Health and Social Care Bill

Baroness Donaghy Excerpts

Monday 19th December 2011 Lords Chamber

[Baroness Farrington of Ribbleton]

My Lords, I rise to speak about the importance of the role of the police. I made my maiden speech in your Lordships’ House on the subject of care of mentally ill people taken into custody in police cells. I was struck at that stage—I declare a former interest as a member of a police authority and a visitor of police cells—that time after time, I was informed and became aware that people were being taken into custody, not because it was most appropriate, but because their problems were mental health related. They were being taken into police cells for their own protection or for the protection of other people, because there was nowhere else for custody officers to deal with this. I hope the Minister will take this carefully into account when looking at the role of the police, in particular at that initial point of contact. Sadly, many people who end up in custody and police cells have problems that are either mental health related or drug or alcohol related. It creates a problem for the police service, particularly at weekends. It also leads to a reaction to those people who have behaved in a way that causes them to be taken into custody so that they end up in prison, rather than receiving a course of treatment.

[Baroness Donaghy]

My Lords, I support the amendments of the noble Baroness, Lady Finlay of Llandaff, which refer to allied health professionals, and I want to widen them to include the whole health team. We have been talking about structures, consultation, rights of representation, and roles and responsibility in the new structures, but we need to ensure that the service is delivered to the patients by the health team. Nowhere does the Bill appear to acknowledge the importance of the majority of staff in the health and care services: the invisible majority. I know from working in universities for 33 years that there are academics and students, and then all the rest who are often referred to in the negative as non-teaching staff. In the health service, there are doctors, sometimes nurses, and patients, while the rest are rarely referred to as people: they are back office or integrated services. I want to place on record the importance of the health team: the cleaners, caterers, maintenance staff, technicians, receptionists, secretaries, administrators, finance staff, and those involved with transport, as well the allied health professionals mentioned by the noble Baroness, Lady Finlay.

When I was a non-executive director of a foundation trust, we had to deal with the issue of staff who were employed by PFI projects. It is not my intention to discuss the rights and wrongs of PFI, but to illustrate the huge efforts required to ensure that the PFI staff felt part of the health team, even though the foundation trust had no direct management responsibility. The same applies to contracted-out staff generally. Some, though not all, of the problems of hygiene in hospitals and failure to feed vulnerable patients were caused by the separation of these contracted-out staff from the health team. If transport is not co-ordinated, a patient can be in a ward for an extra day. An efficient receptionist can make the difference between an efficient department and a failing department. Those are only two examples. There has been a deafening silence about the health team, and I am seeking a statement of support for all the staff in the health service and an acknowledgement that the future of the service, whatever that is after this unnecessary Bill, will depend on the health team being able to work together in an integrated way.

[Baroness Cumberlege]

My Lords, I address my remarks to Amendment 330ZAB and others that concern the composition of the health and well-being boards, and I would like to say a word in general about the boards.

To me, they are a spark of inspiration. In the next grouping we will have some specific amendments from noble Lords concerning integration, and we have heard a bit about it already today. I have been conscious that throughout the Committee debates the virtues of integration have often been referred to by my noble friend Lord Howe, and part of the integration he has cited is that very valuable tool, the health and well-being board, bringing together social services, health, and importantly, local healthwatch.

The Bill is gratifyingly lean in its suggested membership of the board: just six essential members. However, in Clause 191(2)(g) it gives flexibility in allowing the board to appoint:

“(g) such other persons, or representatives of such other persons, as the local authority thinks appropriate”.

However, in the same clause, 191(9), it must consult with the members of the board. That seems absolutely right and proper. The success of these boards will be in their balance. That is very important, and what we cannot afford is a single constituency trying to pack the board with its own colleagues. The board itself can put a brake on that, and keep the balance right.

