NHS: District Nurses

Baroness Brinton Excerpts

Thursday 10th July 2014 Lords Chamber

[Earl Howe]

My Lords, we recognise the need for urgent action, and that it is required across the piece. We need to train more district nurses, and therefore training places have gone up both last year and this year. We also need to equip district nurses with technology. To that end, the nursing technology fund will address the issue that the noble Baroness referred to initially, which is the time that nurses have to spend with their patients. Technology can make time management much more efficient, and it is also good for the patient, who feels more in touch. NHS England and Health Education England have set up a workforce project which, as I said in my initial Answer, is designed to address not only workforce numbers but also the attractiveness of district nursing to trainees.

[Baroness Brinton (LD)]

My Lords, there has been a 47% reduction in district nurses over the previous 10 years. Does the Minister agree that if we are to have real integration of health and social care, then commissioners, NHS England and Health Education England should prioritise support for district nurses and community posts, not least to reduce the pressure on hospital beds?

NHS: Rural General Practitioner Dispensing

Baroness Brinton Excerpts

Tuesday 8th July 2014 Lords Chamber

[Earl Howe]

My Lords, I do not think that it is a question of opposing choice against the rules that we have in place. The rules are there as a result of very long-standing agreements between the medical profession and the pharmacists. I do not think that there is an appetite on either side to open those rules up for renegotiation. A balance has to be struck somewhere and the professions are content with the balance that has been struck.

[Baroness Brinton (LD)]

My Lords, given that half of patients who use dispensing GP services include at least one person over 65 and that one in six is a disabled person, can the Minister tell us whether the one-mile rule makes sense in very rural areas, where public transport may be very sketchy, especially as the one-mile rule is as the crow flies, not via the roads?

Health: Polypill

Baroness Brinton Excerpts

Monday 7th July 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, the name polypills is slightly unfortunate. When I heard about this, I immediately drew parallels with polyclinics, keeping it in the health arena, at least; but one of my adult children wondered whether this was veterinary medication for our avian friends. The principle, as the noble Lord, Lord Hunt, has outlined—I thank him very much for securing this debate—is that the polypill combines four medicines into one; three to lower blood pressure and one to lower cholesterol. Personally, I prefer the name that they have used in Australia and New Zealand, SPACE: single pill to avert cardiovascular events. It seems a neater acronym and explains much more simply what it does.

I thank the Library for its very helpful research pack, not least because it references the proposal that all over-50s should take it. This is some of the research referred to by the noble Lord, Lord Hunt. Some even suggest that those over 35 who have an at-risk profile might consider taking it every day. Indeed, Dr David Wald at Queen Mary University of London, after his trial, says that 28% of people will benefit by avoiding or delaying heart attacks. However the QMUL studies trial was only 84 patients; perhaps I should say “people”, since it was targeting people who were not yet unwell. Those results show that the blood pressure of around 12% of participants was reduced and 39% had reduction in cholesterol. All this is good, but to have a drug compulsory—because that is how it would be seen, even if it were voluntary—for anyone over 50 seems to me a fairly low benefit ratio.

The papers also describe a cost of “only 50p per day”. This sounds relatively cheap, but it is £15 per month or £180 per year. Even more than that, Dr Wald suggests that it could be sold over the counter and not as a prescription-only medicine. I do not know what the current rate is, but the per-patient allocation for medication in the NHS is not large, and anything over £100 starts to raise eyebrows. The pill would therefore be a substantial burden on the pharmaceutical bill, especially if it was to be used for the entire population over 50 rather than for those who need it.

Even if we accept that there is a good reason to give four tablets in one for healthy people, other considerations still need to be aired. The first is side-effects. The noble Lord, Lord Hunt, referred to statins —I suspect that we all know somebody who is on them—the side-effects of which can range from memory loss, muscle problems, polyneuropathy, acidosis, anaemia, cataracts, immune depression and pancreatic and liver disease. Even if you are lucky enough not to have a response to a single one of those drugs, mixtures of drugs may well have combination side-effects. I know from my own area of rheumatology that some people react badly when a mixture of drugs is taken, and they are instructed to take certain drugs in the morning and others in the evening to avoid such contraindications.

I am slightly unhappy about the reference made by the noble Lord, Lord Hunt, to the polypill being parallel to vaccination. I would much rather that people who were thought to be at risk, which could well be anyone over 50, went down the public health route and were asked to consider lifestyle changes, including stopping smoking, looking at their diet, having their cholesterol tested regularly and, most importantly, undertaking some activity. A lot of publicity was given two or three weeks ago to evidence showing that, for the population over 50, you do not have suddenly to become a Tour de France cyclist or a marathon runner and that steady walking that raises your exertion level a bit every day will do the trick.

