason why the probation service should not carry out exactly the same programme as happens in prisons; that is, people are assessed, programmes are made and conducted, and then the person is transitioned into the community. There is no reason why the assessing, the programming and the supervision of mental and physical health treatment should not happen to somebody on probation in exactly the same way as it happens in prison. However, the probation service needs help and guidance in the provision of that assessment and programming. That is why I am asking the Minister to consider that a representative of the probation service should be included on the health and well-being board, in order to ensure that its needs are included in the plans, so that the probation service can make the delivery of community sentences more effective and more acceptable in the public eye, and is therefore able to contribute to what the Secretary of State for Justice is seeking; namely, a reduction in the prison population.
Lord Low of Dalston
My Lords, I add my voice very briefly to those of the noble Baronesses, Lady Wilkins and Lady Finlay, in support of Amendment 330A, which provides that health and well-being boards should include a representative of education providers in the area. The noble Baroness, Lady Wilkins, has spoken to the amendment very fully and ably; however, perhaps I can underline the point to which she has already alluded. When we considered the Education Bill in Grand Committee earlier in the year, there was great concern that the Government wished to remove the duty on schools which had only recently been laid on them, to co-operate with other services in pursuing the welfare of children. We were particularly concerned about this at the time of the riots, when people were emphasising the role that schools had to play in combating exclusion and disaffection among children. I am glad to say that the Government took the force of our point and withdrew the proposal to remove this duty from schools. I hope that the Minister will agree that a joined-up approach would suggest—as the noble Baroness, Lady Wilkins, has argued—that there should be a reciprocal duty on health and well-being boards, at least to include a representative of education providers on the board.
Baroness Farrington of Ribbleton
My Lords, I rise to speak about the importance of the role of the police. I made my maiden speech in your Lordships’ House on the subject of care of mentally ill people taken into custody in police cells. I was struck at that stage—I declare a former interest as a member of a police authority and a visitor of police cells—that time after time, I was informed and became aware that people were being taken into custody, not because it was most appropriate, but because their problems were mental health related. They were being taken into police cells for their own protection or for the protection of other people, because there was nowhere else for custody officers to deal with this. I hope the Minister will take this carefully into account when looking at the role of the police, in particular at that initial point of contact. Sadly, many people who end up in custody and police cells have problems that are either mental health related or drug or alcohol related. It creates a problem for the police service, particularly at weekends. It also leads to a reaction to those people who have behaved in a way that causes them to be taken into custody so that they end up in prison, rather than receiving a course of treatment.
Baroness Donaghy
My Lords, I support the amendments of the noble Baroness, Lady Finlay of Llandaff, which refer to allied health professionals, and I want to widen them to include the whole health team. We have been talking about structures, consultation, rights of representation, and roles and responsibility in the new structures, but we need to ensure that the service is delivered to the patients by the health team. Nowhere does the Bill appear to acknowledge the importance of the majority of staff in the health and care services: the invisible majority. I know from working in universities for 33 years that there are academics and students, and then all the rest who are often referred to in the negative as non-teaching staff. In the health service, there are doctors, sometimes nurses, and patients, while the rest are rarely referred to as people: they are back office or integrated services. I want to place on record the importance of the health team: the cleaners, caterers, maintenance staff, technicians, receptionists, secretaries, administrators, finance staff, and those involved with transport, as well the allied health professionals mentioned by the noble Baroness, Lady Finlay.
When I was a non-executive director of a foundation trust, we had to deal with the issue of staff who were employed by PFI projects. It is not my intention to discuss the rights and wrongs of PFI, but to illustrate the huge efforts required to ensure that the PFI staff felt part of the health team, even though the foundation trust had no direct management responsibility. The same applies to contracted-out staff generally. Some, though not all, of the problems of hygiene in hospitals and failure to feed vulnerable patients were caused by the separation of these contracted-out staff from the health team. If transport is not co-ordinated, a patient can be in a ward for an extra day. An efficient receptionist can make the difference between an efficient department and a failing department. Those are only two examples. There has been a deafening silence about the health team, and I am seeking a statement of support for all the staff in the health service and an acknowledgement that the future of the service, whatever that is after this unnecessary Bill, will depend on the health team being able to work together in an integrated way.
Baroness Cumberlege
My Lords, I address my remarks to Amendment 330ZAB and others that concern the composition of the health and well-being boards, and I would like to say a word in general about the boards.
To me, they are a spark of inspiration. In the next grouping we will have some specific amendments from noble Lords concerning integration, and we have heard a bit about it already today. I have been conscious that throughout the Committee debates the virtues of integration have often been referred to by my noble friend Lord Howe, and part of the integration he has cited is that very valuable tool, the health and well-being board, bringing together social services, health, and importantly, local healthwatch.
The Bill is gratifyingly lean in its suggested membership of the board: just six essential members. However, in Clause 191(2)(g) it gives flexibility in allowing the board to appoint:
“(g) such other persons, or representatives of such other persons, as the local authority thinks appropriate”.
However, in the same clause, 191(9), it must consult with the members of the board. That seems absolutely right and proper. The success of these boards will be in their balance. That is very important, and what we cannot afford is a single constituency trying to pack the board with its own colleagues. The board itself can put a brake on that, and keep the balance right.
The board itself can appoint additional members, and I can see that being invaluable if the board has chosen a subject which it wishes to target, such as obesity, as mentioned by my noble friend Lady Jolly. Poor housing was also mentioned, as well as alcohol, sexual health, prisons, probation, or children. There is nothing to stop the board giving the individual a short tenure, if the board so wishes. However, if we concede to all these additional, very persuasive arguments that are being put for adding more and more members—I had a quick count of all the amendments on the Marshalled List—we would have statutory boards in the order of 24 members. That is a nightmare for quick decision-making.
I chaired a joint finance committee years and years ago, when we were trying to do the same thing, and we had a board of that size. It became a talking shop. No one would take the decisions that were really necessary. With great respect to local government, where I spent 20 years, we do not want another committee of the council. These boards have to be different.
I said I thought the concept was a spark of inspiration, but I can see this spark extinguished very quickly if we end up with big, unwieldy, cumbersome talking shops. The health and well-being boards should be composed of the great innovators; people with unusual and challenging ideas; people who are prepared to think the unthinkable; imaginative people, fleet of foot, trying new ideas, and abandoning them if they do not work out. Above all, they should be the risk takers.
We know that innovation seldom comes from large, cumbersome committees. It very often comes from young people sparking off ideas. These are people who are probably quite difficult to work with. The Steve Jobs, the Bill Gates, the James Dysons of this world, determined to get their ideas from the drawing board into our homes, changing our lives for the better. They are the people who are not afraid of disruptive innovation.
The NHS thirsts for innovation, but it cannot face the disruption. One of the examples of successful disruptive innovation that I came across is Hairdressers for Health. In a very impoverished area south of Manchester, where you heard the crunch of broken glass under your feet when you walked, where graffiti was everywhere, where the school was protected by razor wire, the hairdressing salon was one oasis of peace and sanity. A junior director of public health, who was very anxious to increase the uptake of cervical screening, recruited the hairdressers to ask their clients—people will know that hairdressers always refer to their customers as clients—whether they had had a cervical screen and, if not, to give them the reason why they ought to go and have one. The hairdressers were given a book of difficult questions that they could answer and a phone number if they got stuck. The results were really impressive. When I asked the women why they went for cervical screening, they would say, “Tracy does my hair. She does it beautifully and I really trust Tracy”.
There are a million reasons why you should not go down that road. If you had a big, cumbersome committee, I can just hear the remarks, “The hairdressers aren’t up to it. The hairdressers really won’t have the information. The clients won’t believe the hairdressers”. No, here was a courageous young director of public health, not working through a huge board, thinking really laterally and doing something terrific. That is what we want from these health and well-being boards. We do not want large committees full of worthies shirking innovation because it is just too risky. Of course, there are always a million reasons why you should not do something. What started as an inspiration is quickly reduced to the boring status quo because that is safe. It takes an awful long time to get back to the boring, safe status quo.
When people decide for themselves, they are more likely to be successful. I applaud the flexibility of the Bill. I see merit in every case that is being put today. The case is being put extremely persuasively, but I urge your Lordships to resist the temptation to tie the hands and stamp on the autonomy of the new boards. We need them to be a success. I am working at the moment with some that are in shadow form. The good will that is in those boards is terrific. We should be enhancing and cherishing that and not directing exactly how they should work. If we do that, I regret that we will simply have just another committee of the council.
Baroness Benjamin
My Lords, childhood lasts a lifetime. Whatever happens to people during childhood, they will take with them long into adulthood. Sadly, many children’s early lives are broken by the relentless mental and physical suffering that they go through daily. Even children who suffer from lesser known conditions such as sickle cell, which is not widely recognised by teachers or schools, are made to feel inadequate and lose their confidence. We need to put in place a holistic provision of care for those children, for their voices to be heard and for them to know that society cares about their well-being. That will give them hope for the future.