The board itself can appoint additional members, and I can see that being invaluable if the board has chosen a subject which it wishes to target, such as obesity, as mentioned by my noble friend Lady Jolly. Poor housing was also mentioned, as well as alcohol, sexual health, prisons, probation, or children. There is nothing to stop the board giving the individual a short tenure, if the board so wishes. However, if we concede to all these additional, very persuasive arguments that are being put for adding more and more members—I had a quick count of all the amendments on the Marshalled List—we would have statutory boards in the order of 24 members. That is a nightmare for quick decision-making.

I chaired a joint finance committee years and years ago, when we were trying to do the same thing, and we had a board of that size. It became a talking shop. No one would take the decisions that were really necessary. With great respect to local government, where I spent 20 years, we do not want another committee of the council. These boards have to be different.

I said I thought the concept was a spark of inspiration, but I can see this spark extinguished very quickly if we end up with big, unwieldy, cumbersome talking shops. The health and well-being boards should be composed of the great innovators; people with unusual and challenging ideas; people who are prepared to think the unthinkable; imaginative people, fleet of foot, trying new ideas, and abandoning them if they do not work out. Above all, they should be the risk takers.

We know that innovation seldom comes from large, cumbersome committees. It very often comes from young people sparking off ideas. These are people who are probably quite difficult to work with. The Steve Jobs, the Bill Gates, the James Dysons of this world, determined to get their ideas from the drawing board into our homes, changing our lives for the better. They are the people who are not afraid of disruptive innovation.

The NHS thirsts for innovation, but it cannot face the disruption. One of the examples of successful disruptive innovation that I came across is Hairdressers for Health. In a very impoverished area south of Manchester, where you heard the crunch of broken glass under your feet when you walked, where graffiti was everywhere, where the school was protected by razor wire, the hairdressing salon was one oasis of peace and sanity. A junior director of public health, who was very anxious to increase the uptake of cervical screening, recruited the hairdressers to ask their clients—people will know that hairdressers always refer to their customers as clients—whether they had had a cervical screen and, if not, to give them the reason why they ought to go and have one. The hairdressers were given a book of difficult questions that they could answer and a phone number if they got stuck. The results were really impressive. When I asked the women why they went for cervical screening, they would say, “Tracy does my hair. She does it beautifully and I really trust Tracy”.

There are a million reasons why you should not go down that road. If you had a big, cumbersome committee, I can just hear the remarks, “The hairdressers aren’t up to it. The hairdressers really won’t have the information. The clients won’t believe the hairdressers”. No, here was a courageous young director of public health, not working through a huge board, thinking really laterally and doing something terrific. That is what we want from these health and well-being boards. We do not want large committees full of worthies shirking innovation because it is just too risky. Of course, there are always a million reasons why you should not do something. What started as an inspiration is quickly reduced to the boring status quo because that is safe. It takes an awful long time to get back to the boring, safe status quo.

When people decide for themselves, they are more likely to be successful. I applaud the flexibility of the Bill. I see merit in every case that is being put today. The case is being put extremely persuasively, but I urge your Lordships to resist the temptation to tie the hands and stamp on the autonomy of the new boards. We need them to be a success. I am working at the moment with some that are in shadow form. The good will that is in those boards is terrific. We should be enhancing and cherishing that and not directing exactly how they should work. If we do that, I regret that we will simply have just another committee of the council.

Health and Social Care Bill

Baroness Donaghy Excerpts

Tuesday 25th October 2011 Lords Chamber

[Baroness Jolly]

My Lords, I do not intend to take an awful lot of your time with my comments. I agree with many comments made by my noble friend Lady Williams, and I share the anxieties expressed by the noble Baroness, Lady Murphy. To a certain extent I am bemused, because we have a perfectly good NHS constitution. It has been said that it is only three years old and indeed it is. It was a result of the work of the Labour Peer the noble Lord, Lord Darzi, and involved a huge cross-party effort. This is to be commended. This amendment does not match it in breadth or scope.