I therefore wonder whether this “wonder drug” is not trying to solve too much in one easy go, but I am not alone. In an article that appeared in the Daily Telegraph on 19 July 2012, Dr Margaret McCartney, a Glasgow GP, was reported as saying that more evidence was needed before a mass programme was embarked on and:

“The history of medicine is rich with ideas that sounded great but either didn’t prove effective—or worse, did harm”.

Natasha Stewart, a senior cardiac nurse at the British Heart Foundation, was reported as saying:

“Research into polypills is encouraging, but there are still many questions to answer before this ‘wonder drug’ is prescribed … However interesting this potential new pill is, medicines are not a substitute for living a healthy lifestyle”.

The polypill sounds very enticing, but I am concerned about it for three reasons. First, it is already being described as a wonder drug long before extensive research and careful monitoring of side-effects, including those caused by combining four into one, have been done. As I said earlier, many people are already under strict instructions not to mix certain drugs because they interact. Secondly, the cost at 50 pence a day is not insignificant. To prescribe the pill for a large number of people who will not need it in the longer run seems futile. Like Public Health England, I would much rather see proper medical assessment MoTs being given at 35 and 50, so that people becoming more at risk can be given lifestyle change advice, have regular tests on cholesterol and other things that will indicate whether they are at risk, and can consider whether their level of activity is appropriate. My final concern is that, if the polypill is made available across the counter and not on prescription, some—perhaps many—may think that the pill alone will protect them without their looking at their own lifestyle issues.

Having been pretty depressing about all this, I want to end on a positive note. If further research at a statistically significant level can demonstrate the benefit of the pill, and if the Medicine and Healthcare products Regulatory Agency is satisfied with its efficacy, quality and safety, then, yes, I would welcome it, but there is too little for us to go out and be utterly positive about at the moment.

NHS: Better Care Fund

Baroness Brinton Excerpts

Thursday 3rd July 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I congratulate the noble Lord, Lord Kennedy of Southwark, on securing this debate about the better care fund. This is probably a timely moment to pause and reflect on new routes to integration in the health and social care sectors, but we need to do so with some caution. It is too early to see the implementation of the first round of approved projects to its conclusion, and of course both local council and health budgets are under serious pressure, as all speakers so far have indicated. We also cannot expect full integration without being honest about the cost. It will be interesting to see what emerges in the manifestos of all the parties in the run-up to the next general election.

Still, I am pleased that the coalition Government are determined to see a real start to full integration in health and social care. There has been much lip service paid to it over the years but a marked reluctance by everyone, from politicians in Parliament to local authorities, the NHS and front-line staff, to make it happen. I suspect that this has been for a number of reasons.

First, there is the perception that there is financial competition between the two sectors, each worried about not losing funding to the other. Secondly, financial mechanisms are in place that inadvertently discourage integration. Reports from some areas show that this is a serious issue. Thirdly, which is the most important, the two cultures—social care, whether local government or private providers, versus health—could not be more different. I do not think that the NHS would define itself as naturally entrepreneurial; and it takes a long time to change its ways of working. There have been some major crises recently where we are now seeing wholesale changes in the way we work, as exemplified by the Francis report. The social care sector is a mixed economy, with public service providers working alongside large and small businesses and social enterprises—not just a different model to health but a different model within social care. Therefore it is completely understandable that dialogue at the start of this major project is difficult. But there is progress.

Before turning to that progress, I want to give you one story that absolutely illustrates why we need integration. The aunt of a friend of mine, who lives in Bradford, was receiving both health and social care support at home, which was important because it meant she could live independently. One of her issues was ulcerated legs, with one leg much worse than the other. The bad leg was being treated by the district nurse on daily visits. The better leg was checked and put into support tights by her domiciliary care worker. As a result of cuts made by the Labour-controlled council, all domiciliary care classed as moderate needs was cancelled, including hers. Can noble Lords guess what is coming? Under the local PCT rules the district nurse was not allowed to help with the better leg, so this elderly and vulnerable woman had to rely on a male elderly neighbour to put the special support tights on her leg last thing at night. You see, one leg was NHS and one leg was social care. That was until the better leg deteriorated to the point at which the district nurse was permitted to come in and dress that one too. Honestly, you could not make it up.

That is at the front line; it is not the district nurse but the person in the PCT who is setting down the rules. That sort of behaviour in commissioning makes an absolute mockery of integration. That is what I mean by the clash of two cultures. There are other stories of silo thinking. In some areas there is very little discussion between social services staff and health professionals such as physiotherapists and occupational therapists. Patients are referred by physios and OTs, but there is not a continuing dialogue. One physio recommended an electric wheelchair for a patient, on the basis that this would keep her fully independent, but the wheelchair department’s rules are so strict that the patient did not meet the stringent requirements. As a result, the local authority had to offer a carer to come in to help get her up in the morning, costing both the patient and her council much more money than an electric wheelchair would have cost.

