NHS: Accident and Emergency Services
Baroness Finlay of Llandaff Excerpts(12 years, 3 months ago)
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Earl Howe
We have been taking action in several areas. We released additional money to ensure that immediate pressures were relieved in the health service in the spring and, as I have said, that was successful. We are encouraging, and have ensured, the setting up of urgent care wards, which amount to the kind of discussions across the system in local areas that are needed to ensure that there are no blockages in that system. More fundamentally, we have tasked Sir Bruce Keogh to undertake the work that I referred to earlier, looking at the root causes of why there have been these pressures on A&E. There is no single answer to that question.
Baroness Finlay of Llandaff
My Lords, I declare my interests, including that my daughter is an A&E consultant in London. Are the Government planning specifically to put in some additional resources to support A&E departments now, given that the consultants need more infrastructure support, including people at a much lower grade—clerical staff, care assistants and alcohol support workers—to cope with the peaks that occur of those who have come in having abused alcohol, who take staff away from the other very sick patients, who are often in resus and whom they are also trying to look after at the same time?
Earl Howe
The answer to the noble Baroness’s question is yes. We are looking very carefully at workforce issues and the mix of skills needed in those A&E departments that have been struggling. I refer not simply to A&E consultants but also specialists in their field—perhaps alcohol is a good example—who can deflect the pressure away from staff looking after acutely ill patients.
Smoking: Cigarette Packaging
Baroness Finlay of Llandaff Excerpts(12 years, 4 months ago)
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Baroness Finlay of Llandaff
To ask Her Majesty’s Government what is the basis for the decision not to proceed with standardised packaging of cigarettes.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
Standardised packaging remains a policy under active consideration. The Government have not ruled out its introduction. However, we want to spend more time assimilating information about the likely effect of such a policy in this country and learning from experience abroad. Let me be clear: we are not going soft on tobacco, which is a leading cause of premature death. We have an ambitious tobacco control plan and will press ahead with tobacco control policies, including removing tobacco from displays in shops.
Baroness Finlay of Llandaff
I declare my interest as president-elect of the BMA. As 200,000 11 to 15 year- olds start smoking each year in the UK, what are the criteria and time frames that the Government will use to judge the outcomes of standardised packaging in Australia? The high mortality rate does not appear until about 25 years after these youngsters start smoking. As this is fundamentally a child protection issue, how will the Government now prevent vulnerable children—particularly those in local authority care—from starting smoking, given that the Department of Health’s own systematic review showed that current packs are particularly attractive to youngsters and that they mislead them into thinking that some brands are less harmful than others?
Earl Howe
My Lords, we want to keep a close eye on what is happening around the world before making a decision. We are keeping standardised packaging under active consideration. It has been newly introduced in Australia, and other countries are intending to follow suit, so it is sensible for us to see what we can learn from other countries’ experience. The impacts could be several. They could include, for example, health benefits, as well as impacts on businesses such as retailers and tobacco manufacturers, and could possibly bring about a change in attitude to smoking.
On the risk to children, the noble Baroness is of course absolutely right. Evidence suggests that action needs to be taken to reshape social norms around smoking so that tobacco becomes less desirable, less acceptable and less accessible, particularly to the young. That is why we are committed to ending tobacco displays in shops. We have a TV-led marketing campaign to encourage smokers not to smoke at home or in cars and we have banned the sale of tobacco in vending machines, which has removed a source of cigarettes that underage smokers could access as often as they liked. There is a range of work going on.
Health: Prescription Drugs
Baroness Finlay of Llandaff Excerpts(12 years, 4 months ago)
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Earl Howe
My noble friend will be encouraged to know that Public Health England has published a commissioning guide for the NHS and local authorities which sets out its expectation that support should be available in every area for people with a dependency on prescription or over-the-counter medicines. Local authorities are now, as she is aware, responsible for commissioning services to support people to recover from dependence in line with local need. Most of the support available for people who are addicted to prescription drugs is with their GP and not in services treating those addicted to illegal drugs, but there is a range of services available.
Baroness Finlay of Llandaff
To better understand the size of the problem, will the Government consider adding a box to the yellow card, which has been successful in reporting adverse drug reactions, to state that the doctor suspects that this person may have dependence on the drug? That would provide ongoing epidemiological monitoring.