We are now in Committee and it is not sensible of us to prolong the debate. We have many, many days yet to go and we really need to move on and get on with the Bill. However, I want to finish by thanking the noble Baroness, Lady Thornton, for her compliments about our conference motions and the way in which our policy is made following votes by our members at conference. The second subsection of this amendment came from a motion to our conference last spring. We wanted the NHS to work for patients and not providers and as a result of this and the Future Forum deliberations, this was acknowledged. Furthermore the Monitor duties were changed to reflect this so that they now are about the promotion and protection of patient care. I really feel that we need to move on and get on with the Bill.

[Baroness Donaghy]

My Lords, I support this amendment for three reasons. I will be brief, bearing in mind the comments made by the noble Baroness, Lady Williams.

First, in a Question in the House today, the noble Lord, Lord Low of Dalston, asked for an inquiry into the nature and extent of commercial lobbying of Ministers. If it is considered bad now, I have a great fear that it will be an even bigger problem when we get to the commercialisation of the National Health Service. As a former member of the Committee on Standards in Public Life and a former acting chair, I regard it as a reassurance to have reference to the Nolan principles in this amendment. More importantly, I think that it will be a reassurance for the members of staff who work in the health service.

I want to draw the Committee’s attention to two of the most important parts of the principles: openness and accountability. We have already seen—certainly in my experience as a non-executive director of a foundation trust until a couple of years ago—phrases such as “commercial confidentiality” creeping into discussions about how we conduct our health service. How much more will that phrase creep in when the kind of proposals in this Bill become an Act?

Currently, research and knowledge are shared by the medical profession, both nationally and internationally. If you are involved in any way in higher education and medical research, you will see how important that is for the advancement of medicine generally. Unless we embed these principles in the amendment, I fear that they will be under threat and the efforts of our medical profession will be compromised.

Health and Social Care Bill

Baroness Donaghy Excerpts

Wednesday 12th October 2011 Lords Chamber

[Baroness Donaghy]

My Lords, we all have direct experience of the health service, some good and some not so good. Like most noble Lords I support change. I would like to go on to a hospital ward and find someone in charge. I hope that no one else will have to go through the obscene ping-pong of an elderly dependent relative going backwards and forwards between care home and hospital, not knowing what is best for them, but having them regarded either as a bed-blocker or a health risk.

Of course we need improvements, but it is vital that our own personal prejudices do not get in the way of the overall picture. To pretend that this Bill will solve any or all of these issues is to present a false prospectus. Despite raising these matters, we still do not know how failing organisations will be dealt with, how we will prevent GPs from abusing financial incentives, or how local authorities will be able to afford to set up elaborate new structures. We still cannot work out how the word “streamlining” can be used in the context of more committees, more overlap and more cost. Asking us to agree to this Bill is not just asking us to walk into the unknown, which is fair enough—innovation is good—it is asking us to dismantle our home beforehand.

If this were 1997, things were so bad there would have been popular support for any change, even a rotten one like this, but we are not in 1997. Things are different now. Enormous resources, self-respect, massive innovation and professional incentivisation have changed the agenda. We are now trying to protect what has been achieved. I was once involved in appointing new consultants. It was one of the most exhilarating of experiences. The new generation is chock-full of talent, is aware of the importance of outcomes and does not think that money grows on trees. We are so fortunate in our health service staff, and we should be praising them and taking them with us. As a former chair of ACAS, I know that consent is what leads to better productivity. I say to my noble friend Lady Wall that of course health service staff want certainty. They have wanted it for 63 years, and they are not going to get it. Do not be tempted by the seductive words that any decision is better than none. I have a friend who has worked in the health service all her life and is now on her 24th reorganisation. I am not saying that uncertainty is good or desirable in itself but, as the NHS constitution says, the NHS belongs to the people. As long as that is the case, politicians will always tinker. The alternative is that they might not belong to the health service any more and might be on worse conditions and have inferior pensions.