That is enough of the difficult stories. Of course, there are shining examples: not just in Torbay, but in Cambridgeshire and other places. I ceased being a councillor in Cambridgeshire 10 years ago, but even then we had a joint trust between health and social services, as it was in those days, to really start to change the funding. The money was pooled and attitudes really started to change.

We need to hear what these good examples are doing, but also to understand why they work. Unless commissioners and finance directors understand the benefits of integration, there will be a reluctance to move away from the current model. The Bradford case illustrates the point perfectly. Three more minutes of the district nurse’s time would have prevented the better leg from deteriorating and thus costing the NHS more in the long run. Therefore, while there are any cases such as the Bradford one we are nowhere near integration. That is why the extra money from the Government for integration—the £2.7 billion to councils to join up with health and social care providers, as well as local authorities’ extra £100 million this year and an extra £200 million next year—is so vital.

I was delighted to learn from Lib Dem councillors at their annual conference last weekend that the LGA estimates that councils have more than match-funded the total money of £3.8 billion for next year, 2015-16, taking it to £5.4 billion. However, the cost of this means that councils are now spending 35% of their total budgets on social care. Therefore support from central government is essential and I do not believe that we can wait until next year for that to happen.

Personally, I somewhat regret the debate about NHS money being taken by local government. I am sorry to disagree with the noble Lord, Lord Turnberg, but I think that changes in practice will reduce the costs of acute care. Indeed, the noble Lord, Lord Kennedy, referred to amputations for diabetes sufferers in this regard. That is exactly the sort of invest-to-save cost that we should be seeing with the better care fund—for example, spending on preventive care to avoid trips and slips, and in ensuring appropriate support at home for patients being discharged to reduce the “revolving door” syndrome whereby patients return to hospital in a few days. Spending on all those initiatives would help to reduce the crisis in acute care and help to reduce the pressures on its budget.

Where integration is working well, there would not even be an issue about whose money it is, not least because the better care fund plans have been jointly signed off by not just local authorities but clinical commissioning groups and health and well-being boards. Plans have also had to demonstrate how local providers have been engaged. Adult social care services have to be at the heart of the integrated system, supporting health in everything they do by improving hospital discharge and bolstering reablement services.

We have to explode the myth that the better care fund was never intended to solve the financial problems in local government and parts of the NHS. That is one of the reasons why population changes are adding £400 million to council social care budgets every year and why, frankly, budgets must be looked at in this current year. Therefore, will my noble friend the Minister say whether the Government are looking at providing support for the health and social care sector before we even get anywhere near winter problems this year? That is absolutely vital.

I believe that the better care fund is right for the nation’s finances. Investing to save rather than saving to invest is the right thing to do. I believe that in the longer run we need a transformation fund to help the culture change and ease the impact of all the changes that we are talking about, but it must have targets, too, and peer support—something which local government is very good at. The introduction by the Labour Government of the Improvement and Development Agency really helped transform councils that were in trouble and helped with the ground-breaking changes in many council services. It would be good to see that stretched into health and other sectors, too.

In conclusion, I am pleased that the better care fund is now getting well and truly under way but am slightly concerned that NHS England seems to be changing the criteria for targets for the first round and hope that that will not delay the implementation of any of the projects. That must not continue. We will be nowhere near full integration until health and social care for older people in this country are fully funded.

Health Care and Associated Professions (Indemnity Arrangements) Order 2014

Baroness Brinton Excerpts

Monday 30th June 2014 Grand Committee

[Baroness Cumberlege (Con)]

I declare an interest as a fellow of the Royal College of Obstetricians and Gynaecologists, a vice-president of the Royal College of Midwives and a patron of the National Childbirth Trust and Independent Midwives UK. I have other interests that are in the Lords’ register. I thank my noble friend for introducing this statutory instrument so clearly and for meeting the noble Lord, Lord Hunt, and myself, when we discussed the issue of independent midwives.

Draft statutory instruments are not usually a very gripping subject, but this one is because it affects the livelihood of so many people. It is therefore being introduced as an affirmative resolution. Not many statutory instruments, when enacted, will ensure that a professional is denied the right to practice—denied their livelihood. However, I start from the premise that every practitioner should have professional indemnity insurance. Some independent midwives are possibly the only group reluctantly acting without it but not only do they recognise the need for it, they want it and are prepared to go to great lengths to achieve it. This statutory instrument has concentrated minds and focused on the practicalities to achieve it, and from that point of view I welcome it.

It has been a struggle because insurance bodies draw no distinction between midwifery care and obstetric care, and of course the service given by each profession is very distinct. Obstetric treatment is very often a high risk activity, whereas midwife care is much less so. Successive Governments have adopted a policy that women should have choice—choice in healthcare but particularly choice in maternity services. This policy has been very widely welcomed by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the National Childbirth Trust, which have listened to women and have fought fairly long and hard to achieve this choice. All the evidence that they and others have gathered shows that women and their partners want choice. After all, there is nothing more important in life than giving life and bringing up the next generation.

