The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House, I shall now repeat a Statement made earlier today by my right honourable friend the Secretary of State for Health in another place on the subject of the Secretary of State’s report to Parliament on the health service, the Secretary of State’s mandate to the NHS Commissioning Board and the NHS Constitution. The Statement is as follows:
“With permission, Mr Speaker, I would like to make a Statement about my first annual report to Parliament on the health service, published today, alongside the report on the NHS Constitution and the draft mandate to the NHS Commissioning Board.
This year, the NHS has made major progress in the transition to a new system, one based on clinical leadership, patient empowerment and a resolute focus on improving outcomes for patients. In a year of change, as the annual report shows, NHS staff have performed admirably. Waiting times remain low and stable, below the level at the election, with the number of people waiting over a year at its lowest ever level. Today, only 4,317 patients are waiting more than a year for treatment, dramatically lower than in May 2010. Nationally, all waiting-time standards for diagnostic tests and cancer treatment have been met.
The £600 million Cancer Drugs Fund has helped over 12,500 patients to access the drugs previously denied them. We have extended screening programmes, potentially saving an extra 1,100 lives from breast and bowel cancer every year by 2015. More than 90 per cent of adult patients admitted to hospital–around 260,000 every week–are now assessed for venous thromboembolism, a world-leading programme. In 2011 and 2012, 528,000 people began treatment under the expanded Improving Access to Psychological Therapies programme, up from just 182,000 in 2009-10, with almost half saying they have recovered. Following the success of the telehealth and telecare whole system demonstrator programme, including a 45% fall in mortality, we are on course to transform the lives of 3 million people with long-term conditions over the next five years.
The NHS is also improving people’s experience of care. Patients are reporting better outcomes for hip and knee replacements and for hernias. In the latest GP patient survey, 88% of patients rated their GP practice as good or very good. The outpatient survey shows clear improvements in the cleanliness of wards and patients reporting that they were treated with respect and dignity. MORI’s independent public perceptions of the NHS survey shows that satisfaction with the NHS remains high at 70%. Mixed-sex accommodation breaches are down 96%. MRSA infections are down 25% in a year, while C. difficile infections are down 17%.
Real progress, too, is being made in public health. More than 570,000 families have signed up to Change4Life. And our support for the school games and Change4Life sports clubs in schools is helping to secure the Olympic legacy. The Responsibility Deal has seen the elimination of artificial trans-fats, falling levels of salt in our diets and better alcohol labelling. By the end of the year, over 70% of high street fast food and takeaway chains will show calories on the menu. To drive forward research into key areas like dementia, I have announced a record £800 million for 11 National Institute for Health Research Centres and 20 Biomedical Research Units.
All of this and a million more people with an NHS dentist, every ambulance trust meeting their call response times, 96% of patients waiting for fewer than four hours in A&E, QIPP savings across the NHS of £5.8 billion in the first year of the efficiency challenge and NHS commissioning bodies delivering a £1.6 billion surplus, carried forward into this financial year. Yes, all of this and a new system taking shape. The NHS Commissioning Board has been established, health and well-being boards are preparing to shape and integrate local services and 212 clinical commissioning groups, managing more than £30 billion in delegated budgets, are preparing to lead local services from April next year. We are also starting to measure outcomes comprehensively for the first time. Far from buckling under pressure, with the right leadership and the right framework, NHS staff are performing brilliantly.
In addition to the NHS annual report, I am today publishing a report on the NHS Constitution. The Health and Social Care Act 2012 strengthens the legal foundation for the constitution, including a duty on commissioners and providers to promote and use it. This report, the first by a Secretary of State, will help commissioners and providers to assess how well the constitution has reinforced the principles and values of the NHS, the degree to which it has supported high-quality patient care and whether patients, the public and staff are aware of their rights.