National Health Service (Licensing and Pricing) Regulations 2013
Baroness Finlay of Llandaff Excerpts(12 years, 4 months ago)
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Baroness Finlay of Llandaff
I have a short query, which I hope that the Minister can clarify for me. It relates to the cross-border flow between England and Wales, either of providers or patients as users of services where NHS Wales is paying for services provided by NHS England or a provider in England. I would like reassurance that there will be no way that the experience of patients going from Wales into England, or the ability for providers from Wales to provide services to patients along the border, are in any way jeopardised within these arrangements and that they have equality within the provision.
Lord Hunt of Kings Heath
My Lords, I declare an interest as chair of an NHS foundation trust, president elect of GS1 UK and a consultant and trainer with Cumberlege Connections. I am grateful to the Minister for his explanation of these regulations. I want to put a few points to him.
I start with Part 2 on licensing, specifically paragraph 3 concerning monetary penalties. Can I ask the Minister about the logic of fining providers, when all that happens is that worse care will be provided for patients as the organisation will have less money? I think that the figure of up to 10% of turnover would virtually bankrupt most providers. While I certainly accept the need for penalties and consequences for failure, I wonder whether they would be better being not financial, as the reality is that they will not happen in many cases because the people who suffer will be those who get services. I just wonder about the logic of that.
It took NHS England months to wake up to the fact that the A&E problems were to do with the failure of systems, but for months it was pressing CCGs in some parts of the country to fine hospitals for poor A&E performance. I think that NHS England has completely lost the plot when it comes to understanding what is happening in the health service. I cannot think of a more hopeless response to the crisis than to come along and say, “We should fine hospitals”. I worry about this whole approach to fining. I say to the Minister that there are very limited signs that systems understand the winter problems and there is a real reluctance to get to grips with what needs to happen. This is a worry for the future which may not have much to do with the regulations, but my seeing the Minister here represents a good opportunity to raise them with him.
Does the Minister think that fines and targets can lead to some perverse incentives? Of course, it is right to issue targets, but I wonder whether the Minister might comment on a very interesting section of the Chief Medical Officer’s Report for 2013, published earlier this year, where she refers to the low number of instances of MRSA and C. diff. I do not think that there is any doubt that the targets that were set for the health service have been responsible for the focus that has led to this very welcome improvement. My understanding is that part of the response to this by the NHS has been to use antibiotics which should have been reserved for hard-to-treat infections. There is now real concern that the antibiotics that go with those hard-to-treat infections have been used rather widely, which is causing great problems in more general infection control. According to the CMO, while the typical, large, 1,000-bed acute NHS hospital has two to three MRSA bacteraemias per year and 50 to 60 C. diff cases, 400 to 500 bacteraemias involving Gram-negative bacteria can occur in a 1,000-bed-type hospital, 10% to 15% of them being due to strains resistance to those antibiotics for hard-to-treat infections. You can reach a point where individual targets become counterproductive because the focus of the NHS is simply on C. diff and MRSA and not on the wider infections which clearly need to be tackled as well.
Will the regulations lead to more specific targeting which can in turn lead to perverse incentives, or is a more sophisticated approach likely to be taken? It is clear that the Chief Medical Officer is concerned about the way in which some MRSA and C. diff targets are leading to perverse behaviours.
On Part 3, the rationale for each of the thresholds described for penalties, prices and licence changes has not been explained in relation to an evidence base. In other words, why are the thresholds where they are? What work has been done to suggest that those are the right thresholds? Of course, now they will only be tested post-implementation, but it would have been good to have seen a clearer review mechanism that enabled a sensible approach.
In respect of the mechanisms to lodge an objection to the pricing methodology, my understanding is that the Foundation Trust Network has stated throughout the development of the policy that the 51% threshold for an objection, together with the denominator comprising all tariff services, is too high a threshold to be met. Is the noble Earl prepared to look at this? That might be a reasonable approach for general objections to the general approach, but it is insufficiently sensitive to address sections of the tariff that may be inadequately compensated—cancer services, for example. The noble Earl will be aware that there were issues around the tariff for children’s services and women’s services. My reading of that is that if you were a specialist adviser your chances of reaching the 51% threshold would be very limited. Could this be looked at?
If my noble friend Lord Warner were here I am sure he would raise this. It is the question of what happens to non-foundation trusts. I know that Monitor is working closely with the NHS Trust Development Authority, but I would welcome clarity about what will happen to trusts outside Monitor’s remit to ensure that there is an even-handed approach across all providers in the sector. No one is more admiring of the work of Sir Peter Carr as chair of the NHS Trust Development Authority. The noble Earl knows that Sir Peter has held chairmanships under both Governments for many years. While he is a marvellous person, there is a fear that he will hold the chairmanship of the NHS Trust Development Authority for many years to come because of the issue about what on earth will happen to those non-foundation trusts that are clearly not going to reach FT status any time soon.
