National Health Service
Baroness Barker Excerpts(9 years, 10 months ago)
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Baroness Barker (LD)
My Lords, I, too, thank the noble Lord, Lord Turnberg, for giving us the opportunity to discuss these matters today. He, like a number of other noble Lords, is a veteran of such discussions. While I pray in aid documents such as that produced by the Royal Commission on Long-Term Care, the Wanless report, Wanless II, the Darzi report and now the Five Year Forward View by Simon Stevens, he will perhaps agree with me that, over the time that he and I have been Members of this House, the issues facing the National Health Service have not changed but have remained the same. We have had report after report telling us in varying degrees of detail what the shortcomings of the National Health Service are, how it does not integrate with a sufficiently unbroken social care system and what it needs to do to put that right.
My right honourable friends in another place, Norman Lamb and Paul Burstow, have similarly followed those discussions. I am pleased to say that, in their time in government, they have enacted quite a number of the recommendations put forward, not least the return of public health to local government. Back in the time of Derek Wanless, the observation was made that if our tax-funded National Health Service was to endure, it would have to do so in the context of a population that was informed and engaged about its own health, and that the NHS could not tackle that on its own. I hope that any future Government, tempted as they no doubt will be to rearrange the service—let us call it not a top-down reorganisation but a rearrangement—will resist the temptation to take public health back from local government and will leave it where it is, with the health and well-being boards, to give them the chance to build on the work they have done on prevention in the past two years. Some 70% of the health service is now about enabling people to manage long-term conditions.
It occurred to me—particularly in the past week, when we have been inundated with stories about how the NHS is failing to deal with emergencies—that much of the literature on the NHS is directed at how we deal with an ageing population. At the same time, we have rather lost sight of how young people engage with the NHS. The most interesting findings over the past month or so concerning the problems in A&E were not about lots of older people who are no longer being supported by social care turning up inappropriately in accident and emergency units but rather the number of young people who turn to accident and emergency units as opposed to their GPs. That is a very worrying issue to which we should give great thought, because GPs continue to be the linchpin in terms of most people’s ability to manage their own healthcare and their health and well-being in the longer term. If young people are engaging only with A&E on an episodic basis, that will store up problems for the NHS in the longer term.
Finally, one of the most laudable things that has happened in the past two years is the increased attention that this Government have given to mental health, which is supported by the Opposition. We are finally beginning to understand the importance of mental health and the problems that we cause the country in the longer term if we ignore it. Some interesting work has been done by new organisations which have not previously taken any part in our health debate, such as Mumsnet, which has talked for the first time about the incidence of mental health problems in very young people aged under 11. It also talks about the high incidence of perinatal mental health problems beginning to challenge orthodox providers in the National Health Service and the voluntary sector. I sincerely hope that the next Government will continue to work with organisations, perhaps new and emerging voluntary providers, to take a completely fresh look at some of the long-standing problems that we know have challenged the NHS.
We as a party have said that we will aim to increase NHS funding by £8 billion. We will do so on the basis of continuing challenge and reform. It is possible for there to be a 25% reduction in preventable mortality by 2025, but only if we continue to change the way in which the NHS interacts with the population, the voluntary sector and the people who are capable of addressing the problems upstream that present as emergencies to the NHS.
NHS: Accident and Emergency Services
Baroness Barker Excerpts(9 years, 10 months ago)
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Earl Howe
My Lords, I thank the noble Lord for his endorsement of the model which my noble friend proposed for GP presence in or alongside A&E departments. I fully agree with him on that. It works well. As regards local authority funding, social care expenditure, in particular, has decreased over the past three years. Obviously that has had an effect on the NHS. It would be idle to pretend that it has not. However he will know the very constrained funding environment in which we stand, and I understand that the party opposite has not undertaken to reverse the reductions in funding to local authorities for understandable reasons. That means that we have got to think clever, and one of the initiatives that we are launching next year is the better care fund which will bring together the NHS and social services in a meaningful way. By far the lion’s share of the funding in the better care fund will go to social services.
Baroness Barker (LD)
Since 2010 there has been an average decrease in social care funding in local government of 26%. Are the Government tracking the coincidence of reductions in budgets for things such as continuing care beds and increased attendance at A&E?
NHS: Dermatology Services
Baroness Barker Excerpts(9 years, 11 months ago)
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Earl Howe
My Lords, I will have to write to the noble Lord on that issue. I know that there is not an issue in relation to the number of dermatologists serving in the health service. We believe that number to be satisfactory. But as regards the emergence of leaders in the sense that he has described, I shall have to take advice and let him know.