As we have heard from noble Lords across the House, we need joined-up policies for everyone to work together. I hope that my noble friend the Minister will show compassion and understanding when he considers these amendments, which I believe put children first and show that we are a nation that cares about our children, our future.
Lord Warner
My Lords, I want to say a few words about children in this group of amendments. I know and agree with the arguments put forward by the noble Baroness, Lady Cumberlege. We do not want this to become a huge talking shop. I sympathise with and support that idea, but I think that children are different in kind, in part for the reasons given by the noble Baroness, Lady Benjamin. If we are serious about investing in the future, we need to pick up some of the issues around children much earlier. Diabetes and obesity are big issues facing our society. Many of our services are not very good at picking up the needs of children and responding to them in a comprehensive manner. There are lots of organisations that speak on behalf of them, just as there are lots of organisations that speak up for other interest groups, but I would say that the investment issue on children is much more significant than the investment issue on 80 to 85 year- olds, or even 70 year-olds. That is not to say that those people do not need a good or compassionate set of services responding to their needs, but if we as a society neglect the voice and needs of children, we are just bringing a lot of problems upon ourselves as a society—more so than if we have less good care at much older age groups.
From my time as a Minister, I thought that the voice of the child in the NHS was really quite muted. The working across boundaries in the needs of children is often far less good than it should be. We need to put in the Bill a stronger requirement to listen to the voice of children and to have their representatives fully focused in the health and well-being boards. They are different in kind and their voice has not been heard enough. Too often, public services operate through parents rather than going straight to the child. That is particularly an issue with young carers and with adolescents. We need a bit of a wake-up call on the needs of children in our NHS and social services and across the spectrum of their needs. I hope that the Minister will look carefully at this issue in the particular circumstances of children.
Lord Beecham
My Lords, these few clauses relating to health and well-being boards are perhaps less politically exciting than many of those that we have spent days debating—days that are rapidly drawing to a close—but they are potentially highly significant and their importance will be realised over time. The purpose of these boards is to facilitate integration between local government and the National Health Service in the planning and provision of all services relevant to the health and well-being of the present and the future population. They should take a strategic view of a range of services—health in its conventional sense; public health, which is now effectively to be restored to local government; social care; children’s services; housing; environmental services; leisure; and the criminal justice system, all of which have been mentioned by various of your Lordships this morning.
In addition to that fundamental strategic role, these clauses provide for greater democratic accountability at local level and the engagement of the community and the voluntary sector. As we have heard, they also ought to provide for the engagement of staff with a range of professional skills to be brought to bear on the issues that communities face.
I listened with some care and, frankly, growing concern to the observations of the noble Baroness, Lady Cumberlege. If I may say so, she got it wrong about the purpose of the health and well-being boards. They are not operational boards. They are to produce a health and well-being strategy. They operate at that level. They will not be directly involved with implementing that strategy. They will not be responsible for the range of services which will be required both to work together and to work efficiently to impact on the health and well-being of an area.
The noble Baroness also perhaps misunderstands how influential bodies like local government can be. When I had responsibility in the area of social care in Newcastle, many years ago, I was able, with a committee of 15, to drive through a significant programme of change in our authority. We created one of the first welfare rights services, we trebled meals on wheels, we doubled the home help service and we made vast changes in the way that we provided for children’s services and adult services alike. It is perfectly possible to do that with a reasonably sized committee, provided that there are people on it with the kind of vision which is necessary, and people in the employ of whatever authority is providing those services who, equally, have drive, sensitivity and vision.
In looking at the role of the health and well-being boards, then, we have to have regard to that area of responsibility. Of course they will be working to an agenda which will actually be set rather separately, in a sense, because it is the local authority and the clinical commissioning groups which will be responsible for the preparation of the joint strategic needs assessment. That is the basis upon which matters will have to be carried forward.
I am afraid that the noble Baroness, Lady Jolly, joins the noble Baroness, Lady Cumberlege, in possibly having slightly misunderstood the nature of one of the problems that she touched upon. She is absolutely right that housing has to be an integral part of the programme to deal with health, both for communities and individuals, but her amendment is the wrong way around. It is not that the health and well-being board has to take into account the views of the planning authority. It is the other way around—the planning authorities and housing authorities should be drawing up their plans on the basis of the strategic needs assessment and the health and well-being strategy that follows it. We are not at odds about that, really; it is perhaps simply the wording of the amendment. I will have to make a confession about the wording of my amendments later, so I might also plead guilty to the charge that I have levied at noble Baronesses opposite.
Before coming on to the amendments as such, there are two or three questions upon which I would like to hear the Minister’s views. The first is in relation to the relationship between the national Commissioning Board, and its local outposts in particular, and the health and well-being boards. The Bill refers to the position of the national Commissioning Board, but I am interested to learn how he sees the role of the local outposts—I think that is the phrase—which will be established, because part of the agenda which will remain with the national Commissioning Board will impinge pretty directly upon the local strategy and will have very significant and very specific local implications.
Going beyond that, perhaps the Minister would comment upon whether the Government intend to replicate at national level the kind of joint working across departments that they are, perfectly properly, looking to create at local level. Will we see some ministerial committee or some forum for relevant government departments? I go beyond even those that have so far been mentioned. I am thinking in particular of the Department for Work and Pensions and the impact of the Welfare Reform Bill, as well as its general responsibility for benefits; and, bearing in mind the observations of many noble Lords about having regard for the needs of children and young people, but also adults and people with learning disabilities and so on, the Department for Business, Innovation and Skills clearly has a role. It would be interesting to learn whether the Government’s thinking has taken them beyond the local level to looking at how these matters might be addressed nationally.
In addition to that, there is the question of community budgeting, as the phrase now is: whether it is envisaged that it has a role in this context and whether some of the pilots being considered nationally could address those issues.
I will now speak to the amendments in my name and those of my colleagues, Amendments 330ZB, 330ZAB, 331A, 331AAA, 335A, 336A and 336AA. Amendment 330ZB requires the publication of an integrated commissioning plan to which all partners must have regard. That might go somewhat beyond the terms of the Bill as it stands at present, but it seems essential that there should be an integrated commissioning plan across the piece. We are, after all, talking about very considerable sums of public money being spent. Since most of the health budget as such is being devolved to clinical commissioning groups, we are talking about £80 billion nationally. That would be translated into smaller but nevertheless significant sums of money locally, to which would be added the local authority’s own contributions in any given area across its own responsibilities. For a large authority, we are probably talking of a budget of close to £1 billion —possibly more—which will be encompassed within, though not directly administered by, the health and well-being board.
Amendment 335A calls on the health and well-being board to have the responsibility of signing off the clinical commissioning group’s commissioning plan. This is to ensure consistency and a degree of accountability for the work undertaken by the clinical commissioning groups. That is backed up by another amendment which gives the health and well-being board the right to request information as to the progress in implementing the strategy, so that, in addition to the scrutiny committee of the local authority—it in any event has a wide range of possibilities to scrutinise what is happening—the board itself, having set the strategy, is able to see how it is being implemented.
We now come to the question of membership. This is certainly a somewhat difficult issue. There are a whole range of amendments, most of which I would agree with, setting out the wide range of organisations which should be included in membership of the board. They include representatives of education providers; pharmacies; the probation and police services, mentioned by the noble Lord, Lord Ramsbotham; allied health professionals, about whom the noble Baroness, Lady Finlay, spoke; and people from the field of alcohol and drug abuse and the field of safeguarding. It is a significant number.
The Bill at present constitutes the health and well-being board as a committee of the local authority, yet somewhat paradoxically, as the noble Baroness, Lady Jolly, pointed out, only requires a single member of a local authority to be appointed to a board. Admittedly, this is as a minimum, but it could hardly be less. Interestingly, my own authority in Newcastle recently agreed a shadow board, in my absence, which is 25 strong. That strikes me as slightly on the high side, but it includes two representatives from each of the two clinical commissioning groups in the city, from the three trusts that serve the city and from a range of other organisations —many of which reflect the bodies to which noble Lords have referred this morning in debate or in amendments—as well as just three councillors.
Lord Mawhinney
I am most grateful to the noble Lord. I think he knows that I listen carefully to him when he is on his feet. The essence of a democracy is that people are elected to represent their community. I can see an argument for having some professionally trained people adding their expertise, because it might be a stretch to expect locally elected people to command the technicalities of a professional view, but given that commitment of democracy, why does the noble Lord think it necessary to have so many other people representing—in the best possible spirit, I hasten to add—specialist vocations or vested interests?
