Health and Social Care Bill

Baroness Barker Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Kakkar]

My Lords, the noble Earl, in his thoughtful introduction of the Bill on Second Reading, identified the challenges that face all mature healthcare systems such as our own in terms of the changing population demographics, with an older population, more chronic disease and the need to improve clinical outcomes through integration of the new technology innovations and pathways of providing care.

In trying to understand how those important objectives will be achieved by the Bill we need to try to identify potential strategies. One of the most important is to ensure that the health service focuses on integrated care in the future. We know from quite a lot of important experience around the world that integrated care has the opportunity to improve clinical outcomes. We have heard of the patient with diabetes that the noble Lord, Lord Patel, described who ended up with the potentially unnecessary amputation of toes. Integrated care could have improved the clinical outcome in that case by avoiding a deterioration of the patient. Careful supervision in the community and the appropriate integration of different specialties and disciplines could have avoided that outcome. We know that integrated care has the opportunity to drive improved patient experience. We have heard about the potential for integrated care to improve patient safety. The example given by the noble Baroness, Lady Cumberlege, of the remarks made by Martin Marshall with regard to “lost in the system” puts patients at great risk, and the importance of integrated care and enhancing patient safety should not be neglected.

We also know that integrated care can achieve the important objective of taking our system towards a value-based healthcare system where, in addition to improving all the good clinical outcomes and improvement in experience and safety, the healthcare system can also deliver better value and ensure that the vital resources available and devoted by Government to the provision of healthcare can be used most effectively. Therefore, I strongly support the amendments that speak to the need to emphasise in the Bill the importance of integration.

The Bill has the important purpose of ensuring that a legal framework exists for driving forward future provision of the National Health Service, and also provides an important opportunity to set a vision and ensure that those ultimately responsible for implementation have an appropriate focus at the outset and can design the service moving forward in such a way that it achieves the objectives and meets the challenges that the noble Earl set at Second Reading. To ensure that there is a focus on integration is a very important objective. It will help achieve those important challenges. Failure to emphasise integration would run the serious risk of losing the opportunity to drive forward the improvements in healthcare and in the utilisation of resources that the health service desperately needs.

[Baroness Barker]

My Lords, the noble Baroness, Lady Pitkeathley, mentioned that she wrote a book 40 years ago. I wish I had written a book about the experiences of older people in various parts of the healthcare system. Many noble Lords talked about integration at different levels. My view is that integration just within acute hospitals will be ever more complex in future because they will be treating many people with dementia. The treatment of people with dementia in different parts of acute hospitals is a growing scandal. It poses a challenge to health professionals of all kinds, many of whom have never bothered to think about the issue of dementia. They will have to think about it for their own specialisms in future.

I have taken part in this sort of debate many times and come to the conclusion that the debate rests on a single factor: information. It is the sharing and availability of information and data about outcomes. Everything else is secondary. The previous time we had a serious discussion about this was when we discussed the proposals of the noble Lord, Lord Darzi. Some of what he achieved, in particular in improving stroke care in London, rested on the willingness and ability of people just in different parts of the NHS—let us not be too ambitious—to share information. I ask the Minister what the department has learned since the passage of the legislation of the noble Lord, Lord Darzi, about the crucial issue of sharing information about patients and their treatments, and other data on outcomes. Until we address that issue, and until health professionals feel able to maintain client confidentiality while sharing information just with other professionals, everything else will be redundant: we will never crack any of this until we get that right. Therefore, I ask the Minister how the department’s thinking was influenced in the preparation of the Bill by what the noble Lord, Lord Darzi, achieved.

[Baroness Masham of Ilton]

My Lords, integration has been said to be important and I agree. I agree also how important specialised nurses are to those with long-term conditions such as diabetes, stroke, epilepsy, Parkinson's, tuberculosis, spinal injuries, many neurological conditions, rheumatoid arthritis and many more conditions. Specialist nurses should not be cut. They are the vital link between primary and secondary care. Pain control should be included in integration. Nothing so far has been said about it. Last night, I was at a presentation about rheumatoid arthritis, and it was stressed that pain control is important.

Integration means much more with long-term conditions. Occupational therapists are employed by local authorities to adapt houses. What is going to happen in the new regime to the wheelchair service? Who is going to look after that? What about housing for those with serious disabilities? What happens now? If there is no suitable housing, patients stay in hospital far too long. Professionals should all be working together.