Baroness Barker (LD)
My Lords, NHS England has set the objective of all patients receiving a timely and accurate diagnosis within three months of referral. Is that objective being met?
Learning Disabilities: Health and Care Services
Baroness Barker Excerpts(9 years, 11 months ago)
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Baroness Barker (LD)
My Lords, the report recommends that the Government should respond to the Bradley report five years on, which deals with how the criminal justice system treats people with learning disabilities and autism. Could the Minister say whether the Government will respond to that report—and, if so, when?
Earl Howe
My Lords, the Bradley report, which was a seminal report, was subject to a five-year review earlier this year. We will consider reports of progress and further recommendations in that report in conjunction with the Ministry of Justice, the Home Office and NHS England with regard to future policy development.
Health: Lesbian, Bisexual and Trans Women
Baroness Barker Excerpts(9 years, 11 months ago)
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Baroness Barker
To ask Her Majesty’s Government what the National Health Service is doing to improve the health of lesbian, bisexual and trans women.
Baroness Barker (LD)
My Lords, in 1999, shortly after I became a Member of your Lordships’ House, I met Lord Campbell of Croy at an event. During our conversation he said, with a note of some pride in his voice, that he had been the Member speaking in your Lordships’ House when the ladies abseiled in from the Gallery to protest against Section 28. Much has changed since then. Section 28 is now history and, as someone who suffers from vertigo, I have to say that I am glad we no longer have to descend by ropes; we can walk in and take our place alongside everybody else in your Lordships’ House.
Today is historic. This is the first time that we have ever had a debate in this House about lesbians, bisexuals and trans women, and their health needs in particular. I am not turning my back on our gay brothers but I just ask them: today, please don’t rain on our parade.
I am delighted to say that the noble Baroness, Lady Gould, has agreed to take part today. She is my predecessor as the chair of the gender identity forum, and she will be talking about the needs of trans women. This debate has been planned and is being followed by many members of our community. I wish to thank in particular Jane Czyzselska from DIVA magazine, and the readers who contributed points; Jess Bradley from Action for Trans Health; Ruth Hunt, the admirable new director of Stonewall and the Lesbian and Gay Foundation in Manchester, which, under the leadership of Siân Lambert, produced a report, Beyond Babies and Breast Cancer, which sparked today’s debate.
The NHS constitution says that it,
“provides a comprehensive service available to all”,
irrespective of,
“gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status”.
However, the problem is that we have a growing body of evidence that says that it does not do that.
In 2008 we had Stonewall’s report, Prescription for Change: Lesbian and Bisexual Women’s Health Check. There was a bisexuality health briefing in 2012, a GP survey covering 2012-13 and the Beyond Babies and Breast Cancer report. It may be small-scale and most of it is very qualitative data, but there are consistent findings that lesbians, bisexual women and trans women experience discrimination in the NHS. The problem is that lesbians are often lumped in together with gay men. The needs of gay men are not insignificant; they are very important, but they are different. On the other hand, lesbians are included in the health needs of all women, yet our health needs are very different. Somewhere along the way, principally because of a lack of awareness and training in NHS staff, we end up getting a very poor service.
Almost half the women who were surveyed for those reports were not out to their GP, and when they did come out their statements were ignored. Only three in 10 lesbian and bisexual women said that healthcare workers did not make inappropriate comments when they came out. I have a wonderful quote:
“I was once asked by a male GP if I was in a sexual relationship. To which I replied yes. He asked if we were using condoms. I said no. Before I could say anything else, he went on a 10 minute rant about using condoms, being on the pill, STIs. When he stopped for air, I replied that I would ensure that my girlfriend would take care from now on. He spluttered and went bright red before promptly stabbing me with an injection that I really didn’t need!”.
Another story is as follows:
“After coming out to a nurse at a GP practice when I went for a smear, she did not know whether to test me for chlamydia and suggested that I see next time if I’m ‘still …’—presumably she meant still lesbian! I haven’t been back to the GP since”.
That is the important thing, and I can attest to similar experiences myself over the past 30 years. When there is such an inappropriate response from a health worker, it completely undermines your confidence.
Very few lesbian and bisexual women have been properly tested for STIs, and those who do turn up at genitourinary medicine clinics have a much higher incidence of STIs than heterosexual women. Quite often, health workers give them the wrong information and advice. One woman said:
“I was treated for cervical cancer after receiving a positive smear. I was originally told that I didn’t need a smear as I had never had sex with a man”.