Lord Beecham
In the first place, I am grateful to the noble Lord, Lord Mawhinney, for recognising when I am on my feet, given that there is not much of me to be seen. In relation to his question, I am not suggesting that they should be voting members. That is the point. There is a difference. The voting members—I do not mean executive members—should be confined to elected councillors and those representing the other partners, the clinical commissioning groups and the trusts. It is a partnership arrangement. You have this sort of arrangement in care trusts and the like. It is an acceptable one, but at the very least there should be equality of arms between the elected members and those from other organisations.
Baroness Murphy
Can we be quite clear that the noble Lord, Lord Beecham, is asking for a health and well-being joint board on which the director of social services and the director of public health—two crucial people contributing to the board—have no vote?
Lord Beecham
That is exactly right. They do not have a vote in the council, which determines a budget of several hundred million pounds and deals with huge issues of social care and public health. They are paid officers. That is a distinct, separate role. On this, the noble Lord, Lord Mawhinney, and I are entirely at one.
There are ways in which the current positions can be improved. I hope that the Minister may be able to give an indication today that there is some scope for change. However, there may be issues that we need to address on Report if what is basically a good plan cannot be further improved today.
Baroness Cumberlege
I do not really accept the noble Lord’s criticism of my thinking. Of course I understand that these health and well-being boards are essentially planning boards. I will read very carefully what he has said in Hansard, but I am sure he accepts that you cannot do the planning if you are totally ignorant of the implementation of what you are planning. Clearly, finance and other things come into this. The health and well-being boards that I have spoken to say that what is really important to the success of the board is the equality of members on it. If he is saying that only local government councillors have a vote, I think that people who also hold budgets—the clinical commissioning group people and the health people—would be very upset if decisions were made involving their finances without them having an opportunity to put their case in a vote, if it comes to that. Again, the boards that I have been speaking to and working with have said that they would always try very hard to avoid a vote.
When I came into the health service from local government, I found the whole culture very different. I enjoyed working as an equal partner with those who were advising me, such as the district or county medical officer and others. We really should leave this to the health and well-being boards to decide how they want to run their business. Why do we always think we know best? Every health and well-being board will be totally different, representing different areas of the country and all sorts of different interests. For once, let us have a light touch and trust the people who are going to be doing this business.
Lord Beecham
I think we need to set out a minimum requirement. That is all I am seeking to do. I am not seeking to circumscribe.
Lord Beecham
The minimum requirement in the Bill is the wrong requirement. That is the point for some of us, at any rate.
Lord Beecham
Rubbish is the responsibility of district councils, as the noble Baroness, Lady Jolly, would point out—at least its collection is.
We clearly do not agree about this. The Bill does not go sufficiently far to underpin democratic accountability. It goes too far to entrench professional and bureaucratic interests, whose voice should certainly be heard but who should not be able to vote on these decisions, just as they are not in central or local government.
Earl Howe
My Lords, this group of amendments has prompted a very worthwhile debate. They all relate to health and well-being boards, and in particular their statutory minimum membership, their responsibility for preparing joint strategic needs assessments and joint health and well-being strategies, as well as their role in promoting integration. On the first of these issues, concern has been expressed about the membership of health and well-being boards. I am sympathetic to the very important points that several noble Lords have raised. We are all keen to ensure that health and well-being boards access the best expertise and professional advice on the myriad complex challenges facing the health and well-being of their local populations. However, taken together these amendments would significantly increase the minimum membership of each health and well-being board, making the requirements substantially more prescriptive. We want to preserve local discretion and flexibility in these arrangements and the ability of boards to shape wider membership in a way that reflects local priorities. These amendments would severely limit that flexibility and discretion. Their other big downside is that they could lead to larger and somewhat unwieldy boards, making meaningful dialogue and decision-making more difficult. My noble friend Lady Cumberlege was absolutely right to sound the note of warning that she did.
In general, we want to avoid being too prescriptive. The Bill sets out a minimum membership for health and well-being boards, but members can be added by either the local authority or the health and well-being board. I would say to the noble Lord, Lord Beecham, in particular that following the Future Forum report, we made a commitment that it will be for local authorities to determine the precise number of elected representatives on their board. We fully recognise that health and well-being boards will want to draw from a range of expertise beyond the statutory membership, such as clinicians, allied health professionals, police, probation service and voluntary sector groups. However, in deciding who to invite, they will need to consider local needs and priorities and the delicate balance between having the right people and having too many to make it an effective board.
The noble Baroness, Lady Finlay, was quite right to emphasise that the right people needed to be there. It is perhaps worth highlighting in that context that we have retained the power for the Secretary of State to issue guidance on the preparation of joint strategic needs assessments, and there will be power to issue guidance on the preparation of joint health and well-being strategies, particularly when it comes to defining what best practice looks like.
The noble Lord, Lord Beecham, asked how the NHS Commissioning Board would fit in with health and well-being boards. The NHS Commissioning Board will be required to send a representative when asked by the health and well-being board and where the discussions touch on the proposed exercise of local commissioning functions of the commissioning board, for example when discussing primary care commissioning. It will also be required to send a representative to participate in the health and well-being board’s preparation of the JSNA and a health and well-being strategy. With the agreement of the health and well-being board, the Commissioning Board may appoint someone to represent it who is not its member or employee, such as a clinical commissioning group representative.
Lord Beecham
Does that mean that it will be the local outpost, if that is the correct phrase, of the national Commissioning Board that will have that relationship, or will this in effect be directed from London?
Earl Howe
It will almost certainly be the local outpost that will have direct responsibility for those matters.
A number of amendments would introduce specific requirements in relation to the JSNA, but before I move on to that I have been informed of something that I think I probably implied, if not stated. It would be up to the board to decide who would be most appropriate to attend at a particular health and well-being board meeting.
I agree that the JSNA must be a full analysis that covers the current and future health and social care needs of the local population. It will be a framework to examine inequalities and the factors that impact on health and well-being. This could include aspects such as deprivation. Its scope will naturally include health and social care needs that are related to a wide range of areas, such as alcohol harm, disability or older people.
Baroness Massey of Darwen
Could the Minister tease out for us the difference between the words “may” and “must”? Is he saying that the word “may” will refer to issues that will be in guidance and the word “must” will be in the Bill, or is it more complicated than that?
Earl Howe
I hope the noble Baroness will have sensed from my remarks that we want to avoid being overprescriptive. On the other hand, we are clear about what best practice looks like, and in framing JSNAs and the health and well-being strategies we have provided for statutory guidance which can set out what best practice looks like.
I think that that is the appropriate balance, rather than putting “must” in the Bill all the time. Local authorities are autonomous bodies and we must hesitate before directing them too closely. I very much agreed with the points made by my noble friend Lady Cumberlege on this. It is not, of course, that we regard these as unimportant; it is a question of how much we mandate and how much we leave to local discretion.
Baroness Finlay of Llandaff
My Lords, I will build slightly on that because I have my name on the same amendments. I understand the Minister’s response regarding the need not to be over-prescriptive, and not to have boards that are burdensome and cannot take decisions easily. He has referred to guidance. It would be very helpful if he could assure us that the contents of this debate and the trends and themes that have come through will inform that guidance, and that the health and well-being boards will be asked to particularly consider and consult with the broad range of professionals and prisoners, and the particular needs of children—which I emphasise. This will ensure that their strategy is broad and really meets the needs, so that there is not, inadvertently, a small board taking narrow decisions.
Earl Howe
My Lords, I can assure the noble Baroness that the substance of this debate will most certainly be fed in. We will be revising the statutory guidance on the joint strategic needs assessment in due course to reflect the changing system. As a result of the Future Forums recommendations, we will also be issuing statutory guidance on the joint health and well-being strategy. There is therefore plenty of scope to build in the very salient and important points that noble Lords have raised.
Lord Warner
Lord Warner
My Lords, I shall speak also to Amendments 335 and 336, which I degrouped from the previous grouping.
Amendments 332 and 335 provide an opportunity to press the Government again on securing more precision in this Bill about what we mean by integration. The integration that means most to patients and service users and their carers is the integration of service delivery. That is what Amendment 332 tries to bring out, by replacing reference to people working “in an integrated manner” with wording that ensures that they work in,
“a manner that integrates the delivery of services to individuals”.
Amendment 335 has another go at trying to persuade the Government to include in this Bill a definition of integration. I find it very odd that the Government go to all the trouble in Clause 192—as elsewhere in the Bill—of providing definitions of health services, health-related services and social care services, but will nowhere provide a definition of integration even though the term is liberally sprinkled throughout the Bill. I congratulate them on that liberal sprinkling, and I think that the intentions are very good. However, using the term “integration” in a variety of ways, without being clear what the important meaning of it is to patients, promises a lot but risks ensuring that there is a likelihood of delivering very little change that actually benefits individuals or helps break down the barriers between health and social care. My particular concern is that some people will take away from this Bill that they have met the needs of integration by organisational integration rather than focusing on the thing which matters to individuals, which is the integration of service delivery.