NHS Commissioning Board Authority (Establishment and Constitution) Order 2011

Baroness Barker Excerpts

Tuesday 1st November 2011 Lords Chamber

[Baroness Barker]

My Lords, reading these regulations, I was taken back to 2008, when the then Government set up the Care Quality Commission. We had a set of regulations that were not dissimilar to these to start the process of establishing that board. The CQC became operational on 1 April 2009; its chair was appointed on 15 April 2008 and spent a year in the process of setting up that body. Noble Lords who took part in the legislation around that discussion will remember that we had not begun the Committee stage when the chair was appointed, and there were in subsequent weeks major discussions about the role of the CQC board, its objectives and its composition, all of which were subsequently translated into legislation and regulations and which today carry through into the CQC.

Echoing some but not all the questions asked by the noble Baroness, Lady Thornton, and the noble Lord, Lord Warner, I too want to ask the Minister whether, as with the setting up of previous bodies, it is the intent that there should be an initial process when a basic structure for establishing the body takes place, and whether it will be added to and changed as the legislation governing the body goes through Parliament. I too want to know whether this board will be required to meet in public, if that is the outcome of the debates that your Lordships are due to have in the next few weeks on the legislation. Also, is it a de minimis position to have five members? That might well be changed in future. Like the noble Lord, Lord Warner, I want to understand the scale of the budget and staffing structure that this board has to oversee.

Can the Minister say more about conflicts of interest? In these regulations, we have a clear but standard definition of conflict of interest, which is about pecuniary interests of board members. This board is going to operate in relation not just to the Secretary of State but to clinical commissioning groups, which opens up the capacity for there to be different conflicts of interest other than direct pecuniary ones, which I imagine that the Government can foresee and would wish to prevent. Would it be reasonable for noble Lords to assume that as the legislation progresses matters like that will be decided and will be the subject of further regulation?

Finally, how long does the department believe the process of transition will take and who will be responsible for monitoring the cost of the establishment of what I take to be a shadow board, which, as I said, is not an unprecedented step for a Government to take in a matter such as this?

[Lord Turnberg]

My Lords, many of the points that I might have raised have been raised by my noble friends, but I still have some concerns and quite a lot of confusion as to what this body will do. Will it have budgetary responsibilities from day one and, if not, when will it start having some responsibilities for the huge amount of money at its disposal? What controls will be placed upon it? If it is going to meet in public only occasionally, who will hold it to account if things seem to be going wrong? What role will the Secretary of State play if it does not seem to be delivering what it should? It has an enormous set of responsibilities. Will it have sub-committees or will it be decided, among the five non-execs and others, how it will go about its business? I find the whole thing rather confusing at this stage. It would be nice to have some clarity and I hope that the noble Earl will be able to give it.

Health and Social Care Bill

Baroness Barker Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Bichard]

I have some sympathy with the suggestion that we should set out at the beginning of the Bill the values and principles on which the service is based. My difficulty is that I fear the amendment is not appropriate or adequate in its current form. Therefore, I will be unable to support it for reasons that other noble Lords have given, and for two others in particular.

First—and others may find this provocative—the NHS is still not driven often enough by the primacy of patient care. It is not, therefore, enough to say that the primacy of patient care will not be compromised by structural or financial reorganisations. We should surely be much more positively committed to the need to redesign services around patients, and I thought that that was one of the major purposes of the Bill. It is difficult to believe that in a modern world we can be content that people should stay in accident and emergency departments for four hours and longer. That is a question not just of resources but the way in which we design the service and the primacy we give to the patient. We cannot be comfortable that that is happening enough. I agree that we should not have more structural reorganisation, but that in itself is not enough. We should positively redesign our services.

The second reason why it is difficult to agree with this particular amendment is that if we are going to have a clear statement of values and principles, they should be clearly directed at the commissioning agent itself—the service—not to contractual providers. They should be built into contracts and specifications, and the service should ensure that these are taken seriously. I am afraid that the amendment seems to be muddled in that respect, and we cannot expect people performing functions to behave in a way that the commissioning agent is not specifying and requiring. Therefore, the values should be directed primarily at the commissioning agent.