The noble Earl mentioned the Competition Commission.
Earl Howe
I take the noble Lord’s point about uncertainty and confusion that I know exists in certain parts of the health service as to what all this means. I can tell him that officials in the department have had some very productive discussions with both the OFT and the Competition Commission to ensure that their approach need not set unnecessary hares running as regards apprehensions that a purist competition-based approach will be taken by these bodies. I am satisfied that that will not happen. My advice is that the Competition Commission, in particular, has welcomed the input of departmental officials in terms of the factors that need to be brought into play when making a judgment on what is in the best interests of the health service and patients.
At the same time I am aware that a number of useful events and conversations took place within the health service itself when we clarified with providers the considerations that the OFT and the Competition Commission will look at in proposed mergers. We are ensuring that when proposals are made the benefits of mergers are clearly defined in terms that will resonate with the competition authorities. The noble Lord is right that we are in new territory in many senses, but I am optimistic that the system will work in the way that it should. It is certainly about looking at competition aspects but, more pertinently, looking at the criteria that I mentioned earlier, such as the public interest in the case of licence modifications, the test of appropriateness in pricing methodology, and in the case of mergers, the interests of patients in the health service. The OFT and the Competition Commission must take into account the benefits of a proposed reconfiguration if they consider it under the Enterprise Act 2002. I remind noble Lords that that is the governing Act, so in theory at least, we have been in this situation for more than 10 years. In doing so the competition authorities must consider whether those benefits would outweigh any substantial lessening of competition that they find.
The noble Lord asked about the tariff, and in particular, primary care. We agree that payment mechanisms need to be aligned to drive better outcomes and better value for patients. They also need to be responsive and flexible, for example to enable services to be provided in an integrated way. Monitor and NHS England will work together to move the tariff in this direction. They are best placed to do that given their different roles.
The noble Lord asked me what would happen if the tariff proved to be inadequate. We expect the tariff in future more closely to relate to the costs of providing particular services. If the price payable for a service would make it uneconomic for a provider to provide a service, Sections 124 and 125 of the 2012 Act provide for a process for local modifications of the price payable.
My advice is that NHS England and Monitor are working very well together in this regard. Guiding principles have been defined and six shared principles for pricing have been agreed: that the pricing mechanism should enable and promote improvements in care for patients and taxpayers; that it should enable efficient providers to earn appropriate reimbursement for their services; that it should have regard to sustain the NHS offer in the long run; that it should not preclude the delivery of the Secretary of State’s mandate for NHS England; that it should have regard to the principles of better regulation; and that it should support movement towards a fairer playing field for providers.
I hope that I have answered most if not all the questions, but I undertake to write to noble Lords if I have failed to do that.
Baroness Finlay of Llandaff
I seek a small point of clarification. I take the example of a Welsh provider that is providing services for Welsh patients and that is also licensed to provide for patients coming across from England. In the event of them being deemed not to meet the conditions and therefore a fine potentially being levied at 10%, would that be only 10% of the contract issued on behalf of the English patients? Two very different healthcare systems will be operating.
I realise that this is complex, but the two healthcare systems are becoming more divergent yet the population on the border has to access both sides, I am concerned that these are some of the things that need to be clarified. It is a detail, I know.
Health: Diabetes
Baroness Finlay of Llandaff Excerpts(12 years, 4 months ago)
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Earl Howe
I would be happy to meet the noble Lord. I am aware that the whole area of the cataract threshold and, perhaps more importantly, the interpretation of that threshold, is one that NHS England is now actively looking at to ensure greater consistency around the country.
I do not agree with the noble Lord’s interpretation of the screening figures. The UK countries, I believe, lead the world in the area of diabetes eye screening. This is the first time that a population-based screening programme has been introduced on such a large scale. The latest figures show that up to March 2013, 99% of people with diabetes who were eligible for screening were offered it in the previous 12 months.
Baroness Finlay of Llandaff
My Lords, given the importance of prevention, have the Government been monitoring the progress of access to insulin pumps for children with diabetes, in order to prevent eye problems later in life, given that they have better control with insulin pumps?