I hope that the Minister will think further about inserting a definition of integration in the Bill, to give it more precision. I would be happy, as I am sure other noble Lords across the Benches would be, to help him to try to secure a definition. I do not claim that getting that definition right is easy, but I think that while the Bill is in this House it is worth the trouble of trying to get a more precise definition of the integration that would really benefit individuals in the area of service delivery.
Amendment 336 also seeks to push integration, but in a very specific way. It proposes that a local authority with a health and well-being board may approach the national Commissioning Board about assuming,
“some or all of the functions (and associated funding) of a clinical commissioning group where such a group agrees that this is in the best interests of patients”,
particularly if it improves integration. The Government are very keen to argue that people at local level should be able to shape their local arrangements for commissioning and providing services. I have a great deal of sympathy with that approach. This amendment would enable clinical commissioning groups and health and well-being boards to come together to form a single body for commissioning services in accordance with a joint service needs assessment. Given the variation in the size of clinical commissioning groups, there may be some large ones that would like to share staff and reduce overheads by amalgamating their activities in the way that this amendment permits. In addition, some of us believe that it will not be possible to sustain 250 or more clinical commissioning groups, which might then raise the issue of merging those groups and possibly going further and merging the merged with a health and well-being board as well.
There is no compulsion or pressure in this amendment. It merely enables clinical commissioning groups and health and well-being boards to come together, integrate their activities, share priorities and work closely together in the way that public money is spent, particularly in relation to integrating services across the NHS and local government boundaries. I hope that, in the spirit of local decision-making, a permissive but non-mandatory power of this kind could be inserted into the Bill.
I would very much like to hear the Minister’s views on this probing amendment and whether he sees merit in it. I shall be returning to the issue of integration, and a definition of it, on Report. I think there is support for this across many parts of the House. I beg to move.
Baroness Williams of Crosby
My Lords, we on these Benches have strongly supported the many references to integration that have been made in Committee, and it is obviously central to the whole of the attempt to deal with the major problems that confront us all over the next few years. However, I completely agree with the noble Lord, Lord Warner, that it is not very clear what this is, other than a nice word. The more flesh that we can put on it, the better all round, and the clearer the position of local authorities will be.
Many local authorities have of course already delivered, on behalf of the primary care trusts, the kind of approach that the noble Lord, Lord Warner, has been advocating, but the situation has to go a great deal further. We are particularly attracted by his Amendment 336 because it is very clear and precise in what it suggests about the relationship between CCGs, particularly those who wish to devolve some of their responsibilities, or in some cases are unable to deliver on those responsibilities.
I would like to say, from these Benches, on behalf of my noble friend Lady Jolly and myself, is that it is crucial that at an early stage health and well-being boards are able to mount mechanisms for early decision-making. If a CCG is unable to meet part of its responsibilities—and that may happen at relatively short notice—it is critical that the health and well-being boards have structures within their own management which would enable them to deal with the issues rapidly. It would be no good at all if there is a long interregnum when services to patients are put at risk.
I would advocate, in addition to what the noble Lord, Lord Warner, has said, that the new health and well-being boards should make an early approach to seeing how they would deal with what might be, if not an emergency, at least the beginnings of an emergency in the particular aspect of what the CCGs are proposing to deliver.
Baroness Murphy
My Lords, I have added my name to these amendments. Like the noble Lord, Lord Warner, I have come back time and again to this issue of what we really mean by integration, and what it will mean for patients, clients, and people living in the community. It must be a seamless service. They do not mind, of course, where the services come from, but it has to be utterly without gaps. It has to operate 365 days a year, year after year after year, if it is to work.
It seems to me that these health and well-being boards have two huge areas that they will have to work in: the public health and well-being functions around housing, the health of children, and the education of children, for example; and the delivery of services. These two arms are quite difficult to meld together in any joint planning arrangements. The joint strategic needs assessment will try to produce these two focused blocs, but it is actually quite difficult. I am sure I am not the only alumnus, or graduate, or perhaps I should say survivor, of joint planning arrangements. I am even a survivor of a health action zone. I know how difficult it is, and how many hours of work go into properly well-functioning joint planning arrangements, which can commit funds. It takes hours of time and extraordinary leadership from health and local authorities to make them work properly.
I am not sure that I think these health and well-being boards are an inspiration, as the noble Baroness, Lady Cumberlege, does. They are a bit of an improvement on what went before, but to work properly they are going to have to work very hard locally to get it right, and get the structures right. I think it would help enormously if they were working towards something real. For me the real thing would be the integration of the working of health and social care, both at the patient level and at the public health and well-being end of the population. Our Amendment 336 provides one option for a way of working together—an option that local organisations might want to take up. It is an idea, and I am sure that we can think of many others that would also fit the bill. I want these boards to be real and their functions to be made practically useful on the ground, so I support these amendments.
Lord Patel
My Lords, I have my name on these amendments. Of course, we have had an opportunity to discuss integrated care at length at other times. However, I agree that integrated care and the delivery of it is one of the key challenges in the Bill. I agree with what the noble Lord, Lord Warner, said. To a patient, integrated care is the care they need: primary care, secondary care, social care and care in the community.
What leverages will there be for the commissioners to promote the integration of health and social care? They will have the budget, but what other incentives will they have? There is some evidence that contracting of provision of care to a population, particularly the elderly, the frail and those with complex diseases, will require much more care but also use more resources and services. It is not only value for money, but improved patient experience and patient outcomes. How will the commissioners be encouraged to do this? Does the Minister think that three separate outcomes frameworks in health, social care and prevention will help or hinder integration of care? There is also an issue about who will lead this change, if we think that this is the key challenge in the Bill. I agree that putting a clear definition of what we mean by integration, or what a patient means by integration, into the Bill will give a clear message to all those who commission and deliver the care, to know exactly what they have to do.
Baroness Pitkeathley
My Lords, my name is on Amendment 332. As other noble Lords have said, the Committee hardly needs reminding of our previous debates about the integration issue, or of the importance of health and well-being boards to the interests of patients. It is too easy, as the noble Lord, Lord Warner, has reminded us, for those delivering care to think that they are delivering an integrated service, because they are talking to each other—although it is not as common across services, in fact, as we might like to think—or because they are making joint plans, or they have made some kind of structural change, to give a nod to integration. What matters is how the services are received. Are they received by the patient in a way that is coherent and co-ordinated to the patient and to their family and carers?
The services will be delivered by a variety of providers—more, it seems to me, than the two arms the noble Baroness, Lady Murphy, reminded us about; that is, not only by health and local authorities but also by third sector organisations, particularly for those with long-term and chronic illnesses; by charities, by social enterprises and of course across the private sector. However the health and well-being boards end up being constituted in a particular area, it seems to me that some of the members at least will be patient representatives. They will be in an ideal position to monitor the patient’s response to service delivery and that it is indeed being integrated across all those services. It is very good news that the Future Forum is now working on integration. Will the Minister assure the Committee that the report, which I think he said would be available in January, will be available to the House by the time of our Report stage?
Baroness Barker
My Lords, my name is not on these amendments, but I want to make a couple of points, partly because I have a longstanding interest in this and partly because in recent weeks it has been a very personal feature in my life.
The noble Lord, Lord Warner, is absolutely right to keep pressing the Government to come up with a definition of integration. Like him, I struggle to know what it is. I know the factors that should be focused on, which create or prevent integration. One is the overall sense of purpose in your work. For many of the health and well-being boards, the key role will be in the prevention of illness. The biggest challenge for hospitals and the acute sector, which perhaps they have not yet woken up to, in the way in which they are going to have to work with health and well-being boards is about discharge from hospital and ensuring that people who have been ill, particularly older people, have access to nursing care in the community that enables them to live with long-term conditions.
One of the most important factors is money. The noble Baroness, Lady Murphy, made me flash back to many a meeting that I have been involved with, but one in particular in a borough in south London where the local Age Concern had an excellent handyperson scheme. They worked with the OTs to dramatically speed up the process of older people being assessed and given aids and adaptations that enabled them to live with long-term conditions. I well remember sitting in the meeting when somebody from the health service announced that the health service were going to start their own rival service. Why? Because a pot of money had come along and they were going to use it. Patterns and flows of money have been the bedevilment of integration, very often.
Integration can work well, particularly when both parties take a strategic view of what they are supposed to be doing. I cite again the case in Islington, when my colleagues were running the council. The local authority took the decision that it would do everything related to children and the PCT decided that it would take responsibility for adults and long-term care. That is a very imaginative way to start addressing problems at a strategic level. If you address them properly at strategic level, the greater the chance that when it comes to individual cases, you will indeed get integration of services around a person.