There are other ways of contracting this viral infection. Sometimes lesbians get a bit fed up with having to be the teachers of the health workers who should be dealing with us.
A number of reports both in this country and abroad have been published about the fact that rates of smoking and alcohol consumption are statistically higher among lesbians and the gay community. It is tough when you have to deal with discrimination every day, and sometimes it is hard to be as healthy and fit as you should be. Some of us make an effort. I am pleased to report that I managed to give up smoking two years ago and I am still going strong. But there is only one alcohol clinic that is specifically targeted at gay women, and that is Antidote, run by London Friend. The problem is that generic services really do not target their messages at lesbians at all.
I turn to cancer screening. Because of lifestyle factors, we know that lesbians and bisexual women have a higher rate of diagnosis, but again there are no specific services and very few specific messages targeted at women from our community. On mental health, the reports we have suggest that although many women live perfectly healthy and happy lives, there is an increased incidence of mental ill health. Its prevalence is greater still among bisexual women. I have to say that there are no data on any of these conditions to show what happens to lesbian, bisexual and trans women from black and minority ethnic communities. There are simply no resources. Lesbians cope well, but there are no mental health services that are particularly designed to help us, and as a consequence we have to be pretty resilient on our own.
Some things can be done that could make a difference. The biggest difference would be made if clinicians and front-line staff in primary care recognised and understood that some of us are gay. They should not always ask questions that presume we are not. Bless them, sometimes they say things for the most benign of reasons, but it is still discrimination and they need a lot of training to help them get over what is essentially a flaw in their medical practice. Some partnerships have been formed between certain specialist organisations and lesbian and gay community groups which have worked very well. Manchester has the Pride in Practice project where the Lesbian and Gay Foundation has worked with nurses and doctors so that they are trained to ask questions in a way that does not make a presumption about the person to whom they are talking.
There are many more things that could be done. I am not asking for special services. That is not going to happen, given the financial situation at the moment. The NHS is a service for us all and therefore some of us, because of our background, have the right to expect that that universal service will meet our needs.
I have four specific points to put to the Minister. The first is to ask when Public Health England will put forward a strategy for promoting the health and well-being of lesbian and bisexual women. There is one for gay men; there is not for lesbians and bisexual women. Secondly, will NHS England develop a data standard on sexual-orientation monitoring? At the moment there is no monitoring of the way in which we interact with the NHS. Thirdly, the biggest problem is that GPs simply do not know how to talk to us. Can the Minister work with the Royal College of General Practitioners to develop some standards for questions to be asked of patients in a non-pejorative way? Lastly, in our work with GPs, could the health outcomes of lesbians and bisexual and transsexual women be part of the overall monitoring of GP practice?
We are citizens of this country. We are taxpayers. We support the National Health Service. It is only fair that we should expect it to recognise that we exist and should be able to access those services with dignity like everybody else.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Baroness Barker Excerpts(10 years ago)
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Baroness Barker (LD)
My Lords, the Minister, the noble Baroness, Lady Greengross, and I have a fair degree of form on this subject, going back over a number of years. Indeed, as I listened to the Minister introducing this matter to the House tonight, my mind wandered back to the dreaded days of the NHS Redress Bill, when the noble Lord, Lord Warner, sought to assure those of us who, in those days, sat on the other side of the Chamber that all would be well in the NHS and there was no need for a duty of candour because a new culture of openness was going to work its way through the NHS.
I have to say that things have changed because back then the professional bodies representing the staff of the NHS fought that duty of candour tooth and nail, so it is rather pleasing to have the news this week that they now have changed their minds and are willing to accept that they should uphold the duty of candour. They are moving to a point of discussing with their members not whether, but how, they do that.
I agree with the Minister that the CQC in its present form is a long way from CSCI and its predecessors in their various guises. It is properly constituted, far better resourced and has a focus to its work. Albeit that it works across a far bigger canvas than it ever did in the past, it is already performing to a much higher degree than before.
However, I return to the point the noble Baroness, Lady Greengross, and I made during the passage of the Care Bill. In that legislation, in relation to care homes and incidents where vulnerable adults may be thought to be at risk of abuse, this House fell short in its legislative function in that it did not give a power of entry to people or bodies who suspected that there might be abuse taking place. It is with that deficiency in the law sitting in place that we have to judge all the regulations and guidance such as this that come before us and ask ourselves whether, if a person was being abused or maltreated in a care home, it would be detected.