Yesterday the noble Baroness, Lady Bottomley, spoke of the burdens of ministerial office in the Department of Health, and I have no doubt that all Ministers work way beyond their best capacity. However, I believe that she obfuscated the true meaning of ministerial responsibility by emphasising day-to-day business and micromanagement, and her Tesco analogy really let the cat out of the bag: there is a national Commissioning Board if ever there was one. Some towns have so many Tescos that they are campaigning against them. Its success was built at the expense of the small provider—the local shop—and suppliers so desperate for contracts that they would enter into deals of slave-like proportions. Yes, quality was improved, but it was achieved by pushing down the exploitation to the lowest level.

Let us be clear: we are all in favour of better integration of services, but I think there are yawning gaps in the Bill about how social care will be treated. This subject is not new. In 1968, there was the Seebohm committee report, the health Green Paper and the Royal Commission on Local Government in England—the Maud report. In the debate on the Seebohm report in this House, Lord Amulree said:

“There is a need for a link between the residential homes … and the hospitals … This is something which does go wrong at the present time”.—[Official Report, 29/1/69; col. 1180.]

Amen to that 43 years later. That comment was made when most residential homes were run by local authorities. If it was difficult then, how much more of a challenge will it be under the current set-up? I believe that care homes are a scandal waiting to happen.

What of the Government? The Prime Minister is to be admired for two reasons. First, he has the luck to have one of the most talented Ministers in this House to present this Bill. The noble Earl can truly make this “Titanic” look like Roman Abramovich’s yacht. Secondly, I admire the Prime Minister for his loyalty to his friends and, in particular, his friend Andrew Lansley. I share the same birthday as the Prime Minister, although, unfortunately, not his age, so perhaps we share that value, but the Secretary of State’s stubbornness is now a liability, and the Prime Minister should consider whether personal friendship is more important than running the country.

What is this Bill really about? It is about two things, and they are simple and stark, so they have to be wrapped up in lots of packaging. First, it is passing the ration book to GPs so that they get the blame. Secondly, it is laying the groundwork for the privatisation and dismantling of the National Health Service.

I shall finish with a quotation from Benjamin Disraeli. It is not:

“England does not love coalitions”,—[Official Report, Commons, 16/12/1852; col. 1666.]

or even his comment on the Liberal Government of the day:

“You behold a range of exhausted volcanoes”.

It is this from February 1851:

“I read this morning an awful, though anonymous, manifesto in the great organ of public opinion, which always makes me tremble: Olympian bolts; and yet I could not help fancying amid their rumbling terrors that I heard the plaintive treble of the Treasury bench”.—[Official Report, Commons, 13/2/1851; col. 602.]

In a previous speech, I compared the health service with Little Red Riding Hood, with the noble Earl as an unlikely wolf sitting in bed with a frilly nightcap and speaking with a soft voice. When you consider how to vote, beware not only the big, bad wolf but, under the bed, the plaintive treble of the Treasury Bench.

NHS Future Forum

Baroness Donaghy Excerpts

Thursday 15th September 2011 Lords Chamber

[Baroness Donaghy]

My Lords, I also thank my noble friend Lady Wheeler for the opportunity to have this debate today. We have heard reference to the start of the political party conference season. The Future Forum exercise and the Government’s response have been presented by some as a David and Goliath battle to secure major concessions on the reorganisation of the health service—plucky Nick facing up to the giant privatiser and winning while claiming that it is not about winning. But we have the wrong bedtime story here. It is not David and Goliath but more like Little Red Riding Hood. I appreciate that the noble Earl might appear to be an unlikely wolf, but let us not forget that even the wolf dressed up in a frilly nightcap and adopted a soft voice. There are more questions than answers here, and some of the original questions remain. Why is there to be a major upheaval of the health service when all the staff are working flat out to provide a good and comprehensive service? Why are more quangos to be created rather than fewer? What will be the real role of Monitor in its revised format? And why are we giving £80 billion to the NHS Commissioning Board, the daddy of all quangos?

Since the Future Forum listening exercise, and here I must commend the diligence of its members, a revised Bill has been presented which we will debate in this House in October. But the Bill gives rise to new questions. First, in revised Clause 1, the Secretary of State’s powers and duties are closer to the current duty as set out in the NHS Act 2006, but as has been said, the phrase “to provide” has been deleted on the grounds that,

“having the premises and the staff necessary to offer health services directly does not reflect the reality of the situation in which commissioning and provision rest with the NHS bodies, not the Secretary of State”.