I am therefore pleased to see Amendment 336, tabled by the noble Lord, Lord Warner. I would just query one point with him on drafting. As drafted, there is a slight problem, because it seems to imply that any move towards integration has to be approved by the commissioning board. I know that is not what he intends. Small-scale schemes should just go ahead without reference up the line, so I think he needs to look at the wording, but that is very helpful.
The noble Lord, Lord Patel, is absolutely right. Three different outcomes frameworks setting the agenda for the three different parts of what will make up a health and well-being board is wrong. It is only when people in the NHS understand that they have to help social care outcomes to happen that we are really going to move forward towards integration as a mindset for professionals and a reality for patients.
Lord Warner
Could I just clarify for the noble Baroness that I do not claim that my wording is perfect? I brought the National Commissioning Board in—slightly against my better judgment, I have to admit—because it has the responsibility for, in a sense, approving the commissioning arrangements and spending the money. My instincts were that it would not support this unless it had been consulted and was satisfied with the commissioning arrangements.
Baroness Thornton
My Lords, I will be very brief because my noble friend and other noble Lords have pretty much covered the territory here. This small group of amendments is rather important and significantly improves the Bill. I realise that they are probing amendments, but they do three things. The first amendment is about changing culture. It talks about the manner of the integration of services, not just an integrated manner. The second one says that we need to define integration. This must be perhaps the third or fourth debate that we have had on integration in the past however many weeks. It seems quite clear that there needs to be some definition of integration in the Bill. My noble friend Lord Warner explained that. Given that many parts of the Bill offer a list of different ways in which things can be described and done, I see no reason why the same list on integration cannot be included. The third point in the amendment to which I was pleased to be able to put my name is about encouraging co-operation across the piece. Having the national Commissioning Board mentioned in that is rather important.
Those three points about changing the culture, defining what you mean and encouraging co-operation seem to me to be the type of message that any health and well-being board will look to as it starts up its work. It will look to what is in the Bill, what is in guidance and what is in statutory instruments to help it to work out what to do. To have something that defines the kind of culture that is expected, defines integration and the way the bodies should work, lists the bodies that should work together, if not in the Bill then certainly in guidance, and explains the manner in which they are expected to work seems to me to be a very helpful way forward.
Earl Howe
My Lords, these amendments from the noble Lord, Lord Warner, are primarily concerned with strengthening the role of health and well-being boards in promoting integration between health and social care and wider aspects. I completely understand why noble Lords have felt moved to support these amendments. They are undoubtedly well intentioned, but I am afraid that I have a problem with them.
Amendment 336, which I will speak about more fully in a second, could be seen to enable changes to be made to the fundamental responsibility for functions, which we are clear would not be right. Amendments 332 and 335 would also introduce a prescriptive definition of integration. I resist that idea not just because it would be counter to the principles of localism, which we believe are very important, but because it could act as a diversion from effective integrated working between commissioners. I do not see the need for a definition beyond what the clause already says, which seems quite clear.
We have a shared intent on the importance of integration, but I cannot agree that this cause would be aided by pinning down a definition in primary legislation. I see no need for that. Apart from anything else, having a definition set in primary legislation would risk creating inflexibility as times and practices change. We should focus on removing barriers on the ground to ensure integration. That is where the Government’s response to the Future Forum’s work will, I hope, make a difference. We aim to publish our response to the Future Forum’s report before the Report stage of this Bill.
I am sure that Amendment 336 is intended to be helpful, but it might create confusion between the arrangements mentioned in the amendment and those made under Section 75 of the NHS Act, which would enable local authorities and CCGs to enter into partnership arrangements such as lead commissioning and pooled budgets. Existing provisions in the Bill are designed to encourage and enable the NHS and local government to improve patient outcomes through more effective co-ordinated working. The Bill provides the basis for better collaboration, partnership working and integration across local government and the NHS at all levels. I hope that that, in part at least, answers the question posed by the noble Lord, Lord Patel.
Indeed, health and well-being boards will have a strong role in promoting joined-up commissioning between health, public health and social care. Through their duty to promote integrated working between commissioners, they will also be in a good position to promote more integrated provision for patients, social care service users and carers. They will also be able to encourage close working between the commissioning of social care, public health and NHS services and aspects of the wider local authority agenda that also influence health and well-being, such as housing, education and the environment. Through statutory guidance on preparing the joint health and well-being strategy, and the Government’s mandate to the NHS Commissioning Board, we will be encouraging lead commissioning and integrated provision.
There are enough levers and mechanisms in the system to encourage every part of the system to look for ways of joining up services, and the commissioning of those services. I hope that I have reassured noble Lords of our intentions, and that the noble Lord feels able to withdraw his amendment.
Baroness Thornton
If a new health and well-being board got in touch with the Minister, or perhaps with the Commissioning Board, and asked whether it would please say which form of integration it should be using or how it should be doing this, would he tell it to work it out for itself?
Earl Howe
My Lords, we have to give credit to people on the ground to be the professionals that we know them to be. Integrated working can take many forms, as we have discussed quite often in Committee. I will not rehearse the various manifestations of integration. Once we have mandated the duties in the Bill and issued statutory guidance on what good practice looks like, I really think that it will be up to people on the ground to decide how best to set about fulfilling the duties and expectations placed on them.
Baroness Williams of Crosby
I will pursue for a minute mechanisms for an early decision. I do so because the health and well-being boards will obviously be new and will be moving into a relatively new structure in their relationships with the medical and clinical CCGs, and they might not realise that this could happen rather quickly. No one is thinking of laying down the law, but a mechanism under which they are reminded that this could arise quite suddenly at an early stage and that they therefore need a structure that enables them to react quickly is an important feature of what the noble Lord, Lord Warner, was arguing.
Earl Howe
This is exactly why we have established the early implementer health and well-being boards. These cover virtually the entire country; a very small number are not yet in existence. I can tell my noble friend that local authorities have seized this opportunity with alacrity and are getting to grips with just the kind of issues that she has in mind.
We have a lead-up time available to enable the boards to consolidate the learning that is undoubtedly going on and the dialogue that is taking place with the pathfinder clinical commissioning groups. We are supporting that process from the centre. I hope and believe that by the time the health and well-being boards go live they will be in a very good position to hit the ground running.
Lord Warner
My Lords, I am grateful to all noble Lords for the support that they have given, and indeed am gratified by it. I hear what the Minister says, but we have been talking about integration for 25 years. You have to be one of life’s supreme optimists to think that just because the Government have passed this Bill you are going to change the culture of 25 years. It is very important that we try to have a go at a definition in this Bill. I will read very carefully what the Minister has said but I can assure him, as a Christmas present, that I shall be returning to this subject on Report, after taking some soundings at the local level. He is quite right: we do need to be sure what people at the local level want, but I do not think that we can move away from trying to give a lead on what we mean by integration. In the mean time, I beg leave to withdraw the amendment.
“Health Service Ombudsman for England and Health Service Ombudsman for Wales
All patients receiving care from an organisation that receives any funding from the NHS shall have the right of complaint to the relevant health service ombudsman.”
Baroness Finlay of Llandaff
My Lords, this Bill in vast part concerns England only. This amendment concerns both England and Wales. I have tabled it to try to clarify an area in the role of the ombudsman which is currently not clear. Having spoken to the ombudsman in Wales at length about this, and discussed it with the ombudsman in England, with the emergence of any qualified provider and a range of licensed providers in this system, it seems that there is a need to clarify the role of the ombudsman, to make sure that patients have a final port of call when the complaints system has failed them.
I will quote from the Complaints and Litigation report of the House of Commons Health Committee from the previous Session. It states:
“Many people see the role of the Ombudsman as a general appeals process for the complaints system, but the remit under the Health Service Commissioners Act is much narrower than that. The Committee is of the view that a complainant whose complaint is rejected by the service provider should be able to seek independent review. The legal and operational framework of the Ombudsman’s office should be reviewed to make it effective for this wider purpose”.
The Health Service Commissioners Act 1993 set out the principle that the ombudsman should be able to investigate an issue if the provider was providing services,
“under arrangements with health service bodies or family health service providers”.
The Public Services Ombudsman for Wales was established in 2005, and also has a responsibility for cross-border work. Last year, however, there was an investigation into a children’s hospice in Wales which revealed the ombudsman’s difficulty when investigating an organisation that provides services for and on behalf of, and receives funding for providing services to, patients in an area but which does not fall under the NHS jurisdiction in any way, and simply has a contractual service-level agreement. The report from the ombudsman in Wales states:
“The Ombudsman does not have jurisdiction for the hospice and was unable to investigate Mr & Mrs A’s concerns about the hospice’s actions”.
It goes on to say:
“The Ombudsman commented on his lack of jurisdiction for the hospice, and that there was no other independent body able to investigate Mr & Mrs A’s concerns about the hospice. This is profoundly unsatisfactory. The Ombudsman asked the Welsh Assembly Government to consider what action it could take to bring the hospice into his jurisdiction”.