Over the years, choice has been eroded thanks to the closure of maternity units, but in some places midwife-led units or birth centres have replaced them. They are often under threat as well. I welcome midwife-led units because they are another form of choice but I regret the diminution of home births because that is a choice denied. I ask my noble friend: how many home birth services in the NHS are on temporary hold and how many have closed? I know that they are very detailed questions and I would welcome a written reply if that suits my noble friend better than responding now. I am asking these questions because Independent Midwives UK provides for home births. That is a government policy and one that has been strongly endorsed by NICE. Independent Midwives UK provides continuity by a named midwife throughout antenatal care, birth and postnatal care—another government policy. Throughout the NHS this has proved to be pretty unachievable because community midwives are drawn into the acute services whenever there is a shortage, and because there is frequently a shortage it happens frequently.

The department’s new definition of continuity is co-ordination. A named midwife should co-ordinate the care, as my noble friend said previously. We should ask women what they think. Is co-ordination the same as continuity? Of course it is not, when in extremis women cannot even get their co-ordinator on the telephone 24/7 but they can with an independent midwife. Do they build a relationship with the co-ordinating midwife, assisting at that seminal moment of giving birth? No, because she is not there; she is too busy co-ordinating.

Independent midwives in all their forms—as social enterprises, employee-owned organisations, provident industrial societies with “bencom” status and so on—want to provide choice, continuity and care for women both in the independent sector and for the NHS. They are based in their communities and many provide services for vulnerable women, asylum seekers, those with mental health problems and so on, on a pro bono basis, but like the rest of us they cannot live on fresh air. They are seeking commissions with clinical commissioning groups. They are working towards direct referrals from GPs who welcome the continuity of knowing the midwife responsible for a mother who needs advice and support. Can my noble friend suggest ways in which the Government could support independent midwives, who are the professionals who not only support the Government’s policy but are the professionals who actually carry it out?

The NHS mandate, which sets the agenda for NHS England and which my noble friend and his ministerial colleagues shape, is an opportunity to ensure that alternative choices are there for women and their partners. Will he encourage the ministerial team to focus on this issue and enable independent providers of services to thrive, thereby enhancing government policies, giving women choice and providing the continuity that they seek?

In closing, I pay tribute to the Nursing and Midwifery Council, which has taken a very measured view of this statutory instrument, has listened and has tried to meet the needs of all concerned, amending its guidance as necessary. I look forward to my noble friend’s reply, in writing if necessary.

[Baroness Brinton (LD)]

My Lords, I completely endorse all the points made by the noble Baroness, Lady Cumberlege, and I am glad that there has been some give from the council to try to move this difficult issue forward.

I want to make a slightly different point. In these febrile days, when everything in the EU is damned, it is most welcome that this regulation comes from a new directive that is going to give patients across the EU the security of knowing that there will be indemnity and insurance available in every state. It may not be directly comparable but there will be something there. I am pretty sure that this will not hit the headlines but I see it as a major benefit to those of us who travel in Europe, as well as those coming to the UK. It is the sort of thing that is completely hidden from the headlines; it should not be.

On the difficult issue of indemnity insurance for midwives, I have been wondering, having come late to this debate, whether or not there is scope for NHS England, the regulatory councils and the insurance councils to try to work better together. The financial services industry talks frequently about the problems of insuring a very small service. This clearly is that, and it does not fit into an ordinary framework. Yet the midwives have been through exactly the same training as their counterparts elsewhere in the NHS and I am sure that clinical commissioning groups will demand that they have insurance cover. That is absolutely right. Therefore, the problem is in looking at this small cohort of midwives rather than seeing them as part of the greater group who have qualified under the same professional regulation.

I ask the Minister whether discussions will continue to ensure that no one could be denied service simply because they may not fall neatly into one of the categories. Again, I congratulate the Nursing and Midwifery Council on at least trying to find a solution to this difficult problem but it should not be said, as it is in paragraph 8.3 of the Explanatory Memorandum, that there is a balance that has to be made here and, as it affects only a few people, we should perhaps be prepared to let it go. I do not believe that we should.

[Baroness Emerton (CB)]

My Lords, I have one or two points to make. It is not very often I disagree with the noble Baroness, Lady Cumberlege, but we really have to focus on the safety of mother and child.

I am talking about independent midwives only, not the whole directive, because I support the directive. I think there is a problem in that the midwifery profession generally is the most regulated of the nursing professions. They are required to be relicensed every year. They are under a supervisory midwife. They are, if anything, more supervised than the nursing profession. I chaired the professional conduct committee of the previous regulatory body and the midwifery cases that came forward were, in the main, where things went wrong with independent midwives. Mistakes are made—I am sure we all accept that—but the problem is that very often they lack support out in the community.