I regret that I cannot support the amendment; I would like to see a clear statement of values early in the Bill, but this is not it.

[Baroness Barker]

My Lords, when I looked at the amendment that the noble Lord, Lord Hunt of Kings Heath, had put his name to, I was immediately taken back to the debates on the Mental Health Bill that many Members of the House worked on. I am sorry that the noble Lord is not in his place. I mention a phrase of his in that debate. I have some form as regards proposing that there be principles at the head of a Bill, just as he has a lot of form in resisting them. He and several of his colleagues spent a considerable amount of time resisting all attempts to have principles inserted into that Bill. When we were discussing that issue in 2007, the noble Lord, Lord Hunt, in reply to my noble friend Lord Carlile, said that,

“putting the principles in the Bill is not a constitutional problem, rather we are concerned about the practical impact of those principles”.—[Official Report, 8/1/07; col. 46.]

That for me is the problem with the amendment.

Various Members of the Committee have talked about the NHS Constitution. I am afraid that the consequence of selecting some parts of it may be that the noble Baroness, Lady Thornton, is unintentionally placing other parts of the NHS Constitution at a lower legal status. I want to defend the members of my party at their conference in Sheffield. When they voted on a resolution, they were not voting for legislation. They were passing some words in the form of a resolution. This section has been taken from a far bigger resolution. They were expressing their views, which were then taken forward into the Future Forum work. I would not condemn them for doing that. But I do not think that those words are now adequate to achieve what is intended.

A number of noble Lords have talked about openness and accountability, and the importance of the Nolan principles. Those are important. As we continue through this Committee stage, I want to look in great detail at how those principles are applied to the NHS Commissioning Board, and to clinical commissioning groups, because it is how those principles work in practice that is important.

For a number of reasons I cannot support this amendment. But I would think it unfair to characterise anybody who does not support it as resiling from these or any other principles. We do support many of them. We will return to many of them during further stages of this Bill, and I hope that we will make sure that some of them are passed into the legislation, but not this amendment in this form.

[Lord Owen]

My Lords, I support the proposed new clause. It is not perfect, but that is not the issue. What we are really debating is whether we want, at the start of this legislation, something that talks about the principles and values of the National Health Service. It will not be easy to find the right words. The noble and learned Lord, Lord Mackay of Clashfern, drew attention to some very fine words in the original NHS Act, and they might well find their place. It is not a preamble, but it has the spirit of a preamble behind it. It is very necessary.

Let me explain one thing. People know that I was a doctor, a medical scientist, and also a Minister of Health. But it is not so well known that I was for 15 years on the board of Abbott Laboratories—one of the largest healthcare companies in the world—and there will be many occasions in Committee when I will be dealing with conflicts of loyalties because I am still a shareholder. I just wish to state that.

It is also important to realise that I am not opposed to the market. Indeed, at very early stages in 1985, I was the advocate of the internal market. I must say I am ashamed of that advocacy now. So often the work that was done on an internal market is used to justify the external market that is the basic fundamental underpinning of this Bill, which I am afraid will become an Act.

Ten years old is a very impressionable age. My father, in 1948, said to our family that this was a day of freedom for him. He had voted Labour in 1945. He had been a general practitioner through the 1930s in the Welsh valleys, and he had never got used to charging patients. This was the day when he no longer had to charge patients. But he always said with a rueful smile that there were a few exceptions. One was the Gypsy encampment, which considered that a consultation had taken place only if silver had crossed the palm.

We all know there is a market and there always has been. People have talked about the independence of general practitioners, which has been fiercely fought for. But the interesting thing about this National Health Service legislation is that it was not only a Labour Government achievement. When I was on the Labour Benches I used to proudly claim it as a Labour achievement. Then when I worked with the Liberals and the alliance, I used to claim it was Beveridge. The truth of the matter is that if there are two outstanding people who can claim paternity to the spirit and values and principles of the NHS, they are Beveridge and Bevan.

There is a great wish in this country, wherever people are situated in the political colour frame, to keep some of these values in whatever happens to this NHS. I happen to agree with the noble Lord who spoke that this is a disastrous Bill. It will unutterably change the principles of the National Health Service, and I shall reflect that argument. I have not done so to date because I have tried to see a mechanism whereby the Bill can be discussed. Others will, with perfectly genuine motives, consider it an achievement and the right direction for the NHS, but I think that we ought to be able to agree on the values. I hope that, whatever happens to this amendment in a vote, we will not lose the basic spirit of trying to find a form of words that will underpin these principles and values. They are very important.