Hospices are just one area of provision. They are well known, and it is very unusual for there to be complaints in hospices. However, they do occur, and it seems that those using the services of any independent provider in such a way should have the same right of redress as if they were in an NHS facility. The purpose of the amendment is to simply clarify that wherever a patient is being treated, if the NHS has any interest whatever—if this patient is being treated as part of an NHS provision —it should come under the remit of the ombudsman to investigate should the ombudsman feel it is warranted.
I looked back through the report of the Health Service Ombudsman for England and noted that there were 325 complaints last year that did not fall into the remit because they were for privately funded healthcare. This amendment does not ask that the ombudsman’s report should necessarily cover privately funded healthcare. In all honesty, however, if somebody is receiving healthcare, however it is funded, and if that is part of our licensed, inspected and regulated system in this country, where it goes seriously wrong and those bringing a complaint feel it has not been handled satisfactorily, my own view is that we have a national duty to be able to investigate. In doing so, we may find that our inspection processes have failed and that our regulatory processes are not functioning as they should.
That is the background to what might seem a very simple amendment. I really hope the Government will look kindly on it, because having discussed it and its wording in detail with the ombudsman in Wales, I know that it is certainly supported there. I also know that it is not opposed by the ombudsman in England.
Baroness Williams of Crosby
My Lords, the combination of the noble Baroness, Lady Finlay, and the noble Lords, Lord Walton of Detchant and Lord Wigley, is a pretty powerful triad by any standards. I express my support for what the noble Baroness said. We have seen some remarkable work done by the ombudsman for England—who I think is retiring from her post—particularly in respect of the care of elderly people. It has been very important in giving the public a sense that they have access to the highest levels when they have a complaint.
My only concern about this amendment is that it is very important indeed that as far as possible complaints are dealt with by health and well-being boards locally, because very often local knowledge is crucial in understanding why something has gone badly wrong. I always think it is significant that the ombudsman for England has been most effective when she has written reports that cover an area. When it comes to a personal complaint, very often it is the local level which is the appropriate one to deal with it. More than that, very much part of the education and understanding that a health and well-being board can bring to the whole issue of patient responses and patient care in the NHS is that people should at least see the local level as the first point of complaint. Having said that, it is obviously important that there is a final, as it were, court of appeal —I do not mean that in a legal sense of the word —and that is what the ombudsman ought to be. Clearly he or she should be independent of any particular interest in the health service, and I agree with the noble Baroness, Lady Finlay, that it should apply across the board to all providers whether private, voluntary or within the NHS structure.
With those few words, I support the amendment and think it is an important one. However, I emphasise that the starting point should always be, wherever possible, at the local level, and that the ombudsman should be seen as the last and final resort.
Baroness Wheeler
My Lords, I support this amendment from the noble Baroness, Lady Finlay, and I am grateful to her for explaining its context and background so clearly. The Parliamentary and Health Service Ombudsman is currently excluded from investigating complaints about the health service in Wales, so this amendment will ensure that the role of the Public Services Ombudsman for Wales, in investigating complaints against local health boards, NHS trusts, GP services and community health councils in Wales, is recognised and included in this Bill.
Ensuring that the Public Services Ombudsman for Wales has the legal right to share complaints reports with people he or she considers appropriate is a minor but important amendment and safeguard. I look forward to the Minister’s response.
Baroness Northover
My Lords, the amendment links to an important point of principle which we wholeheartedly support: that any patient or person who receives NHS-funded treatment or care, whether the treatment or care was provided by an NHS or private provider, should have recourse to the Health Service Ombudsman, should their complaint not be resolved through the NHS complaints arrangements at a local level. I assure my noble friend Lady Williams that that is the first stage.
I reassure noble Lords that these types of situation are already provided for in law. I wish to address directly what the noble Baroness, Lady Finlay, has raised, which is the situation in Wales. The Public Services Ombudsman for Wales recently called for his office to be given more power to independently investigate hospices. This follows complaints from the family of a teenage girl who died of leukaemia, about the way their concerns over her care were handled. The ombudsman pointed out that he had no power to investigate the family’s complaints against the hospice, although it received public funds, as it did not fall into the same category as a hospital or a council-run service.
In response to a report published by the Public Services Ombudsman for Wales in 2011, we understand the Welsh Government are looking into extending the ombudsman’s remit, to enable him to investigate complaints about hospices and hospice services, as well as extending the existing complaints advocacy arrangements to cover complaints about hospices.
I therefore hope that the noble Baroness will be reassured by what I have been able to say, in that regard.
Baroness Finlay of Llandaff
I seek a little clarification. If I have understood right, the noble Baroness said that any provider is covered by the Health Service Ombudsman in England, and any cross-border provision would also be covered by the Public Services Ombudsman for Wales, irrespective of who that provider is. Therefore, the only change needed in primary legislation is to the remit of the Public Services Ombudsman for Wales, to make sure that the remit for non-NHS providers is extended within Wales; but that otherwise all patients, wherever they are in England, wherever they have come from and irrespective of the provider, have recourse to the NHS ombudsman. I suppose the same should apply to Scotland as well, though there is not the same cross-border flow.
Baroness Northover
To clarify, I say that all care paid for by the NHS in England is covered—that is the crucial thing. My noble friend Lady Williams also mentioned other care that might be covered. Whoever provides the care, the crucial thing is who pays for the care. Even if there is a private provider or a voluntary provider as well as an NHS provider, if the NHS is funding that care it comes under the ombudsman’s responsibility.
Baroness Finlay of Llandaff
I do not want to detain the House much further, but I think this is something we need to discuss, and probably away from the Floor of the House. One of the issues about hospices is that their care is not fully funded by the NHS: it is only partly funded. Some providers receive grants to provide care because they are mostly charitably funded, partly NHS-subsidised and helped—but it is not that the NHS is paying for that complete package of care. That is where the confusion and the difficulty lie. It would be helpful if we could unpick this later and see whether we need to return on Report with a very small amendment, so that we can make quite sure that the system is watertight for all patients.
Baroness Northover
I am very happy to take up the noble Baroness’s suggestion that we discuss this further. I hope she will be reassured by what I can say about Wales. However, if there is a company, for example, that is providing care partly within the NHS funding, the ombudsman would not cover the rest of what they are doing. It could lead to confusion if that were the case. I mean the NHS-funded part of care. However, I am very happy that we should discuss this concern further. I hope that on that basis the noble Baroness will be willing to withdraw her amendment.
Baroness Finlay of Llandaff
I am grateful to the Minister for that reply. On the basis of that and of further discussions, I beg leave to withdraw the amendment.
Lord Clement-Jones
“Power to regulate pharmacists
(1) The Medicines Act 1968 is amended as follows.
(2) After section 58(6) there is inserted—
“(7) Subsection (2)(a) does not apply to the sale or supply of a medicinal product by a person lawfully conducting retail pharmacy business where the sale or supply is in accordance with a prescription and, having exercised all due diligence, believes on reasonable grounds that those requirements have been fulfilled.
(8) The activity under subsection (7) shall be regulated by the General Pharmaceutical Council.
(9) The General Pharmaceutical Council may take what steps it considers necessary under section 6(1) of The Pharmacy Order 2010 (S.I. 2010/231) in relation to a person who performs an activity referred to in subsection (7).”
(3) After section 64(5)(b) there is inserted—
“(6) Subsection (1) does not apply to the sale or supply of a medicinal product by a person lawfully conducting retail pharmacy business where the sale or supply is in accordance with a prescription and that person selling or supplying the product, having exercised all due diligence, believes on reasonable grounds that those requirements have been fulfilled.
(7) The activity under subsection (6) shall be regulated by the General Pharmaceutical Council.
(8) The General Pharmaceutical Council may take what steps it considers necessary under section 6(1) of The Pharmacy Order 2010 (S.I. 2010/231) in relation to a person who performs an activity referred to in subsection (6).”
(4) After section 85(5) there is inserted—
“(6) Subsection (1)(a) to (c) does not apply to the sale or supply of a medicinal product by a person lawfully conducting retail pharmacy business where the sale or supply is in accordance with a prescription and that person selling or supplying the product, having exercised all due diligence, believes on reasonable grounds that those requirements have been fulfilled.
(7) The activity under subsection (1) shall be regulated by the General Pharmaceutical Council.
(8) The General Pharmaceutical Council may take what steps it considers necessary under section 6(1) of The Pharmacy Order 2010 (SI 2010/231) in relation to a person who performs an activity referred to in subsection (6).”.”