Therefore, the noble Lord, Lord Hunt, is right to focus, as he has done, on the issues of complaints procedures and emergency planning. I accept that within the overall framework service providers are now required not only to provide their services but to report on outcomes for individuals and standard of care, but nonetheless, there is something slightly amiss. For me, it goes back to the issue of power of entry. It goes back to the point at which a concerned relative has the power to override things.
I would also like to ask the Minister for a point of clarification. It seems that Ministers are quite clear that the introduction of new basic standards rectifies what was clearly an unsatisfactory position whereby one could not prosecute a provider unless and until an improvement notice had been issued. That was clearly wrong, and a number of providers got off the hook on that technicality. Will the Minister clarify, if he can, that under these regulations a breach of fundamental standards is still not in and of itself a reason to trigger a prosecution and that a reason to trigger a prosecution is a breach of the regulations? I would like to know how the department sees that working in practice to cover the deficiency to which I alluded a moment ago.
Finally, I welcome the fit and proper person test. It is long overdue. It is a good job that it is coming to the statute book as quickly as it is.
Viscount Hanworth (Lab)
My Lords, the quality of the provision in old people’s care homes varies widely. In the best of them, the residents are treated with respect and solicitude. In the worst of them, as we have witnessed recently, they are treated callously and brutally by underpaid and badly trained staff.
The increasing longevity of our population is leading to a rising demand for the provision of care for the elderly. Until recently, the implications of these developments have been ignored by all but a few concerned parties. The matter was brought forcefully to the attention of the public at large by the financial collapse of the Southern Cross enterprise, which was responsible for at least 20% of the national provision of residential places in care homes. It was running 752 homes when it collapsed in 2011 with losses of £300 million.
Southern Cross had been acquired by the private equity firm Blackstone Capital Partners for £162 million in 2004. Thereafter, it expanded rapidly. Through acquisitions, it tripled the number of homes that it was managing. The directors became multimillionaires. Inspections that were conducted during the period of its expansion raised grave concerns over the provision of care by homes within the Southern Cross portfolio. Indeed, the enterprise was warned about failing standards in its homes as it prepared to float on the stock market.
A more dramatic instance of the failure of care was provided by the scandal of Winterbourne View, a public-funded private hospital. A “Panorama” investigation broadcast in 2011 exposed the physical and psychological abuse suffered at the hospital by people with learning disabilities and with challenging behaviour.
The problems besetting care homes have been due, in part, to the inadequacy of their regulatory oversight. They have also been due, in large measure, to the increasing financial stringency under which they are operating. The income received by the homes from fees has been falling. Those fees have been paid on behalf of the great majority of residents by local authorities. Their income has been driven down by the Government’s austerity measures. At the same time, their costs have increased through factors outside their control, such as rising energy prices.
Another adverse condition is that the borrowing of the care home sector averages 75% of its net assets. This abnormally high level of indebtedness has been a result of the borrowings that were linked to the spate of acquisitions that preceded the general financial crisis of the sector. It has been pushed even higher by trading losses. This will expose the sector greatly to the widely anticipated rise in interest rates in the not too distant future.
The Government have reacted to these problems in a manner that many people regard as inadequate. They have not sought to improve the financial circumstances of the care homes. Instead, they have sought to improve the regulatory framework affecting the care homes via amendments to the secondary legislation associated with the Health and Social Care Act 2008, which will come into force in April 2015.
According to the testimony of the Minister of State for the Department of Health in the Commons on 16 October, the new regulations will,
“bolster the power of the regulator to take enforcement action, including bringing prosecutions against providers of poor care”,
and issuing penalty notices.
He remarked that, under the existing regulations,
“a notice had to be served first before moving to prosecution. If the provider complied with the notice, nothing could be done”.—[Official Report, Commons, Sixth Delegated Legislation Committee, 16/10/14; col. 4.]
The essential purpose of the new regulations is, therefore, to encourage improvements in the quality of care by strengthening the sanctions for failures.
Care Quality Commission (Reviews and Performance Assessments) Regulations 2014
Baroness Barker Excerpts(10 years ago)
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Baroness Wall of New Barnet (Lab)
My Lords, I support in principle the wording of the business that we are dealing with, particularly the emphasis on regular assessment of other than the provider trusts. I share with the House and the Minister why I now feel that that is even more important. I declare an interest as chairman of Milton Keynes Hospital NHS Foundation Trust. Just last week, we were inspected by the CQC. Obviously, we do not yet know the outcome of that. The CQC was with us for four days and there were 40-odd people there.