Earl Howe
My Lords, that tends to be a matter for provider trusts, working in conjunction with clinical commissioning groups. I am aware that there is concern about the variability of access to insulin pumps. Of course, they are not a universal remedy for every diabetic patient, but where they are appropriate they should be commissioned. If I can give the noble Baroness the latest information on that, once I have consulted NHS England, I would be happy to do so.
NHS: Accident and Emergency Units
Baroness Finlay of Llandaff Excerpts(12 years, 4 months ago)
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Earl Howe
My Lords, the noble Baroness is absolutely right. There is no doubt from Sir Bruce Keogh’s urgent and emergency care review, published this month, that attendance at an A&E department often reflects the lack of availability or the lack of awareness of alternative sources of help. Some patients may default to A&E departments when they are unsure about which service is most appropriate to their needs. That has to be addressed and is being addressed in Sir Bruce’s review. It will look at the entire system of emergency care and how we can make sure that it provides the right care, in the right place and at the right time.
Baroness Finlay of Llandaff
Will this review include an audit of the number of patients who are in A&E but cannot be sent back to their normal place of residence, whether that is their home or a care home, because of the lack of immediate transport and an absence of immediate referral systems to community services that could monitor and review the patient back in the community?
Health: Children's Heart Services
Baroness Finlay of Llandaff Excerpts(12 years, 5 months ago)
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Earl Howe
My Lords, I pay tribute to the work done in Newcastle in this extremely complex area of surgery. The noble Lord knows that hospital better than anyone in this House, and I understand the disappointment felt in Newcastle about this decision. Nevertheless, I would slightly qualify the comment that he made at the beginning. Although I agree that the decision must depend on outcomes and the quality of care, it must also bear in mind the sustainability of the service into the future. While we can recognise good care when we see it now, we must be sure that the service is capable of being sustained on that level into the future.
Baroness Finlay of Llandaff
Is the Minister able to tell us how many vacancies currently exist among highly specialised staff in children’s heart units and what NHS England is doing to monitor vacancies? During a time of uncertainty, when staff do not know what their future will be, recruitment problems can arise, and where vacancies occur at a very senior, highly specialised level, that in itself can threaten the quality of the service and indeed jeopardise long-term sustainability.
Earl Howe
I do not in fact have any statistics on vacancies, although if I can acquire them I shall certainly pass them on to the noble Baroness. However, the central point that she makes is of course right, and the second recommendation made by the IRP relates to the need to have sufficient staff in place to deliver a safe service. It says that patients should receive this service,
“from teams with at least four full-time consultant congenital heart surgeons and appropriate numbers of other specialist staff to sustain a comprehensive range of interventions, round the clock care”,
and, interestingly,
“training and research”.
I think that that sends a signal that will resonate with many noble Lords in the context of debates that we have had in the past about centres of excellence in the NHS.
Medicine: Experimental Drugs
Baroness Finlay of Llandaff Excerpts(12 years, 5 months ago)
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Baroness Finlay of Llandaff
My Lords, in light of the proposed EU directive that is being led by MEP Glenis Willmott to facilitate clinical trials and the work done by Empower: Access to Medicine, led by Les Halpin, are the Government working with the Halpin protocol, which aims to overcome the legal barriers—real or perceived—to early access to, and development of, medicine in the UK?
Earl Howe
My Lords, the Medicine and Healthcare Products Regulatory Agency is at the forefront of the negotiations at European level to ensure that the new clinical trials regulation, which will replace the current directive, is much more conducive to companies directing their clinical trials towards Europe, in particular, we hope, the United Kingdom. This needs to happen. The trend over the past 10 years has been in the wrong direction and we want our own market share to increase; there are already signs that it is doing so.
Care Bill [HL]
Baroness Finlay of Llandaff Excerpts(12 years, 5 months ago)
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Lord Sutherland of Houndwood
My Lords, I very much support the intention behind the amendment. It points us where we should be going. It is evident that the way in which professionals are trained deeply affects how they carry out their duties for the rest of their lives. That is a sign of good education. The noble Lord, Lord Warner, has been pointing the direction in which health and social care will and must go. It is essential to lay down the basis so that professionals accept that it is the shape of things to come.
Baroness Finlay of Llandaff
My Lords, for many years in medicine, there has been a move to try to ensure training in the community, but its implementation has been woeful. It has not been instigated as rapidly as people have been campaigning for over many years. I hope that the Government will look favourably on the spirit behind the amendment, although, in an odd way, the wording may be a little too restrictive. It is a very important move to ensure that, as more patients are moved out to be cared for in the community, community services can deliver what they need. With very sick people in the community, a different skill set will be needed from that which is currently available.