Lord Clement-Jones
My Lords, the amendment has been tabled with the support and assistance of the Royal Pharmaceutical Society and has been designed as a new clause that amends the Medicines Act 1968. It is also designed to increase patient safety by removing barriers to a learning culture across the prescription dispensing process, and to remove the injustice that pharmacists alone, among healthcare professionals, face through criminalisation. Single dispensing errors should be treated in a proportionate way that retains the ability to prosecute those who have been negligent or who have committed a deliberate act but that does not penalise pharmacists who wish to declare a dispensing error in the interests of patient safety.
The role of pharmacy continues to be vital to communities throughout England. Pharmacists are at the forefront of providing advice to patients in an increasingly high-pressure environment. In 2010 nearly 927 million prescription items were dispensed in England. This is a 4.6 per cent rise on 2009 and a 67.9 per cent rise on 2000. Despite this, the error rate of dispensing remains minuscule.
What is the background to the current state of the law? Sections 58, 64 and 85 were inserted into the Medicines Act 1968 to regulate the quality of medicinal products being manufactured in pharmacies across the country. There were concerns that the production of these items, primarily creams and solutions that could be prepared to suit to individual needs of patients, required a legal standard of purity. Nowadays, the practice of creating preparations in community pharmacies is practically non-existent. However, these sections of the Medicines Act have been used in a way that they were not originally intended for: to prosecute a pharmacist who makes a single error while dispensing a medicinal product. The law as it stands makes a single error an automatic criminal offence that is punishable by up to two years in prison.
Why should we support this amendment? Currently, pharmacists are expected to declare dispensing errors in the knowledge that they will face prosecution if they do not do so. Clearly, any person who is either wilfully negligent or deliberately acts in a way to harm a person must face prosecution under criminal laws. This amendment would allow that to continue but would also enable a proportionate response for those who make an error. Minor errors should be learnt of and dealt with through improved practice rather than through discouraging healthcare professionals from feeling able to report errors. Decriminalising dispensing errors will be beneficial to patients and the pharmacy profession through the creation of a culture of learning.
The current system goes against the spirit of openness in which pharmacists and other healthcare professionals should be allowed to work, so as to enhance patient safety. This amendment, or something similar, is the right way in which to tackle this important issue. The passage of the current Bill presents an opportunity to tackle this, and one that should not be missed. I beg to move.
Baroness Finlay of Llandaff
My Lords, I support the amendment. It raises a very important issue, namely what happens when an error occurs. At the moment, there is an enormous disincentive for the pharmacist to do what one would say is the right thing, which is immediately to contact the patient, or their family, carer or nursing home, to try to put an immediate stop to the further use of that medication and to do all they can to correct the error. In the law as it is written at the moment there is an in-built incentive to a pharmacist to attempt a cover-up, to weigh up whether the error is a major or minor one or one which they might just get away with, or perhaps even to make a phone call that fudges the issue and tries to cover up the fact that they have made a dispensing error, and to reclaim the medication in another way.
In addition to the importance of a spirit of openness, there is an actual safety issue here. We know from looking at medicine and nursing that when you make it easier for people to admit immediately that they have made an error and to do all they can to correct that error, they are much more likely to handle things in an open and honest way and to learn from it. Certainly I say to all my junior staff, “I know that you will make mistakes. The only thing that I will hold against you for the whole of your career is if you do not immediately notify whoever is the consultant covering you at the time. Mistakes will happen, but you must let people know immediately and take every step to correct them”. I do not see why we should be treating pharmacists in law in a way that works against that type of principle and which is inappropriately punitive.
Baroness Pitkeathley
My Lords, I, too, support this amendment. I remind the Committee of my role as chair of the Council for Healthcare Regulatory Excellence, which has an oversight role with the General Pharmaceutical Council. We believe that single dispensing errors should be treated in a proportionate way that still prosecutes those who have been negligent or have committed a deliberate act but does not penalise pharmacists who want to declare a dispensing error in the interests of patient safety—and I very much agree with the noble Baroness, Lady Finlay, that this is about patient safety.
In the interests of patient safety and public protection, we of course expect the regulator to be able to co-operate with other agencies if it is aware of a pattern of repeated single-dispensing errors that might reflect wilful and deliberate acts with the intention of harming patients. In those circumstances, there would of course still be recourse to criminal prosecution. With these exceptions, I very much support this amendment.
Baroness Jolly
My Lords, I, too, support this amendment. I have some personal experience that I can bring to bear, and it was not until I was reading through the amendments a week or so in advance that I put these things together. Some years ago my mother became really ill with a very strange set of symptoms and no one could work out what the problem was. Eventually her GP came round. Like many people of that age, she takes several drugs. He sat down on her bed, took out her box of drugs from her bedside table drawer and went through them. There was one drug that she should not have been taking at all. It was completely wrong and should have been taken sparingly, not three times a day. My mother lives in a small town and the GP knows the pharmacist well, so he high-tailed down to him straightaway to find out what exactly the issue was. In this case, the dispensing pharmacist was unaware that there was a mistake.
It was really quite interesting to see how it had all happened. The medicines were all stored on a shelf in alphabetical order by drug name, not brand name. The drug in question was adjacent to my mother’s normal drug, and both were generics produced by the same pharmaceutical company. The narrow little rectangular boxes looked the same, so the pharmacist had picked the wrong one off the shelf, popped it into the bag with the rest and it had gone home. My mother, whose sight is not what it was, had taken them all out of their boxes and popped them all into her pill box. The deal was done, it was really very easy, and the whole thing was completely indistinguishable.
Fortunately my mother recovered once it was sorted out. It was a regular, well-known, high-street pharmacy, and it was absolutely excellent. It wrote a letter immediately saying that it was going to instigate a clinical governance review. It then wrote again to tell us exactly what it had done, including changing its methods of storage and ensuring that someone double-checked all drugs before they were bagged-up. This had been a mistake, but there is absolutely no doubt that it was completely negligent, and also avoidable. However, it was not criminal. There was no malicious intent. It could have been terrible, but mercifully it was not. The employer spoke to the pharmacist who admitted exactly what she had done once they had worked it all out. The pharmacy took proportionate discipline, and that is what we as a family wanted. We wanted something to happen, for it be arranged that the mistake could not happen to anyone again and for anything that happened to be professional and proportionate. That is what happened. As a result, I totally support the amendment that my noble friend has tabled with the support of the Royal Pharmaceutical Society.
Baroness Masham of Ilton
My Lords, I shall add a few words because a pharmacist contacted me. Pharmacists are being encouraged to take on more and more, and the drugs are extremely difficult. Some drugs are the same but have different names. It is extremely difficult for patients too, and as they often go to pharmacies for advice it is really very important there this is openness and honesty when a mistake is made. However, I would not like this amendment to open a door for more mistakes to be made.
Baroness Thornton
My Lords, I support the amendment. I would have put my name to it, had I had the opportunity. However, in Committee those on the Liberal Democrat Benches have tended to block up their own amendments and have not sought support from across the House, which is a great pity.
My experience in dealing with the many drugs that my mother takes is that in fact pharmacists are often those who spot the doctor’s mistake. Our local pharmacists do an excellent job. My wider interest in this Bill and in pharmacists is that they play the proper, important role they need to play at local level in the health and well-being boards and with the planning at a local level of both preventive medicine and their jobs at dispensing.
This is also about a level playing field in regulation, which is very important. This Bill offers probably the only opportunity that there will be in the next few years to put right this wrong. I hope, therefore, that the Minister will support this amendment—and if not this one, then one like it at a later stage in the Bill—and rectify this error.
Earl Howe
My Lords, the amendment relates to an important issue: the concerns among pharmacists about the risk of prosecution where they normally follow good professional practice but make an inadvertent dispensing error. I am very grateful to my noble friend for raising this issue. I warmly welcome the opportunity to discuss it and have been listening carefully to the points made.
We are on the record as saying that we intend to take legislative action to address the issue. We want to see a learning culture that encourages the reporting of dispensing errors so that any helpful lessons can be learnt. The noble Baroness, Lady Finlay, was quite right about that. However, we need to make any changes in ways that continue to protect patients under the law. The noble Baroness, Lady Pitkeathley, drew our attention to that aspect.
Section 64 of the Medicines Act 1968 provides that,
“No person shall, to the prejudice of the purchaser, sell any medicinal product which is not of the nature or quality demanded by the purchaser”.
This is a strict liability offence, and contrary to what my noble friend stated it does not relate only to pharmacists. Various other healthcare professionals could be affected, as well as other parties who are not subject to professional regulation. Guidance issued to government prosecutors in 2010 has been helpful, but we recognise that it does not remove the underlying problem.
My noble friend is to be commended for raising this issue, but the terms of the proposed amendment present a number of problems that we would need to work through before an appropriate drafting solution could be found. It does not cover other healthcare professionals affected by the current legislation, and in relation to pharmacy it covers only a proportion of pharmacy activity—retail pharmacy—and only where a pharmacist is responding to a prescription. The amendment does not address the different arrangements for the professional regulation of pharmacists that apply in Northern Ireland. There is also some ambiguity as to how it would be determined in practice: that is, whether a pharmacist would be subject to the revised provisions in this amendment. The amendment extends beyond Section 64 and would also change Section 58, on prescription-only medicines, and Section 85, on the labelling of packages and containers of medicinal products, of the Medicines Act 1968.