I am grateful to the NHS Future Forum and to its chair, Professor Steve Field, for their advice on the effect of the NHS Constitution. I have asked them whether there is further scope to strengthen the principles of the constitution before a full public consultation in the autumn. Any amendments would be reflected in a revised constitution, published by April 2013.
Rooted in the values of the constitution, we will drive further improvement across the NHS through a set of objectives called the mandate to the NHS Commissioning Board. The draft mandate is also published today. The mandate will redefine the relationship between Government and the NHS, with Ministers stepping back from day-to-day interference in the service. Through the mandate we will set the Commissioning Board’s annual financial allocation and clearly set out what the Government expect it to achieve with that allocation, based on the measures set out in the NHS outcomes framework.
These include measures of quality, such as whether people recover quickly from treatment, and also people’s experiences, including whether they are treated as well as they expect, and whether they would be happy for family and friends to be cared for in a similar way. It will promote front-line autonomy, giving clinical commissioners the freedom and flexibility to respond to local needs—freedoms balanced by accountability.
Each year, the Commissioning Board will state how it intends to deliver the objectives and requirements of the mandate, reporting on its performance at the end of that year. The Secretary of State will then present to Parliament an assessment of the board’s performance. If there are particular concerns, Ministers will, for example, ask the board to report publicly on what action it had taken or ask the chair to write a letter setting out a plan for improvement. Today’s publication of the draft mandate marks the beginning of a 12-week consultation. I look forward to working with patients, clinicians, staff and other stakeholders to finalise the mandate in the autumn.
These documents show how a new exciting chapter is opening up for the NHS. Starting with strong performance and robust finances, we are driving towards integrated services and community-based care. It will be a new era based on openness and transparency, and focused on what matters most to patients—health outcomes, care quality, safety and experience. It will be an era in which every part of the NHS—the Secretary of State, the Commissioning Board, clinical commissioning groups and healthcare providers—is publicly held to account for what is achieved. For the first time, Parliament, patients and the public will know exactly how the NHS is performing locally, nationally and internationally. It will be a new era in which patients feel in control, clinicians lead services and outcomes are among the best in the world. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I would like to rise, as I usually do, to thank the noble Lord for his response, but I cannot do that on this occasion. The noble Lord must know that most of what he said was absolute rubbish. It sounded suspiciously to me like the words of his right honourable friend Mr Burnham in another place. In fact, I listened to Mr Burnham earlier and I thought that I recognised verbatim some of his turns of phrase in the speech that the noble Lord has just made.
I counsel noble Lords not to accept most of what the noble Lord, Lord Hunt, has just said about the performance of the NHS. He began by saying that the NHS has had two lost years, that we are engaged in an ideological experiment, and that there has been a loss of financial grip and wholesale closure of services. None of that is true. I am disappointed in the noble Lord because he is usually much more constructive and usually much readier to acknowledge the wonderful efforts of those who work in the health service and the achievements that they have brought to us throughout the year. I did not hear him mention those efforts and how grateful we all should be to those who work in the NHS for what they do for us.
I do not see in any of the figures that I read out the picture that the noble Lord presented to us. The NHS has delivered QIPP savings—that is part of the £20 billion Nicholson challenge that noble Lords will know about—of £5.8 billion. It is on track—this year the expected QIPP savings are £4.9 billion. The NHS delivered a surplus last year of £2.1 billion—£1.6 billion in the commissioning sector and £600 million in the provider sector. The commissioners’ surplus of £1.6 billion will be returned to them in full this year. To me, that is not a sign of financial strain. Yes, there are trusts that are reporting a gross operating deficit. How many are there? There are eight, in the entire country of England. Those, of course, are a matter of concern but we are working with those trusts to help them to resolve their difficulties—difficulties that very often originate from PFI deals set up under the previous Administration that were unsustainable. I am not decrying PFI as a tool or a lever, but the fact is that some of the business cases were very poorly founded.