In a situation where things go badly wrong, there is the issue of who is going to pay the compensation to the mother or baby who has to be cared for for many months or even years. The other noble Baroness—I am afraid I cannot remember her name—said that we ought to be looking at something to help the independent midwives, but how do we help a very small group among a very large number of midwives and try to support them when very often the compensation is enormous?

Health: Patient Safety

Baroness Brinton Excerpts

Tuesday 24th June 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, a 2012 report by the American Department of Health showed that 86% of reportable events were not reported, partly because of staff misperceptions about what constitutes patient harm. Will the Minister reassure the House that both the Government and the NHS regard one in five incidents going unreported as unacceptable? What will the Government do to ensure that all staff understand what needs to be reported and do so in a truly open and transparent culture?

[Earl Howe]

My noble friend makes a series of very important points. Clearly, a balance has to be struck here. It would become self-defeating if every single mistake, even one that had no bearing on patient safety, had to be reported by every single member of staff. The system would be overloaded. We are keen to ensure that those incidents that result in potential harm, real harm or—worse still—death are reported, exposed and dealt with. Of course the National Reporting and Learning System, which was originally part of the National Patient Safety Agency when the previous Government set it up and is now housed at Imperial College Healthcare NHS Trust, has the task of collating safety incidents from trusts and drawing lessons from them. That is every bit as important a process as it ever was. It will be the task of NHS England to draw those lessons together and incorporate them in its commissioning guidance. My noble friend has raised that issue and we have a task ahead of us that will take some time to achieve; but I believe that this is a welcome start.

Legislative Reform (Clinical Commissioning Groups) Order 2014

Baroness Brinton Excerpts

Tuesday 24th June 2014 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, this draft legislative reform order would amend the National Health Service Act 2006 in two ways. First, it would allow clinical commissioning groups—CCGs—to form a joint committee when exercising their commissioning functions jointly. The NHS Act already allows two or more CCGs to exercise their commissioning functions jointly, but does not make any provision for them to do so via a joint committee. Secondly, it would allow CCGs to exercise their commissioning functions jointly with NHS England, and to form a joint committee when doing so. The Act already allows NHS England and CCGs jointly to exercise an NHS England function, and to do so by way of a joint committee, but it makes no provision for them jointly to exercise a CCG function.

This draft order has already been scrutinised by the Delegated Powers and Regulatory Reform Committee and I was pleased with its recommendation that it should continue under the affirmative resolution procedure. I hope it will assist the Committee if I set out the need for these proposals.

I emphasise from the outset that the proposed arrangements are voluntary. One party cannot impose the arrangements upon another. This allows CCGs to retain their autonomy and to continue to make decisions that are in the best interests of their local populations. At the moment, the lack of provision for CCGs to form joint committees is placing a burden on CCGs and preventing them from working in the most effective and efficient way. Without the power to form joint committees, CCGs have had to find other means of reaching joint decisions which are binding. As an interim measure, some CCGs are forming “committees in common”, whereby a number of CCGs may each appoint a representative to a committee in common; those representatives then meet, and any decisions that are reached are taken back to their respective CCG for ratification. This leads to costs in people’s time to sit on multiple committees and administrative resource, as well as extra financial costs.

For example, I am aware of the limitations that the current commissioning arrangements are having on the East of England Ambulance Service. NHS Ipswich and East Suffolk CCG is lead commissioner for ambulance services across the east of England, and the remaining 20 CCGs in the region are associates to that commissioning arrangement. The CCGs established a commissioning consortium, which brings together all 21 CCGs to discuss both delivery against the ambulance contract and future strategy for ambulance services. However, due to the restrictions of current legislation, the consortium itself is not delegated any decision-making authority. While most CCGs party to the consortium have delegated a level decision-making authority to the individual officers who attend the consortium, the contract with the ambulance service is large, and decisions may exceed delegated limits. In those instances, decisions must be referred to CCG governing bodies, introducing a delay to the decision-making process.

Clearly arrangements such as these are burdensome, particularly when compared to the simplicity of a joint committee. Primary care trusts, the predecessors of CCGs, were able to form joint committees at which, subject to the terms of reference, all participating PCTs were bound by the decisions reached. We therefore want to allow CCGs a route in which, when they are collaborating with other CCGs, they can take decisions in a properly constituted forum. Furthermore, CCGs when agreeing to form a joint committee will have the freedom to agree terms of reference, including voting arrangements. This will not dilute the emphasis of local decision-making.

Similarly, the lack of any power for CCGs to exercise their functions jointly with NHS England is also causing inflexibility. NHS England and CCGs may wish to act jointly to commission better out-of-hospital services, for example. Making sure that services are integrated around the needs of the patient is the best way of ensuring that care is provided in a safe and compassionate way that most benefits the person. This amendment would allow CCGs and NHS England, as co-commissioners, to develop and agree strategic plans and delivery processes that take into account the effects of services across a whole pathway, facilitating design and continuity of services across primary, secondary and community care.