The legislative ramifications of the issue are therefore quite complex, and I am sure my noble friend will appreciate that we need to get this right. However, let me assure him that we have listened very carefully to the debate and the representations made to us, and that we will continue to work with all relevant parties to find a solution. I also wish to reiterate our commitment to bring forward a suitable legislative change at the earliest possible opportunity. I hope that with those assurances my noble friend will feel able to withdraw his amendment.
Lord Clement-Jones
My Lords, I thank the Minister for his response. I also thank all noble Lords and noble Baronesses who have spoken in the debate. I should at the outset have declared an interest as chairman of the council of the School of Pharmacy. My noble friend the Minister has pointed out, quite rightly, that the amendment as drafted only covers the pharmacy profession. He has also pointed out a point picked up by almost all the speakers in the debate, namely that the essence of the provision is the ability to admit and correct error, which is vital in these circumstances.
I welcome very much the forensic way in which the Minister responded to the amendment. I did not think that it was the kind of amendment that would cause Ministers to throw their hands up in the air and say, “Wonderful! We will put this in the Bill”. It needs refining. One of the key issues is that it currently only relates to retail pharmacy. Obviously, it should cover hospital pharmacy as well. There are also issues about Sections 58 and 85 in Northern Ireland.
The Minister has assured us that he has listened very carefully and that he intends to legislate at the earliest possible opportunity. That phrase was very carefully chosen, I am sure, as my noble friend always chooses his words extremely carefully. If the Minister would indicate that, if humanly possible, this will be inserted either on Report or at Third Reading—as the Bill provides a very good opportunity to include reform—I think that the pharmacy profession and others which, as he said, are subject to this kind of disproportionate criminal liability will be extremely happy. I am sure that they would be very grateful to the noble Lord if he could make sure that that was the case. The Minister is not indicating that he is going to say anything further—but maybe he will.
Lord Clement-Jones
My Lords, the Minister chooses an even more felicitous phrase. I thank him, and I look forward to further progress during the course of this Bill. In the mean time, I beg leave to withdraw the amendment.
Baroness Emerton
“Power to regulate health care support workers in England
(1) The Nursing and Midwifery Order 2001 (S.I. 2002/253) shall be amended to provide that all health care support workers in England shall be registered by the Nursing and Midwifery Council and regulated in accordance with the terms of that order.
(2) For the purposes of subsection (1), a health care support worker shall be an individual whose work is routinely delegated to them by a registered nurse or midwife or has a qualification in health and social care at level one (or higher) of the Qualifications and Credit Framework, in England.”
Baroness Emerton
My Lords, I shall speak to this amendment in my name on the power to regulate healthcare support workers, which is supported by the Royal College of Nursing. I begin by declaring an interest: I am a retired nurse, nurse tutor and manager; former chair of the nursing, midwifery and health visiting regulating body, the UKCC; and past chair of an NHS trust.
I start by looking back to the Bill’s beginning and its aim to improve the quality of patient care at every level of the NHS and to integrate social care, providing holistic care with clearly defined care pathways. The three constituents, as we know, to improving care are improving clinical outcomes, the safety of the patient and a good patient experience. The current situation is that, almost daily, a report is made of essential care being below an acceptable standard, or of poor hygiene, poor hydration, poor nutrition and poor personal care, with staff not even washing patients, making them comfortable or listening to their immediate anxieties. Where healthcare support workers move into areas of work beyond their competence, questions have to be asked about the safety of patients. For example, if a healthcare support worker is left to give drugs without supervision, this is an unsafe practice and a danger to the patient. The responsible person is the registered nurse, who is accountable for delegating any area of practice to the healthcare support worker.
However, the growth in numbers of healthcare support workers dates back a long way and those numbers continue to rise. Over time, there has been a variation of titles, roles and functions, and there have been calls for regulation by the Royal College of Nursing since 1999, when Project 2000 was introduced and the enrolled nurse training was phased out. The reason given for phasing out this training, and the case for change in moving nursing to higher education, was that the rapid developments in medicine and technology led to a need for registered nurses to have a more detailed knowledge to equip them to be fit to the level of practice required—that is, to have a degree qualification. Holistic care of patients demands a correlation of knowledge and practical application that meets the total physical, mental and spiritual needs of patients, their relatives and friends.
Degree courses contain 50 per cent theory and 50 per cent supervised practice. Enrolled nurses had played a very important part in the delivery of care, but they were being abused and misused by being placed in charge of acute wards at night, and taking on roles that their training had not equipped them for. We face the same situation today, where healthcare support workers are abused and misused by being expected to take on roles they have not been prepared for, and are left unsupervised.
This raises three important issues. First, there is the role of the registered nurse, who dedicates and supervises the healthcare support worker. The problem is that if there are not enough registered nurses to supervise, then they become unsupervised. We know from the recent inquiry into Mid Staffs that in order to change the finance situation there, the ratio of registered nurses to untrained nurses was reversed from 60 per cent trained to 40 per cent untrained, to 40 per cent trained and 60 per cent untrained, leaving the registered nurse with a much larger task in supervision.
The role parameters within which the healthcare support worker works, and the preparation they have had, need to be looked at. Who sets the code of conduct—the employer, or the profession of nursing, midwifery and social care? Recent inquiries into failing healthcare systems have pointed to a range of causes, from trust boards and their executive and non-executive members, to the bedside and the delivery of care—that is, registered nurses and unregistered healthcare support workers.
The most recent inquiry was at Mid Staffordshire, which I have already mentioned. Not only was an inquiry held to identify the failings; there was a further inquiry, on the demand of the public, to discover the root causes. Events this year at Winterbourne View, a unit for those with learning disabilities, resulted in a number of healthcare support workers being arrested, and a registered nurse went before the NMC for a hearing on fitness to practise. Inquiries in the 1960s at Ely, Farleigh, Whittingham, Normansfield, and more recently at Stoke Mandeville and Maidstone and Tunbridge Wells trusts, all demonstrated failing systems of care delivery, the involvement of all levels of care staff, and an overall lack of leadership from the board to the bed in maintaining delivery of high-quality care.
How can Her Majesty’s Government allow the NHS to continue a system that has been proven to fail? The public and patients deserve—and have the right to expect—high quality and safe delivery of care. The Royal College of Nursing has been pressing the Government since 1999 to address this issue, and it continues to do so, recognising the complexity of the issue and that there have been some attempts to rectify an unsatisfactory situation. The chairman of the Royal College of Nursing healthcare support workers group sat in on the debate on front-line nursing on 1 December in this Chamber, and pleaded with me afterwards to ensure that regulation of support workers would be taken on by Her Majesty’s Government.
The way in which the assistant nursing practitioner level 4 healthcare support worker has been introduced under Agenda for Change has identified and clearly set out the role parameters within which a healthcare support worker can work under the supervision of a registered practitioner, having reached a recognised but not regulated standard. However, this accounts for only a small number of the total healthcare support workers employed in the hospital and community setting. Further work could easily lead to mandatory training and registration by opening the second part of the Nursing and Midwifery Council register for this clearly identified group. That has been suggested in this House several times.
Baroness Masham of Ilton
My Lords, I have put my name to Amendment 338, as I strongly agree with the Royal College of Nursing that mandatory regulation for all healthcare support workers, in order to ensure standardised training and therefore a suitable skilled workforce, is the best way forward.
As currently proposed, the health Bill provides for a voluntary register, which the RCN believes to be insufficient. A voluntary register will not protect patients from inadequate healthcare workers, who will be impossible to regulate. I am concerned that nurses who have been struck off the register can then take jobs as unregistered healthcare assistants. One only has to look at the dangers patients have been put in when patients died of insulin poisoning at Stepping Hill Hospital near Manchester and nurses were found to be stealing drugs, at the terrible suffering of patients at the Mid Staffordshire foundation trust and at the appalling treatment of residents at the Winterbourne View care home near Bristol. The latest reports from the Audit Commission, the Patients Association and the CQC highlight further problems with care of the frail and elderly. Is there not enough evidence to make the Government realise that something positive has to be done to make matters safer and better for patients?
I agree with the Royal College of Nursing that it is vital to quality patient services that anyone who is responsible for delivering care should be regulated and accountable for their actions. I received a letter recently from someone living in Malta, who said that in the state hospitals they have colour-coded uniforms for all the staff. Care assistants are clearly distinguishable in maroon and white. We have to get our house in order for the sake of patients, who seem to be becoming more and more vulnerable, rather than safer.