The noble Lord asked whether we had instructed services to be rationed. I noted the other day the document published by the Labour Party on its NHS Check. What we have said is that PCTs should not make commissioning decisions on the basis of cost alone in deciding whether to commission a particular procedure. PCTs should consider the benefits of the procedure as well as the cost, but they could reasonably take a view that the evidence on a procedure suggests that it will not normally offer sufficient clinical benefit to justify its cost. That is nothing particularly new but it is very important. In other words, the resources involved may be better used in providing other treatments that have a greater impact in preventing or addressing ill health. No healthcare system in the world can afford to provide every possible treatment, irrespective of the evidence of whether it will do any good. The noble Lord is trying to paint a picture of the NHS denying treatment to people, while what it is doing is sensibly looking at what is value for money.
The noble Lord referred to patient satisfaction. When the public are asked to rate their satisfaction with services, their response may well be influenced by a wide range of factors. Our own polling of the general public, undertaken independently by MORI and published last month, shows that satisfaction with NHS is broadly stable at around 70%. Those are, by and large, people who have used the NHS recently. Of course we acknowledge that there is some disquiet among the public about the reforms to the NHS, which have indeed been misrepresented quite widely. However, acute trusts are not buckling under the strain; they are doing extremely well. Is primary care stepping up to the plate? Are CCGs focused on the big issues? In my experience, the clinical commissioning groups that are forming around the country are having exactly the right conversations. They are conversing with secondary care clinicians, public health specialists and those in social care, and looking at how care can be joined up across the system. It is an exciting opportunity for primary care.
The noble Lord asked about how patients could get choice in primary care. Well, the NHS constitution provides for the right to choice. The noble Lord will know that we have agreed two things with the BMA. One is that the boundaries of PCT practices can be varied, so that if somebody moves a few streets down the road they can still stay at their GP of choice rather than having to move. That is surely welcome. We have pilots around the country operating to look at whether commuters who come into the centre of London, for example, would like to have their GP near their place of work, not necessarily near their home. We will look to see what the lessons are from that; it is entirely right that patients should be given that choice.
The noble Lord referred to the Government not letting go and the tight grip from the centre. I do not know who he has been talking to. This afternoon I went to see the National Association of Primary Care and had a very good discussion; the climate of opinion there was that we had the balance just right between allowing it to influence clinical leaders locally, on the one hand and, on the other, the Department of Health providing sensible guidance and pointers to facilitate the process of clinical engagement.
On social care funding, no, we have not given up on Dilnot—far from it. The principles of Dilnot are sound, and we are working with the Opposition, as the noble Lord knows, to see what the best and most affordable formula might be, and the principles around that formula. I have said in recent days and repeat today that along with the White Paper we shall publish a progress report on funding and the draft Bill, which will be subject to pre-legislative scrutiny.
The noble Lord said that there was no difference between targets and indicators. I beg to differ there. There is an enormous difference between a target that is centrally set by government and an indicator, which is a meaningful signal devised by clinicians themselves to help them to drive up the quality of their own care. That is the difference—and that is what we want to see in the commissioning outcomes framework, which will stem from the NHS outcomes framework embodied in the mandate.
In view of time, I hardly want to rehearse again the rejoinder to the noble Lord’s final comment about privatisation. He should know that the Health and Social Care Act prohibits the takeover of any foundation trust by a private organisation. It simply cannot happen. There is no equity capital to be purchased, for one thing. Privatisation means different things to different people. Yes, if we are talking about choice for patients between an NHS provider and an independent sector provider or a charity, we should welcome that, because choice in that context drives up quality. If we are talking about selling NHS assets and hospitals to the private sector, that is off the agenda—and it will be permanently off the agenda, as far as I am concerned. The Health and Social Care Act ensures that there is no bias in favour of the private sector when commissioners are designing care in their locality, so that as far as possible there will be a level playing field between all types of provider. There is no hidden agenda in this area.