As the noble Earl is aware, I have been very supportive of the CQC and share his aspirations for it. To be honest, our inspection was extremely thorough. We have to wait with bated breath for the outcome, but the enthusiasm, what was described as the buzz around the hospital and the way that people felt strongly about the services that they were giving made a huge difference to the whole thing. I am only three months into that trust, but this was not about preparing for the CQC; it was about the culture of the organisation and wanting to improve. I hope that the CQC comes back with recognition of that, whatever the outcome might be.
The inspection was carried out under the new way of doing things, which I think is great. There were many more people across all the spectrums of our services, at a professional and clinical level. That was superb. The reporting back every night was very good and helpful to the chairman and chief executive. All that felt good and thorough, which is what it is all about. I agree with my noble friend’s view about extending that for the very reason that he just gave. The importance of that inspection to the outcome for our patients was absolutely paramount, regardless of what the outcome might be in terms of the grading or level of assessment we might be given. But without that thoroughness and rigour, particularly with the CCGs, who are the ones making decisions about our services, with the GPs who run them—unless there is a deep dive, as we would call it, into any other part of the health service—the gaps that are still a worry for us may remain.
In particular, my noble friend Lord Hunt said that there was an issue around local authorities. All trusts are struggling terribly with A&E. There are many reasons for that, as my noble friend has said. But one of the big reasons is the lack of rigour in social care and local authorities’ commitment to or understanding of the role that they play. From the experience that we have had over the past week, I believe that this is not a threat to people: it is empowering for them to have the CQC in there, ensuring that the rigour that they are supposed to apply to their work is there and that the role they play in patients’ experience really makes a difference. I urge the noble Earl to consider this opportunity yet again. We made a decision in the Care Act, which I think even more now is really a mistake from which we need to move on. I do not share the cynicism of my noble friend, but I share the concern about whether the CQC can embrace all that.
The investigation into my trust was supported, as I understand it, by far more clinicians than ever before and far more people had a much greater knowledge of the health service. If the CQC can continue to develop in that way, I believe it is in its interest—and, more importantly, in our patients’ interests—that those commissioning groups go wider and deeper into other than the provider trusts.
Baroness Barker (LD)
My Lords, I spent a happy weekend making a start on the 500 pages of regulations that have been issued under the Care Act. What can I tell noble Lords? I am living for pleasure alone. I regard this Motion as the first of many to come our way.
I thank the noble Lord, Lord Hunt, for the opportunity to go back to some of the discussions that we had during the passage of the Bill, particularly on commissioning. We had long debates about commissioning and the extent to which it did or did not impact on services. We also talked at considerable length about the differences between the commissioning of healthcare in the NHS and commissioning in social care. In these regulations, we are beginning to see some attempt to have proportionate and slightly different attitudes towards commissioning in both those settings. I would like to see us taking a more proportionate look at commissioning across the board. To a certain extent, these are the first of the regulations that begin to do that.
We also had extensive discussion about whether performance ratings should be specific to particular services within hospitals or whether they should go across the piece. My recollection, informed quite often by people with valuable experience such as the noble Baroness, Lady Wall, was that there would be a lot of data generated in hospitals, particularly clinical governance data, which would be there to inform one’s opinion about a particular service in a hospital. However, what would have been missed, and what was missed so spectacularly in Mid-Staffordshire, was the across-the-board bad management practices throughout a hospital that undermined patient care. That was why we ultimately took the decisions that we did about the nature of performance review.
I want to pick up two particular issues that are brought to the fore by these regulations. I notice that prison healthcare has been exempted. I understand that there is a sense in which the NHS or the CQC would be able to look at the performance of only a part of prison healthcare. But prison healthcare is, in terms of mental health, addiction services and so forth, becoming much more important. There is a much clearer focus on the amount of ill health that people have within the criminal justice system. I want to be sure that we are not enabling those prison health services to escape proper scrutiny.
My final question to the noble Earl is more fundamental. We had extensive debates during the passage of the Care Bill about the right of entry for those people who are involved in carrying out performance reviews and the extent to which the people responsible for them should be able to go into any service to assure themselves that those services are safe and the people within them are not being abused. I do not see anything in these regulations that gives comfort to those of us who believe we took the wrong decision during the passage of the Bill and that, as a consequence of our failure, there may well be people in health and social care settings who are being abused at worst or ill treated at best.
Baroness Wall of New Barnet
I thank the noble Baroness for giving way. In response to her comments on nurses and hospitals, she is absolutely right. I emphasised the clinical stuff. However, the CQC interviewed everyone on our board: the non-executive directors, me—as chairman—for an hour and a half, and all our executive directors. It interviewed not just the clinical staff but the whole of the trust to make sure that we all understood what we were doing in the job we are employed to do.