I think we all accept that no matter how hard they might try to distance themselves, the political reality is that Governments will always be held responsible for the state of the health service. So why should we worry about semantics, and indeed, is it about semantics? The Government’s response to the Future Forum exercise stated that the Bill would,

“make explicit that the Secretary of State remains fully accountable for the NHS”.

That sounds fine, but where is the responsibility for social care, a question also asked by my noble friend Lady Pitkeathley? What will be the definition of the NHS further down the line if providers are private companies? I am not a lawyer and I have no idea what the legal implications of this change mean, but I am a graduate in English language and literature. I know what “to provide” means and I am concerned that the significance of this omission will grow and grow as the years go by.

My concern is heightened because the responsibility for defining what constitutes the health service is being transferred from the Secretary of State to clinical commissioning groups. While the Secretary of State is still responsible under the new system for the promotion of the health service and ensuring that it is free of charge, clinical commissioning groups will determine what services actually constitute the health service. Just when I tell myself that I am worrying unnecessarily, I am then reminded that in the summer, the Health Secretary instructed primary care trusts to identify three services to be put out to contract. I am supposed to be reassured that the new private providers will not be allowed to cherry-pick, but the Bill only requires transparency in how patients are chosen. It says nothing about the easiest and most profitable types of treatment to provide, which could still destabilise the National Health Service.

I turn to the role of Monitor. The language is definitely softer: its primary duty is no longer to “promote” competition, but to prevent “anti-competitive practices”, a point already raised by my noble friend Lord Rea in his contribution. The Minister in the other place has claimed that this is a fundamental change and that Monitor’s main duty would be to protect and promote the interests of people who use healthcare services not by promoting competition, but by promoting the economic, efficient and effective provision of healthcare services. Again, I would love to ask a seminar of English language undergraduates to write a critique of the difference between promoting competition and preventing anti-competitive practices; drinks on the Terrace for the best essay. The Bill gives Monitor powers to fine hospitals up to 10 per cent of their turnover for anti-competitive behaviour and a new duty to promote integration. What exactly will that mean in practice? Could we see a situation where a hospital which is struggling financially is forced into the arms of a foundation trust in the name of integration? Who will pick up the overdraft? Beware the big bad wolf.

Finally, we come to the issue of what happens if Monitor declares a commissioner’s arrangements for the provision of health services to be ineffective, perhaps where it has failed to comply with procurement regulations. Indeed, what will happen if a service runs out of money? The Government have not yet presented their revised plans for a failure regime. The Minister’s explanation was that they would not rush their proposals for such a regime as it is a complex issue and they want to “get it right”. That is the second time this week that I have come across the “get it right” reason for having no information on a vitally important topic. The first time concerned regulations on the way in which the self-employed would be treated under the Welfare Reform Bill. At some stage we really need an organigram, also called for by my noble friend Lady Wheeler, setting out what the new structure will look like, who is in charge and how social care fits into it all. Without it, I hope that Little Red Riding Hood will stay on her guard.

Health: Academic Health Partnerships

Baroness Donaghy Excerpts

Monday 29th November 2010 Lords Chamber

[Baroness Donaghy]

My Lords, I am grateful to the noble Baroness, Lady Finlay of Llandaff, for initiating this important debate. My interest in academic health partnerships arises from my time as a non-executive director at King’s College Hospital and currently as an independent panel member of the National Institute for Health Research, and to that extent I declare an interest.

The formation of King’s Health Partnership was the result of an enormous amount of discussion and consultation among the foundation trusts of King’s, Guy’s, St Thomas’s and SLAM, together with King’s College London. It is not the first time there has been co-operation between universities and hospitals; it is a long and honourable tradition. What is new for this country is the extent to which that co-operation takes place. To integrate care, education and research through governance and staff co-operation is vital if patients are to receive the full benefit of the existing research which is taking place.