For example, CCGs and NHS England may wish to review service delivery across specialised services, commissioned by NHS England, and any impact redesign may have on non-specialised acute services, commissioned by CCGs, in order for services to be designed and delivered to achieve the best possible outcome for the population served. The inability of NHS England and CCGs to jointly exercise a CCG function and to form a joint committee when doing so makes it more difficult to make timely decisions, which can delay the ability to improve patient safety. Furthermore, the amendments would encourage the formation of new commissioning partnerships, allowing the most effective approach to be used.

The amendments would build upon them by giving CCGs greater flexibility and control in the way that they work. As CCGs become more established organisations, they need to have more flexibility to work together, and with NHS England. In any commissioning structure you have in place, there are always going to be some decisions that may need to be taken locally and some that span a wider population.

CCGs are still accountable as individual organisations. Joint arrangements mean that each CCG is still liable for the exercise of its commissioning functions, even where they are being exercised jointly with another CCG or NHS England. These proposed arrangements will not lead to reconfiguration by the back door. The purpose of these changes is to support more effective joint working and to allow discussions about service redesign to take place across the health economy. The proposed changes will not affect the existing processes and tests that any significant service redesign needs to follow. I beg to move.

[Baroness Brinton (LD)]

My Lords, the NHS Act 2006 started us down the route of commissioning; obviously, with the updating and creating of clinical commissioning groups under the Health and Social Care Act 2012, we are still moving into fairly new territory. Inevitably, CCGs are feeling their way in the new structures, including joint working. I am pleased that the order will now legislate more formally for CCGs to work closely with each other and with NHS England, and to jointly commission where appropriate.

One of the many reports that come back to your Lordships’ House from CCGs and NHS trusts is the desire to gold-plate any system with legal advice. For example, we know that the Health and Social Care Act enabled tenders to be taken for quality and efficacy, not just on cost, as under the 2006 Act, yet we hear time and again that lawyers tell commissioners that cost is the most important point. I also welcome the issues around CCGs and National Health Service England overlapping. The Minister referred to some of those; it is also important where there is a pathway in rare diseases, where there may also be some linkages with CCGs perhaps implementing at a lower level. That will smooth the way for that to work well.

To this non-lawyer at least it seems extraordinary that CCGs could not form joint committees to commission over boundaries. This draft order now makes it crystal clear that joint commissioning and the arrangements for ratification by the separate CCGs are not just acceptable but welcome. It is encouraging to see in the accompanying notes that the consultees to this order also see it as a cost-efficient measure; I add to that smoother working systems and, most importantly, joined-up services for users of the NHS.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the face of it the order is unexceptional, although I agree with the noble Baroness that CCGs have got themselves into a ludicrous state of getting legal advice on almost everything. It is patently obvious that there are ways in which they can come together to make decisions. We also see that as regards tendering, where, despite the commitments the noble Earl made, we see CCGs absolutely panic-stricken about making a decision not to tender out services. If ever one wanted evidence of the foolishness of the arrangements we now have, it would be the kind of reaction we are seeing from CCGs.

I will ask two or three questions on the order. I noted in paragraph 4.6 of the consultation paper that the department points out that there was opposition to the proposal to enable CCGs and NHS England to form joint committees. I understand that while it is mainly about CCGs forming joint committees, they can also form a joint committee with NHS England. The necessary protection is laid out in paragraph 3.6 of the paper we received, which says that:

“The Minister considers that the proposals maintain the necessary protections. CCGs enjoy a degree of autonomy”.

I thought that they were going to be autonomous, but there we go; it has been qualified in that document. The paragraph goes on:

“To this end, NHS England is under a duty … to promote the autonomy of persons exercising functions in relation to the health service. The wording of the proposed amendment to section 14Z9 is designed to ensure that a CCG function can only be jointly exercised with NHS England where both parties are in agreement, thus preserving a CCG’s autonomy”.

I put the point to the noble Earl that if you talk to CCGs, they do not feel autonomous, because they are used to being beaten up by NHS England—receiving incessant phone calls from the local offices of NHS England—and they and the accountable officer find themselves under huge pressure when there are problems with the system. Therefore the idea that there is an equal partnership between NHS England and the CCG as regards a joint committee is simply not believable. Clearly, local area teams will use that mechanism to force CCGs into joint committees and then force decisions through. I would have thought that that is patently obvious from what is happening in the field in the National Health Service. I would be grateful to hear the noble Earl’s comment on that.