Baroness Barker
I thank the noble Baroness for that. I trust that if the CQC was doing its job, it would really go to the seat of power in a hospital and interview the porters.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this has been a useful debate. Although the Motion to Regret moved by the noble Lord, Lord Hunt, relates to regulations which, as he said, cover a certain area of the CQC’s activities, I note his broader questions and will come to those.
These regulations set out which health and adult social care providers will be rated following inspection by the Care Quality Commission. They came into force at the beginning of this month. However, it is clear that the noble Lord’s main concern is not so much about the regulations, although he did query aspects of them and I will address those in a second. I think—or, at least, I hope—that there is a good deal of agreement between us about the way in which the CQC now approaches its task of assessing service providers. The noble Lord’s concern lies largely around the accountability arrangements for commissioning. I will begin by setting out the purpose of the regulations and summarise the considerable progress that the CQC has made in inspecting and rating service providers.
Noble Lords will recall that the Care Act put in place a new system of reviews and performance assessments of providers to be developed by the CQC. The regulations referred to in the Motion specify which providers will be rated by it. They cover NHS hospital trusts and foundation trusts, general practices, independent hospitals and providers of adult social care. The CQC has set out its approach to inspection and ratings in a series of handbooks for each regulated sector. Each service is judged against a number of key questions: is it safe; is it caring; is it effective; is it responsive; and is it well-led? The CQC produces a rating against each of these areas at both location and provider level.
This new system is providing information about the quality of care that goes beyond mere compliance with minimum standards. This information is of value to patients and service users, to commissioners and, of course, to the providers themselves. The noble Lord, Lord Hunt, referred to the comments of the Nuffield Trust around hospital ratings and questioned how such ratings could be communicated to the public in an understandable way. We have committed the CQC to publishing clear, authoritative ratings of providers. Not only are these ratings broken down into the five key questions about services that I have just referred to, but the CQC has also published, where it has been possible, ratings of specific hospital services. The CQC is under an obligation to consult on the development of its ratings methodology. It has done so, and will continue to do so as its methodology grows more sophisticated over time. I completely take the point that ratings must be robust and stand up to scrutiny, but the CQC’s view is that it is more than possible to construct indicators that are genuinely representative of an organisation’s performance.
The CQC has made rapid progress on developing and implementing the ratings system. It has already published more than 130 ratings of NHS providers, and has recently published the first ratings of adult social care providers. Over the next few years, it will inspect and rate every provider that is covered by the regulations. Noble Lords will recall the debate we had last year on whether the CQC should also carry out routine inspections of commissioners. The CQC’s primary purpose is to regulate service providers and the Care Act clarified this by removing its power to carry out periodic reviews of commissioners of both health and adult social care.
Some providers argued that the system we were putting in place left them solely accountable for failings in care that could have some of their roots in commissioning decisions. I listened carefully to the comments of the noble Baroness, Lady Wall, and the noble Lord, Lord Hunt. I accept that there is a link between commissioning and quality of care and that, in some instances, it would be appropriate for the CQC to review commissioners. We have therefore maintained a power for the CQC to carry out special reviews of commissioners under Section 48 of the Health and Social Care Act 2008. However, this will be used only where there is clear evidence that failings in commissioning are leading to poor care for patients and service users and it is subject to the approval of the relevant Secretary of State. Let me be clear: where it is justified by the circumstances, the CQC will be able to inspect commissioning.
Although the CQC is not routinely reviewing commissioning, there are other arrangements for the oversight of commissioners. The noble Lord, Lord Hunt, asked me whether any special inspections of commissioners had happened yet. The answer to that is no in relation to local authorities’ commissioning of adult social care, but the CQC is undertaking a special review of children’s safeguarding in Doncaster. I understand that this review will look at both the provision of services and their commissioning by the local NHS. The review is due to be published in the coming months.
For adult social care, the Care Act puts in place clear duties on local authorities to have regard to the importance of ensuring the sustainability of the market as a whole in order to meet the care needs of local people. Last week, my department published statutory guidance for local authorities as part of a package of secondary legislation which implements the Care Act. This includes a chapter on commissioning and market shaping. Furthermore, the Local Government Association and the Association of Directors of Adult Social Services will shortly publish a set of new standards for commissioning services that has been produced with stakeholders. These standards will provide clarity on what good quality commissioning looks like. They will build on best practice and encourage councils to conduct more thorough self-audit and peer review in order to move towards excellence, covering, for example, commissioning for outcomes, integrated commissioning and workforce issues.