Southern Cross Care Homes

Baroness Barker Excerpts

Tuesday 12th July 2011 Lords Chamber

[Baroness Barker]

My Lords, first, I wish to return to the issue that I raised with the Minister on 16 June when we last discussed this matter: the inequalities in geographical distribution of the problem. In particular, will help be given to local authorities in the north-east, where Southern Cross was the major provider? There are not vast numbers of other providers and the problem is far more acute because there is no surplus residential care into which people can be quickly fitted.

Secondly, will the department put in place a monitoring programme for all the residents of Southern Cross, to be carried out over the next two years to monitor the welfare of the individuals who are in the midst of this crisis? The noble Baroness, Lady Thornton, mentioned a fact that has been borne out by research over many years, which is that when people in residential care are subject to stress of this kind it has a very detrimental effect on their health. I wonder whether, in the midst of this, the Government might take that duty upon themselves.

Reform of Social Care

Baroness Barker Excerpts

Monday 4th July 2011 Lords Chamber

[Earl Howe]

I am grateful to the noble Lord, Lord Lipsey, and broadly my answer to him is yes. They are clearly a set of well considered recommendations which we think are eminently worthy of serious study as a basis for cross-party consensus. However, I will not be tempted to pin my colours to any mast that the Dilnot commission has erected because it is important that we have this consensus as far as we can generate it, and that will mean looking at the detail and at individual recommendations on their own merits, maybe taking forward some but not others, and maybe looking at a staggered timetable. These are all questions that we have to resolve between us.

[Baroness Barker]

My Lords, I am in danger of agreeing with the noble Lord, Lord Lipsey, which is something that always worries me, as he knows. I, too, welcome this. After 13 years of the Labour Government trying in various ways to approach this problem we have, with this report, an architecture that is very important, although I agree with the noble Lord, Lord Lipsey, that there a great many technical matters within it that should be open for negotiation.

The report and the extent to which its objectives are achieved rely on two areas: first, a broad political consensus that it is a fair approach to take to the problem; and secondly, as the Minister said, a number of specific technical issues, the main one being that there should be a consistency in the criteria between eligibility for state provision and any insurance-based cover. That is perhaps the biggest single factor in determining whether the entire system will work. What work will be done with stakeholder groups, including carers and older people, and the private insurance business on that specific point? Only by resolving that can we enable individuals to have the security of knowing when the state will pay for their provision and when they as individuals will be expected to contribute.

Southern Cross

Baroness Barker Excerpts

Thursday 16th June 2011 Lords Chamber

[Baroness Barker]

My Lords, after 13 years of a Labour Government who were not in any way reluctant to diversify the residential care market, there is an even greater plurality of providers than there ever was before. One issue that has arisen out of this case is the capacity of the CQC to evaluate the stability and viability in the long term of a company that is owned by a private equity firm. That is a complex task that might challenge even the Financial Services Authority. Does the Minister agree that in order to reach the stable and viable market that he has suggested, there is a need to look at this in a much wider sense than just this case? Does he agree that the discussions that must inevitably follow the publication of the Dilnot inquiry in July should focus on the role of private equity-funded companies in the residential care market and, as he has also suggested, in the domiciliary care market?

[Earl Howe]

My noble friend raises an important issue. As she knows, care providers have to be able to demonstrate to the Care Quality Commission that they have the financial resources needed to continue to provide services of the required quality. We have embarked on a wide-ranging programme of reform for social care. We are currently considering the Law Commission’s recommendations for modernising social care law and, as my noble friend mentioned, the report of the Commission on Funding of Care and Support is imminent. There are many lessons that have to be learnt from the events of recent weeks. We want to reflect on them as part of our wider reform agenda for social care.