Of course, I have no problem about CCGs working together so that we can get rid of some of the current fragmentation. If we take my own patch of Birmingham, where three and a half CCGs cover the city, there is no chance, it seems, of actually having a strategy for the city which can embrace all the trusts and commissioners unless it is done jointly. I would like to hear from the noble Earl how in fact this mechanism is going to be used to encourage CCGs, which are patently too small in many areas, to come together so that we get some decent strategic planning instead of the fragmented and inadequate contracting process that so many CCGs are undertaking at the moment.

I would also like to ask the noble Earl about consultation when decisions are made by a joint committee. I assume that the consultation rights and responsibilities would apply to a joint committee as much as they do to an individual CCG but, as there is scant evidence of CCGs undertaking proper consultations, I suppose that that is not much comfort. It would be good to hear a little more about how CCGs are going to work this. I must say that after two years of this wonderful new system, I am still waiting for a letter from my CCG saying that it actually feels some form of accountability to me as an individual, but alas that letter has yet to come. From the legal cases which have been brought against some CCGs, it is clear that they do not have any sense of accountability to their local population. That is not surprising because they are membership organisations. They are owned by GP practices, which are the members of the organisation.

This morning I listened to Simon Stevens, appearing before the Public Administration Select Committee, talk about the proposal to hand over some of the contractual responsibilities of NHS England to CCGs. So, in effect, not only are the CCGs membership organisations, they are now going to be given co-power with NHS England to contract with the individual members of the organisations in relation to primary care services. I can well understand why the local area teams do not have the capability to manage the primary care contract. It was patently obvious that they were not going to do so. But what it comes back to is that the governance of CCGs is hopelessly compromised. They ought to be public bodies with much greater lay representation. If they were, we would have much more confidence in the arrangements, but they are not. They are dominated by contractors who have a vested interest in the decisions made by those clinical commissioning groups.

Finally, I turn to page 3 of the impact assessment that provides the evidence base for the supporting paper. It is implied that decisions to deal with specific funding requests might be dealt with by a joint committee. That, of course, is a euphemism for rationing services. Again, we know that some CCGs are making highly dubious decisions about restricting patient services to which NHS patients are entitled. I would like some reassurance that if the joint committee is going to do this, it will be done in public, not behind closed doors, and after full consultation. Recently I have been particularly concerned about evidence which shows that NICE technology appraisals are not being fully implemented in the National Health Service. I remind the noble Earl that it is a legal requirement for a NICE technology appraisal to be fully implemented by the NHS. Again, I would like to hear what the Government are going to do to ensure that CCGs actually play fair by the public and do not unnecessarily restrict treatments.

The order itself is unexceptional and it is supported, but I have to say that the performance of some CCGs leaves a lot to be desired. It is because of the potential of the joint committees to make major decisions that I raise some concerns today.

Mental Health: Parity of Esteem

Baroness Brinton Excerpts

Monday 23rd June 2014 Lords Chamber

[Earl Howe]

My Lords, yes, we are doing so. We are paying attention not just to women in prison but to women and men in prison and in the criminal justice system more generally. We have committed £25 million to introduce a new liaison and diversion scheme in England to identify and assess the health issues and vulnerabilities of all offenders when they first enter the criminal justice system, which I think is the crucial moment. We are building on liaison and diversion services to improve the quality of those services and their coverage across England, and we are trialling a core model in more than 20 areas over the next two years with the aim of moving towards comprehensive rollout by 2017.

[Baroness Brinton (LD)]

My Lords, is the Minister aware that one in 10 children between the ages of five and 16 has a mental health problem and may continue to have problems into adulthood? What are the Government doing to ensure that child and adolescent mental health services are properly funded by NHS England and CCGs?

[Earl Howe]

My Lords, we are investing £54 million over the four-year period from 2011 to 2015 in the Children and Young People’s Improving Access to Psychological Therapies, CYP IAPT, programme. That, along with the measures that I referred to earlier, will, I hope, give a sense of the priority that we attach to children and young people’s mental health services.

National Health Service

Baroness Brinton Excerpts

Tuesday 17th June 2014 Grand Committee

[Baroness Brinton (LD)]

My Lords, I thank the noble Lord, Lord Crisp, for initiating this interesting debate on citizen and patient power. In the brief time available I want to focus on an issue that I believe is more likely to produce real reform in the NHS than many structural changes.

Before doing so, I must declare my interest as a patient with a chronic illness—rheumatoid arthritis—and it is RA Awareness Week, to get the plug in. I have some knowledge of my disease and its consequences and read up on treatments and their side effects. Later on I will talk a bit about the expert patient programme and it will be obvious that I am a convert to it.

First, however, let us go back 50 years. In those days, doctors liked the bedside manner approach, key to which was putting patients at their ease. It certainly was not intended to give patients more power in the NHS. The picture that comes to mind is of James Robertson Justice as the paternalist consultant, patting a patient on the knee and saying, “Don’t worry your pretty little head about it, my dear, that’s my job”—rather like the consultant mentioned by the noble Baroness, Lady Pitkeathley. The good news is that things have improved greatly, but sadly it is also patchy.