I hope that I have covered most of the points covered by the noble Lord and I hope that he will think again about some of the criticisms that he unfairly levelled against the NHS.
Baroness Barker
My Lords, I thank the Minister for introducing a highly innovative document. This is the first time that the NHS has ever been treated in this way, with a document of this kind brought to Parliament and put out to consultation. I am delighted that in such a milestone document mental health has not been forgotten and is included alongside physical health.
I wish to ask the Minister three quick questions, because this document is important and the process of consultation about it is important for the future of the NHS. First, in the section on commissioning, will the Minister tell us whether he believes that the document fully reflects the decision taken in this House during the passage of the Health and Social Care Act that commissioners should not be under any obligation to put services out to tender when there is a justifiable case not to do so in the best interests of patient care? I want to make sure that he believes, as I do, that that point needs to be stressed during this period of consultation.
Secondly, with reference to the Public Administration Committee report in 2011 about the need for government to have robust accountability and audit trails as services are increasingly delivered by other providers, will the noble Lord reassure the House what the processes will be, given all the work that was done by my noble friend Lady Williams of Crosby about the capacity of Parliament and the Secretary of State to have sufficient information to judge whether or not the aims and aspirations of the document have been met in practice? How will it be evaluated and what data will be made available to Parliament to make that judgment?
Finally, I welcome the part of the mandate about the NHS in its broader context, but does the Minister agree that the omission of any mention of housing is a serious one—in particular aids and adaptations, which are so important to prevention of ill health and for the reablement of people who have been in acute care?
Earl Howe
My Lords, I am grateful to my noble friend. On her first question about commissioning and the matter that we discussed during the passage of the Health and Social Care Act, she will remember that the cardinal principle of “any qualified provider” is that it is for commissioners to judge whether putting a service out to tender is in the best interests of patients. If there is no need to bring in competition, there is no obligation on a commissioner to do so. Why should they wish to? On the other hand, a service may be failing. The classic example that I always give is that of children’s wheelchair services. In some parts of the country it is appalling. There is every reason in the world for a community service like that to be put out to tender. Nobody argues with that, if it delivers a better service at the same or roughly equivalent price. So I can reassure her on that point.
On accountability and audit trails, the way in which the board will hold the service to account will be based on the commissioning outcomes framework very largely, but of course there will be very tight financial controls through the accounting officer of every CCG. Broadly speaking, the service will be held to account through the results achieved for patients, the quality of care and the outcomes. There will be metrics attached to those—the indicators that I referred to, which fall below the NHS outcomes framework, as it were.
My noble friend will notice in the mandate that we have quite consciously not articulated umpteen sets of targets or indicators for particular disease areas, such as cancer or coronary heart disease. Once we started to do that, we would produce a volume 500 pages long; nobody wants that—the clear message that we had was that the mandate should be brief, succinct and to the point. That is what we have produced in draft, and we would be very interested to hear what noble Lords think about that. I encourage all noble Lords to feed in their views as to whether we have got the balance right.
On housing aids, I do not think there is anything specifically in the mandate on that. On the other hand, one of the features of the integration of services will be for the health service to work much more closely with social care. We believe that the health and well-being boards will provide the best forum to do that. I hope that through mechanisms such as pooled budgets—and indeed the support that my department is already giving local authorities to bolster their social care budget—such housing aids can be maintained as we move into the future.
Lord Walton of Detchant
My Lords, many aspects of the Statement are most welcome. I particularly commend the reference to the enhancement of research in the National Health Service, which was one of the concerns widely expressed during the debates on the Health and Social Care Bill, which is now an Act. Turning to that Act, can the Minister say what progress is going to be made and what help will be given to the major general hospitals that are intended to become foundation trusts but which at the moment have no particular prospect of becoming so for a variety of reasons?