On private equity finance, I simply make my own observation to my noble friend: I do not think that private equity finance is at the root of the problems that we have been seeing but the business model, which is rather a different issue. It was the choices and decisions made by the management of Southern Cross that made the business fundamentally unsustainable. I do not see that as a reflection directly on private equity providers. We have been clear that we were going to take action to ensure that there was proper oversight of the market in social care. That is why the Health and Social Care Bill specifically allows us to extend to social care, if we chose to do so, the proper financial regulatory regime that we are putting in place for the NHS. However, I suggest that regulation is not the only solution; we need to approach this in a measured way, not least because there are complex negotiations under way. We need to look at social care reform as a whole, which is exactly what we have committed to doing.

Winterbourne View

Baroness Barker Excerpts

Wednesday 8th June 2011 Lords Chamber

[Earl Howe]

My Lords, first, there is a criminal investigation under way and it would not be appropriate to launch an inquiry, even if we were minded to do so. As the noble Baroness knows, the CQC has launched its own internal investigation. It has admitted that there were failings in its processes. South Gloucestershire Council will lead an independently chaired serious case review, as has been mentioned, involving all agencies, which will look at the lessons to be learnt. The strategic health authorities involved have instigated a serious untoward incident investigation. The department will, after these reviews have been concluded, examine all the evidence and report to Parliament.

We want to understand not only the immediate facts and why things went wrong at Winterbourne View but also whether there are more systemic weaknesses in the arrangements for looking after people with learning disabilities and who exhibit seriously challenging behaviour. It is very easy to make the CQC into a scapegoat. It is difficult to ask of the CQC that it polices every room in every hospital at every hour of the day. We rely on the CQC and have been supportive of it. It does much good work and clearly it will want to review its own processes as part of this.

[Baroness Barker]

Does the Minister agree that when this abuse was taking place, a number of professionals, including nurses and doctors, must have gone into that establishment and that these professional bodies should start to conduct their own inquiries into what their staff were doing in there at the time? Secondly, a bad provider of care has everything to fear from an unannounced visit, while a good provider of care has nothing to fear. Does the Minister agree that as a temporary measure the CQC could consider conducting only unannounced visits in the foreseeable future?

[Earl Howe]

My Lords, I am grateful to my noble friend. My understanding is that all patients at Winterbourne View have been regularly reviewed by a multidisciplinary clinical team in the past six months on behalf of the primary care trust that commissioned their care, and most of them in the past three months. I am sure she is right to say that those who have conducted such reviews should examine their processes and my understanding is that that is exactly what will happen.

We have endorsed the CQC’s proposal to launch a programme of risk-based and random unannounced inspections of a sample of the 150 hospitals providing care for people with learning disabilities. They will work in conjunction with local government improvement and development, ADAS, Mencap and with experts with experience of this programme. The spirit of my noble friend’s question is amply addressed in the programme.

Care Homes

Baroness Barker Excerpts

Tuesday 7th June 2011 Lords Chamber

[Earl Howe]

My Lords, that falls a little way outside the Question on care homes and Southern Cross. I am sure the noble Baroness knows that Winterbourne View is a private hospital with completely different commissioning arrangements. However, I should be happy to write to her. A Written Ministerial Statement that sets out the full position on Winterbourne View is being put down in Hansard today.

[Baroness Barker]

My Lords, do the Government know how many of Southern Cross’s 31,000 residents are self-funders and therefore entitled only to information and advice? How many of them receive state care and are therefore entitled to alternative provision? Given the uneven geographical distribution of Southern Cross’s homes, do the Government know whether there will be any local authorities with no residential care provision should Southern Cross fail?

[Earl Howe]

On my noble friend’s last point, there is a national surplus of care home beds—the figure I have here is some 50,000. Therefore, there is, to my knowledge, in no area a shortage of beds. We are dealing here with a series of local markets. The point that I emphasised earlier remains important. Should it come to the closure of a care home—an event of which we should have reasonable notice if it happens—we will ensure that those in that care home are properly looked after.

Health: Mental Health Strategy

Baroness Barker Excerpts

Monday 14th February 2011 Lords Chamber

[Baroness Barker]

My Lords, I, too, thank the noble Baroness, Lady Murphy, for securing the debate and for the first two minutes of her introduction. I will start by pointing out that both David Cameron and Nick Clegg, very soon after they took over as leaders of their respective parties, chose to highlight mental health as an area about which they felt very strongly and which they believed should be properly addressed in a way that the previous Government were not doing. In one of his first Prime Minister's Question Time, Nick Clegg challenged Gordon Brown on the lack of available access to talking therapies. That was a brave thing to do, because, as noble Lords have said, mental health remains a Cinderella part of the health service and not particularly popular. The Government are to be commended for sticking to promises made before the election and coming forward with a strategy that, as the noble Baroness charitably said, is aspirational. However, it is also comprehensive.