Empowering patients about their health issues and treatment seems to have been introduced first in chronic conditions, where a range of healthcare professionals are involved, and frankly, where it is in the best interests of the NHS to make patients more involved in their treatment, whether informally or in a more formal system such as the NHS expert patient programme. In April this year the Health Foundation published a thought paper by Dr Alf Collins, a clinical expert in pain management. This brief 12-page paper is well worth the read: it is a revelation. Right at the start the Health Foundation sets out its goals for,

“a more person-centred health care system. One that supports people to make informed decisions about and successfully manage their own health and care, including choosing when to let others act on our behalf”.

It goes on to say:

“This requires a change in behaviour and mindset from patients and clinicians, supported by a system that puts patients at its heart”.

Let me give you two brief examples of people that I know, to illustrate the difference between the more usual and traditional patient-reported outcome measure, versus the person-centred patient-reported experience measure.

Jane—not her real name—has a chronic disease with pain and fatigue. She is finding her new medication hard to manage, it is making her sick, and she is worried about managing her children and her part-time job. She goes to see her GP and bursts into tears, saying that the pain is excruciating, she thinks the medication is not working and she is at her wits’ end. The GP says, in a kindly way, that she wants to refer her to the mental health team for some psychiatric support. Jane goes home, absolutely convinced that the GP thinks she is mad and does not believe that she is ill at all. Jane's story is real; in fact, yesterday I read it on a bulletin board. The GP was focusing on the outcome. What could she do for this patient to help her instantly? There was a magic solution: a referral elsewhere.

Contrast that with another patient. It is the same illness with the same treatment, but all the healthcare professionals involved with her care ask her questions. The GP in this case asks about the side-effects and what she wants to achieve: does she need time off work, or medication to reduce the nausea so that she can continue to work? She is reminded that depression is a common issue for people with this disease, especially for people with her side-effects at the moment. Does she want further help? The patient consultation lasts exactly the same time, but the latter patient walks away with reassurance, knowing that if she needs more help it is available, and with a prescription for the nausea so that she can try to stay working, which should also help to reduce the depression. This, too, is a recent story—it is mine.

The latter is a patient-reported experience measure and is great for the patient. It is worrying for commissioners, though, because most commissioning is based on clear, achievable outcomes—referrals, medication, operations—rather than the softer and qualitative experience measures. A typical NHS expert patient programme provides patients help with dealing with pain and fatigue; relaxation techniques; healthy eating and exercise; how to communicate with their family, friends and healthcare professionals; and how they can best plan for their future.

Research into expert patients shows that they need fewer interventions, are less anxious, more confident, can communicate better with healthcare professionals, take less time off work and are less likely to suffer acute episodes requiring expensive admission to hospital.

I agree with the noble Lord, Lord Crisp, that England may well be ahead of the curve. A French consultant gave a Gallic version of James Robertson Justice to my mother-in-law just last year, even though she is a retired nursing sister with 40 years’ experience of the NHS and speaks fluent French. What I like about Dr Collins’s paper for the Health Foundation is that it sets out clearly for healthcare professionals how they can move to this different mindset. What is particularly encouraging is that it really helps patients and saves money. What is not to like? Let us hope that this is the sort of thing that moves us to real patient empowerment in the future.

Health: Rheumatoid Arthritis

Baroness Brinton Excerpts

Monday 16th June 2014 Lords Chamber

Asked by

[Baroness Brinton]

To ask Her Majesty’s Government what steps they are taking to ensure that general practitioners are trained to recognise potential rheumatoid arthritis symptoms, and refer such patients immediately to rheumatologists.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, the Government’s mandate to Health Education England includes a commitment that it will ensure that general practitioner training produces GPs with the required competencies to practice in the NHS. The content and standard of medical training is the responsibility of the General Medical Council. The current GP curriculum requires trainees to successfully complete training on care of people with musculoskeletal problems, which includes rheumatoid arthritis.

[Baroness Brinton (LD)]

My Lords, I thank my noble friend for his helpful Answer. However, the reality is that too many GPs do not recognise the symptoms. A new report published today by the National Rheumatoid Arthritis Society shows that a shocking 25% of patients have to stop work within the first year of diagnosis, and with the delays their clinical outcomes are poorer and it costs the NHS much more. What will the Government do to raise awareness of symptoms, particularly among GPs?

[Earl Howe]

My Lords, I pay tribute to the National Rheumatoid Arthritis Society, which is organising Rheumatoid Arthritis Awareness Week this week, between 16 and 22 June. I am aware that Public Health England has run early diagnosis campaigns, which up to now have focused largely on cancer. However, I understand that a broader focus on earlier diagnosis is currently being considered. What might be done to tackle other conditions or symptoms has yet to be decided, but I will keep the noble Baroness informed of developments.