Perhaps I may also briefly mention something that was not covered in the Statement—the crucial importance of issues relating to the education of healthcare professionals, a matter to which I, and many of my colleagues, referred during the debates on the Act. What progress has made on establishing the so-called clinical senates? I know that according to Sir David Nicholson we can no longer talk about regions—we can talk about sub-national structures. What is going to happen to those clinical senates that are going to have the responsibility of holding the postgraduate deans and the programmes of education and training which they will in future supervise?
The other thing about which we were very concerned was the commissioning of highly specialised services which, during the debates, it was agreed would become the responsibility of the national Commissioning Board. What progress has been made in developing the outreach centres under the national Commissioning Board that will be responsible for commissioning those highly specialised services at a local level? In relation to that, there is an issue that is quite crucial and important—the future of the organisation presently called the Advisory Group for National Specialised Services. It has a budget at the moment of about £100,000 a year. It has been able to support the introduction and use of remedies for treatment of a number of exceptionally rare diseases. It fulfils a vital function. Will it be absorbed and taken over by the national Commissioning Board? Will that body then carry on with those responsibilities? These are quite important issues about which many of us are concerned.
Earl Howe
The noble Lord asked me a number of questions and I will do my best to answer them. First, on education and training, the news is that on 28 June Health Education England was legally established as a special health authority and held its first board meeting. From October this year, Health Education England will start to provide national leadership and oversight to the new education and training framework in England. It will take on, as the noble Lord knows, its full responsibilities from April 2013. The chair, Sir Keith Pearson, and the chief executive, Ian Cumming, have been appointed. Both are men of very high calibre, as I am sure the noble Lord knows.
On the matter of clinical senates, the plans for those will develop over the summer. My advice from Sir David Nicholson is that he should be able to provide further and better particulars in the autumn on how they will look. The noble Lord is absolutely right that they will play an important part in helping to advise not only commissioners in the health service but also the local education and training boards about configuration.
On specialised services, the draft mandate emphasises the importance of driving improvements in the £20 billion of services commissioned directly by the board, including specialised services for people with rare or very rare conditions. One of our proposed objectives in the draft mandate asks the board to put in place arrangements to demonstrate transparently that these services are of high quality and represent value for money. Objective 21 is the crucial one to which I would refer the noble Lord.
On the question about the Advisory Group for National Specialised Services, we will be making an announcement about AGNSS as soon as we can. There is work in train at the moment to look at exactly how AGNSS’s work, which of course is very valuable, can be transposed into the new system. Unfortunately, I do not have any definite news for the noble Lord at the moment.
As regards assistance for foundation trusts, the noble Lord asked about the foundation trust pipeline. I would refer him to page 28 of the Secretary of State’s annual report. Broadly speaking, however, apart from a few financially distressed trusts, some of which I have already referred to, we believe that the great majority of NHS trusts will be ready to take on foundation trust status either in the spring of 2014 or fairly soon thereafter. We have no reason to think that the timetable we discussed during the passage of the Bill has slipped materially.
Baroness Williams of Crosby
I add my appreciation to that of my noble friend Lady Barker to the Government for putting so much information before Parliament and for inviting Parliament to help work out some of the massive changes that will be required to enable the NHS to deal with the problems confronting it. I also welcome my noble friend the Minister’s comments making it clear that a level playing field now exists between the NHS and the private sector, contrary to widespread views that the NHS is coming to a messy end.
I have one important question for my noble friend which echoes in some ways the question asked by the noble Lord, Lord Walton of Detchant. It concerns the issue of primary care which he was discussing with the noble Lord, Lord Hunt. Clearly, a reconfiguration of health will be heavily dependent on the ability of the primary care sector to deal with a great many of the issues that come before it and to pass them on to the community or ancillary professions wherever possible in order to avoid unnecessary attributions or referrals to hospital. In that context there is one very disturbing issue which we have to address and on which I would particularly welcome the Minister’s comments. He will know, as most of us in the House who are concerned with the health service will know, that there has been a much more rapid increase in the number of young men and women trained for consultancy than for general practice—the figure is something like three times the increase for GPs in the past five years. Given that there is in general practice a very rapidly rising proportion of young women, there is an issue of maternity care and the necessary reduction in hours associated with many young women GPs. I say that with the recognition that it creates some problems. I think that most of us in the House would agree that their quality is equal to that of the men but often they do need periods of shorter service.