Where local authorities struggle to meet these commissioning standards, they are able to seek support through a system of sector-led improvement. Where a need has been identified, a variety of improvement support can be offered. This may include advice and visits from peers in high performing local authorities; mentoring and leadership training for councillors and officers; and bespoke support from national experts. This approach has been developed in partnership with local government partners in order to improve local authorities’ performance and capabilities. It supports local authorities to take responsibility for their own performance and drive improvement, developing a system of performance management by councils for councils. Sector-led improvement is based on the principles that councils are primarily accountable to their local communities; they are responsible for their own performance and improvement; and they have a collective responsibility for the performance of the sector as a whole.
Turning to commissioning of NHS services, NHS England is responsible for the performance management of clinical commissioning groups and has a statutory duty to carry out an annual performance assessment of each CCG. NHS England must be assured that commissioners are acting efficiently and effectively on behalf of local patients. Using the principles set out in the CCG assurance framework, NHS England supports and challenges CCGs to meet the needs of their local population. The assurance process is informed by robust and diverse sources of evidence, including the CCG outcomes indicator set and a detailed delivery dashboard.
Where concerns are identified, improvement actions are agreed. NHS England has broad powers to ensure that these improvements are made, whether this is through the provision of support and advice or by taking action when a CCG is at significant risk of failure. Examples of the support that can be made available are advice and expertise, facilitating peer review and partnership with other CCGs, or the brokering of conversations between CCG and providers by the area team.
The CCG assurance process has so far worked well. NHS England’s year-end CCG assurance assessment for the year 2013-14 showed that 210 out of 211 CCGs were assured, with 132 receiving some support to improve in particular domains of the assurance framework. An NHS England-commissioned survey of stakeholders, including local health and well-being boards, Healthwatch and patient groups, found that 68% had confidence in CCGs to commission high quality services.
The approach taken in this first year rightly focused on developing the capacity and capability of CCGs, as relatively young organisations, building on the domains which were the foundation of CCG authorisation. This focus on developing the organisational health of CCGs has meant that, as of July 2014, only 13 CCGs still have conditions or directions remaining in relation to their authorisation, compared with 153 CCGs initially authorised with conditions. In one case, a CCG was not assured and NHS England has put legal directions in place to improve its performance. As intervention is the element of the assurance framework which most affects CCG autonomy, careful consideration is, of course, required before NHS England will take this course of action.
Assurance ratings are based on the area team’s assessment of the level of the CCG’s insight of the identified issues and its willingness to take the necessary steps to improve. In cases where serious concerns arise, NHS England has shown that it will take necessary and appropriate intervention action. These legal interventions can take many forms, such as directing the CCG how to perform a certain function or asking another CCG to perform that function. They may even require the removal or replacement of the accountable officer or dissolution of a group.
Noble Lords may have seen recent reports of how NHS England is considering developing the CCG assurance framework to emphasise CCG achievement as well as capability. The detail of the assurance framework is, of course, a matter for NHS England but I am sure that noble Lords will be encouraged that NHS England is reflecting on how the assurance system can be improved. Ultimately, the Secretary of State is accountable to Parliament for the performance of the health system and will hold NHS England to account for how it has fulfilled its responsibilities, including how it has ensured that the health services which both it and CCGs commission are high quality and deliver value for money.
The noble Lord, Lord Hunt, asked about how NHS England is held to account by the department. The Secretary of State has formal accountability meetings with the chair and chief executive of NHS England every two months, which are structured around the mandate objectives and NHS England statutory duties. These are also attended by other NHS England board members, Ministers, the senior departmental sponsor and the Permanent Secretary. These meetings focus on strategic issues and any issues of delivery. Actions for NHS England are agreed in the meetings, recorded in the minutes and followed up in subsequent Secretary of State meetings. This process feeds into an annual assessment of NHS England by the Secretary of State. It is a legal requirement that this is laid before Parliament in response to NHS England’s annual report and covers NHS England’s performance in respect of mandate objectives and fulfilment of its statutory duties.
Meanwhile, NHS England is holding itself to account internally for its commissioning responsibilities. Just as there is a CCG assurance framework, a reciprocal direct commissioning assurance framework has been produced to demonstrate that NHS England is also exposing itself to similar scrutiny of its own commissioning responsibilities. NHS England has made a commitment to CCGs and wider stakeholders that it will apply the same level of scrutiny to its own direct commissioning responsibilities as it does to CCG commissioning. The assurance framework is used to identify concerns where the direct commissioning functions of area teams are particularly challenged. In these circumstances, the issues will be escalated through the line management arrangements in order to ensure that extra scrutiny or support is given as required. Ultimately, NHS England’s board will assure direct commissioning processes.