While not attempting to claim that the King’s Health Partnership is the only viable model, its networking approach has some huge advantages—buy-in from the staff, transparency and galvanising the support of the local communities in the area. AHSCs are important because of their potential for co-operation with the pharmaceutical industry and in attracting the best staff from home and abroad. In this, I add my plea to the Government that they will not stand in the way of attracting the world’s best researchers and clinicians to this country. The intergovernment concession will not fit this particular case and it would be a tragedy if we were to slip down the league table because we were not able to recruit from abroad; this is a highly mobile population.

As a panel member for NIHR I can see for myself the wonderful work which is being done in this country by highly distinguished clinical academics, a significant number of them clustered around academic health science partnerships. Groundbreaking work is being done on Alzheimer’s, multiple sclerosis, diabetes and various forms of cancer which will be translated into treatments within the foreseeable future. However, some of this work is expensive and some of the research is not cost effective in terms of the tariff received. The AHSCs were established without any guarantee of extra money and have been consolidated through good will, commitment and a vision for the future. Unless the Government take these extra costs into consideration, it will be difficult to see how this good will and vision could continue indefinitely. I ask the Minister for an outline of the Government’s commitment to the continuation of these partnerships and some information about how they intend to promote them.

Healthcare

Baroness Donaghy Excerpts

Thursday 28th October 2010 Lords Chamber

[Baroness Donaghy]

My Lords, until last year I was a non-executive director at a foundation trust hospital, and I am an independent assessor for clinical excellence awards at both local and national levels. Therefore, to that extent, I declare an interest.

My views are of course influenced by personal experience. I remember what the National Health Service was like before the Labour Government were elected in 1997. It was coming up for air for the second time. It was starved of resources, innovation and decent buildings. However fashionable it may be to condemn target cultures and so-called spending sprees, the Labour Government tried to catch up on a generation of neglect. Waiting lists were the scandal of the day, with demoralised and underpaid staff and a Nissen-hut building culture. Some of us will never forget that and will for ever be proud of what Labour tried to achieve. However, it was always going to take a generation to succeed and unfortunately we did not have that amount of time.

I always assumed, perhaps naively, that a coalition Government were about strategic consensus but I just wonder whether this coalition Government are not about mixed messages. They claim to support localism but set up the biggest quango in the world, doling out £80 billion. It does not get much more centralist than that. The NHS Commissioning Board will also be taking on responsibility for specialist commissioning and at least 10 other important roles. It is going to be accountable to the Secretary of State for financial stability, and, yes, it is going to be independent of the Government? If it looks like a quango and acts like a quango, surely it is a quango. In order to carry out these functions, the commissioning board will require an enormous framework to build intelligence and process information. Will it have regional offices, provided they are not called SHAs? How will this leviathan work?

Then we come to the proposals for Monitor’s new role. I have had direct experience of Monitor. I joined the board of a London hospital which had just been turned down for foundation trust status and we worked hard to achieve it the following year. Monitor’s job was, as the consultative document says, to authorise foundation trusts. If applicants for foundation trust status were not up to the stringent requirements of financial planning, sustainability, governance and leadership, they did not obtain that status. The new role envisaged for Monitor is to develop a general licence for all. Does that mean that it will lower its standards? It will certainly be a completely different body with completely different skill sets, and it will require considerably more staff to undertake the responsibilities envisaged.

Finally, within three years it is proposed to support all NHS trusts in becoming foundation trusts. It will not be an option for organisations to decide to remain as NHS trusts; they must become, or be part of, a foundation trust. Will NHS trusts still have to meet the current tough requirements in order to become FTs or will there be a lower levelling? Will those who have no hope of achieving FT status due to a long-term lack of financial viability be foisted on existing FTs, deficits and all, leading to a lowering of standards? The consultative document claims that the debate on health should no longer be about structures and processes. However, the Government’s proposals are precisely about structures and processes, and promise to be an enormous waste of badly needed resources.