Finally, there is the very serious problem of the substantial bulge in GP retirement that is coming up in the next couple of years, as the Minister will know. My question echoes that of the noble Lord, Lord Walton, in terms of training and education. What provision is being made to encourage young men and women to go into general practice; is adequate provision being made to train them; and are there incentives for them to enter into the profession in that capacity?
Earl Howe
As so often, my noble friend has alighted on a real issue and I am grateful to her. She is right that we are not seeing enough trainee doctors going into general practice. The previous Government and we have had informal targets for new GPs. We have not met those targets for a few years now. It is a matter of concern and we are working very closely with the universities, the Royal College of GPs and others to see how the numbers can be rectified. It is not just a numbers game because, as she rightly alluded to, we should increasingly be seeing a better sharing-out of responsibilities in the community between not only GPs but community nurses, practice nurses, midwives, health visitors and others. There is quite a lot of work to be done there.
My noble friend is right about women GPs, and headcount numbers in that context are not always the most reliable indicator of the workforce number. This is part of the reason why we set up Health Education England, because with the advice of the Centre for Workforce Intelligence, the body that advises the Government on long-range forecasts of workforce needs, and the input from local providers—primary care providers, not just hospitals—of what they see as their needs into the future, we ought to get a much better handle on long-term needs for the different professional disciplines.
I do not at all brush aside this problem. I hope my noble friend realises that this is a real issue and we are grappling with it. Actually the NHS has grappled with it for a number of years, partly unsuccessfully, but we hope to do better with the new configuration that we have debated so often.
Baroness Wall of New Barnet
My Lords, I welcome the report and in particular I thank the noble Earl for his emphasis—which I would like him to re-emphasise when he responds—on just how hard people are working in the NHS. As always, I reflect my own experience. I do not live in a different world from other people and I certainly know from the trust that I am chair of that people are working exceedingly hard.
Although there are some reservations, if I may say so to the noble Earl, around the progress we are having, I think that that is more about people getting used to what the changes mean. In particular, I want to focus on the CCGs. As the noble Earl knows, my trust has a hospital in Barnet and one in Enfield. Barnet CCG is firing away and working brilliantly. Enfield is still trying very hard to get its act together. The noble Earl knows how much I care about this, and the effect is that we are not getting the primary care out in Enfield where we need it. I would have liked the report to have focused more on moving away from hospitals—which I know is supposed to be heresy for someone who is the chair of a provider trust, but I really believe this—and making sure that we have the opportunity for more primary healthcare and support for those CCGs to be urged forward.
I know we have only a minute so I am not going to say anything else because I know other colleagues have been waiting desperately to get in, but there is a lot more I could say.
Earl Howe
The short answer to the noble Baroness is that she is, of course, absolutely right about service redesign locally. It involves the kinds of conversations that are already happening in many areas between primary and secondary care clinicians to see how we can bring about that shift that most experts agree is desirable and certainly patients want to see. This is an ongoing conversation. I do not know as much as I should about the noble Baroness’s particular area of the country, but I will gladly follow that up with her after this.
Lord Cormack
My Lords, very briefly, my noble friend indicated progress towards the elimination of mixed-sex wards. This issue causes quite a degree of anguish in the country. When can we expect to see the end of them?
Earl Howe
My Lords, my noble friend is absolutely right. However, the NHS has made staggering progress. The reduction in mixed-sex accommodation has been virtually—but not quite—total, but it is something that we continue to emphasise to the health service and which will continue to matter, in the context of the NHS outcomes framework, in the patient experience domain, which is contained in the mandate.