I say to noble Lords, in particular to those who were here a few years ago and who went through the misery of debating what became the Mental Health Act, that there is a stark contrast between the legislation that was passed by the previous Government and this document. I would much rather see a Government committed to, and putting resources behind, some of the aspirations that are in this document. Will it address serious and enduring mental health questions? Probably not. However, it addresses a lot of the issues that were highlighted during the passage of the Mental Health Bill as areas on which the Government needed to work. Therefore, there is much to be commended in it.

In particular, there is much to commend in the way in which the strategy picks up on many discussions that we had in your Lordships' House about how existing mental health legislation was applied disproportionately to different groups in the community, and how certain groups were suffering adversely as a result. It is refreshing to see a document that talks about the mental health of veterans and older people, lesbians and gay men, and people from black and minority communities. That is a refreshing change from the Government, and I strongly welcome it.

I was struck when I read the briefings that we were sent when people outside learnt that we were to have this debate. I looked for the criticisms. Most of them came from organisations such as the NHS Confederation and were not about the contents of this document but about the general position on health funding, to which noble Lords have referred. There was not a great deal to which people took exception in this.

The noble Lord, Lord Touhig, was right to focus on the key question of the ability and capacity of GPs to commission mental health services. At the moment, there is a great hue and cry about GPs’ capacity to commission a whole range of services, and some of the arguments are more compelling than others. It seems that on mental health there is a clear case for the Royal College of Psychiatrists and the Royal College of General Practitioners to work together to inform GPs in very practical ways about how they should go about fulfilling that commissioning process. Can the Minister say whether that is intended to be one of the priority areas in the work of the ministerial advisory group?

There is one very important thing that I wish to dig out from the depths of the strategy document. On page 54, in point 5.84 in the section on improving quality of outcomes, it is stated that payment by results currencies will not be setting-dependent. In lay terms and cutting through the jargon, that means that for the first time we will have a system in which the payment for treatment does not encourage practitioners to keep people in hospital. That is a significant breakthrough. During our discussions on the Mental Health Bill, I remember the noble Baroness, Lady Murphy, talking about the need to make mental health professionals understand that the transition between acute care and community care had to work better for patients. That one measure in itself could have a more profound effect on the organisation of services and outcomes for patients than almost any other, and I was very glad to see it.

Finally, I notice in the document that there is a passing reference to the Mental Health Act and to the increase in the number of community treatment orders issued under it. I well remember people who supported that Bill standing up in this House and saying that we had to support the legislation but that we could review how it was going. I ask the Minister how quickly that will be reviewed and how soon Members of this House and another place will receive evidence on the impact of the legislation. That underpins to a large extent the capacity of professionals to implement what I think is an extremely good strategy overall and one that we should welcome.

Health: Chronic Obstructive Pulmonary Disease

Baroness Barker Excerpts

Wednesday 17th November 2010 Lords Chamber

[Earl Howe]

My Lords, I congratulate the noble Earl on linking mental health with COPD in that neat way. He is absolutely right that smoking is an activity that puts one at high risk of COPD and that smoking is closely associated with poor mental health. Fifty per cent of the tobacco smoked in this country is smoked by those with mental health problems. We are determined to continue efforts to discourage smoking in the general population. We are also keen to raise awareness of good lung health generally, which brings us back to the Question on the Order Paper. To a large extent, such efforts will fall to the new public health service in future.

[Baroness Barker]

Will the Minister say whether the Government have noted the conclusions of the Environmental Audit Committee in the other place, which reported that poor air quality aggravates and is a contributory factor to COPD? Has the Department of Health been in discussion with the Department for Transport about scaling back pollution as part of the forthcoming paper that the noble Lord mentioned?

[Earl Howe]

My noble friend is right to raise the issue of air quality, which is of concern to my department. She is also right that we are working with colleagues across government to look at air quality—particularly in London but also in other cities—which has such a damaging effect on the health of a number of people.