The noble Lord’s particular concern was around specialised commissioning and the overspend that we saw last year. In quarter 4 last year, NHS England forecast an overspend in specialised services of £172 million, an adverse variation to plan which was in excess of £291 million. Departmental analysis found that last year’s overspend in specialised services was due to a combination of factors, some historical and intrinsic, others unique to 2013-14. In April this year NHS England established a specialised commissioning task force in order to make some immediate improvements to the way in which it commissions specialised services and to put commissioning arrangements on a stronger footing for the longer term. The task force is led by Richard Jeavons, Director of Specialised Commissioning, NHS England. Additional resource from within NHS England has been diverted to the task force to ensure that it has the right mix of skills and expertise to enable it to meet its objectives. The task force comprises seven distinct work streams, which are focusing on financial control during the current year and planning for the 2015-16 commissioning round.
NHS England provides updates on the work of the task force to external and internal stakeholders every three to four weeks. There are also briefings given at key meetings and to key groups—for example, the Patient and Public Voice Assurance Group. Updates can be found on the NHS England website. NHS England describes its specialised commissioning task force work as a way to secure financial control in 2014-15 and to plan for 2015-16; it is not a wholesale review of specialised commissioning. The aim is to improve ways of working and to ensure that specialised commissioning is undertaken in the most efficient and effective way possible. The department is working closely with NHS England as it develops proposals for change. NHS England will continue to be held to account through the regular accountability meetings and the annual assessment that I have referred to.
Although these arrangements for the oversight of commissioning are new, I am confident that they are robust. The CQC’s new approach to inspection and the information that it provides about the quality of care through ratings is itself of use in commissioning, and where there is evidence that commissioning decisions are leading to poor care, it will, as I have said, be possible to escalate this to the CQC. I believe that these arrangements strike the right balance, allowing the CQC’s focus to remain on its core task of inspecting and regulating health and adult social care, but retaining an ability to look at commissioning issues when necessary.
NHS: Health and Social Care Act 2012 Reforms
Baroness Barker Excerpts(10 years, 1 month ago)
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Earl Howe
The noble Baroness asks two questions. We had to abide by the terms of the contracts of employment which were put in place by the previous Administration. In some cases, people were made redundant and were then re-employed by the health service at a later date. No one can take satisfaction from that, which is why we are completely revisiting the terms of those contracts. As regards accident and emergency departments, we know that the NHS is under pressure, but there are now more accident and emergency doctors than there were in 2010. The work being done by Sir Bruce Keogh to look at the system across the piece will, we trust, address a number of the pressures that the NHS is now experiencing.
Baroness Barker (LD)
The Minister will know that health commentators usually assess the annual increase in health spending at 4%. In view of that, does he agree that the sustainability of the NHS rests largely on its integration with social care? Does the Minister also agree that this issue should be addressed in the forthcoming Autumn Statement?
Earl Howe
I agree with my noble friend that the integration of health and social care services has a major part to play in making the system more efficient across the piece and more effective for the patient. That is why we are introducing the better care fund, which, at a local level, will channel at least £3.8 billion into pooled budgets to deliver that integration.
Health: Dementia
Baroness Barker Excerpts(10 years, 4 months ago)
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Baroness Barker (LD)
My Lords, as there are currently no effective drug therapies, will the Minister explain what the incentives are for GPs to make early diagnosis of the condition?
Earl Howe
It is generally recognised—although some GPs disagree—that early diagnosis of dementia is vital. It is vital for ensuring that a person with dementia can access the relevant advice, information and care and support that can help them live well with the condition. My noble friend is right that there is currently no cure for dementia, but there are drugs that can help with some of the symptoms and people with dementia have the right to know that they have the condition so that they can better plan for the future.
Health: Cancer
Baroness Barker Excerpts(10 years, 4 months ago)
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Earl Howe
Yes, my Lords: that is the advice I received. It goes hand in hand with other advice around other forms of radiotherapy treatment that are increasing very dramatically. For example, intensity-modulated radiotherapy is a similar form of radiotherapy for different types of cancer—head and neck cancers, principally. The use of that radiotherapy has grown very considerably, partly as a result of considerable investment by the current Government.
Baroness Barker (LD)
My Lords, this treatment works for patients caught very early in the stages of their disease. Is NHS England working with GPs to increase the number of people who they suspect have cases that will respond to this treatment getting into these centres in the first place?