Baroness Wheeler
My Lords, I support my noble friend Lord Warner’s amendment. There will of course be further debate on integration in the wider context of the Bill, but the amendment is important because it underlines that Health Education England must have the strategic overview and understanding of the workforce requirements across the boundaries of health and social care if it is to undertake its role effectively.
Our stakeholder meetings have shown that there is considerable concern among stakeholders on that issue. They want the links between HEE and the social care sector to be more explicit. The noble Earl’s reassurances last week in that regard concerning Clause 88 were helpful, and I look forward to hearing from him further on how HEE is to work with integrated care delivery. I hope that he will concede that my noble friend’s cross-reference in his amendment to Clause 85 is necessary, because it links the HEE’s duty in Clause 88 to have regard to promoting integration to its key role of ensuring that there are sufficient skilled healthcare workers available.
The Health Education England mandate acknowledges that the future needs of the NHS, public health and care system will require a greater emphasis on community, primary and integrated health and social care. HEE is essential in that. Staff must be trained and developed in the skills that are transferable between different care settings and in working in cross-disciplinary teams in a range of different health and support settings. It must also work closely with the social care sector by developing common standards and portable qualifications across the NHS, public health and social care systems. The local LETB role, linking up with the health and well-being boards, is particularly important in that respect.
It is worth briefly mentioning two recent reports on integration, both of which, among other things, reinforce how much awareness and understanding of each other’s roles must take place for integrated services to happen and to be delivered. The shared commitment statement under the National Collaboration for Integrated Care and Support was drawn up by an impressive mix of national partner organisations, including government departments, the HEE itself, regulatory bodies, the Association of Directors of Adult Social Services, National Voices and other stakeholder groups. It pledges to help,
“local organisations work towards providing more person-centred, coordinated care for their communities”.
There is not time to go into detail, but National Voices’ A Narrative for Person-centred Coordinated (“Integrated”) Care, which sets out what integrated care and support looks like from an individual perspective, for both the cared-for and for carers, is a powerful vision for the future. It underlines how closely staff across primary, community, NHS and social care will have to work if this is to be achieved. The section of the narrative on communication describes professionals talking to each other, and patients always knowing who is co-ordinating their care, always being informed about what is going on, and having one point of contact. This in itself would be nirvana to most patients, service users and carers.
The recently published Nuffield Trust report, Evaluation of the first year of the Inner North West London Integrated Care Pilot, looks at developing new forms of care planning for people with diabetes and people over the age of 75. It underlines the importance of staff having a high level of commitment to the pilot and to the care planning process in particular. Initial results show that work on care planning and multidisciplinary groups resulted in improved collaboration across the different parts of the local health and social care system.
On public health, the HEE mandate itself states:
“The health of people in England will only improve in line with other comparable developed countries when the entire NHS, public health and social care workforce genuinely understands how their services together can improve the public’s health”.
Does the Minister accept that the HEE mandate supports the case for the Bill to include an explicit reference on the overall strategic context?
HEE’s role is to provide national leadership for workforce training, planning and development, ensuring that we have skilled, committed staff in the right place, in the right specialities and numbers. We need to meet these challenges of the future and of the changing face of healthcare provision. How to ensure an integrated approach to education and training across the NHS, public health and social care is a very strategic issue. I hope that the Minister will reassure the House on this by responding positively to the amendment.
Care Bill [HL]
Baroness Finlay of Llandaff Excerpts(12 years, 5 months ago)
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Lord Warner
My Lords, I support these amendments. I will pick up the point made by my noble friend Lord Hunt about managers. The public sector needs all the quality management it can get and many of its problems rest on the fact that we do not have a cadre of managers to take many of our public services through the difficult years ahead. The NHS is no exception.
For too long—and my own party has been guilty of it in the past—we have dismissed managers as men, and indeed women, in grey suits who are dispensable. We have to give some strong messages to HEE that if the NHS is to develop and evolve and cope with the problems ahead, we need a strong cadre of managers and we have to develop them over time. It is not too early to start now because we have a real problem not just in staffing chief executives now but in staffing the next cadre of chief executives and the middle management and development programmes for that. The Government would do well to give some strong messages to HEE and possibly even consider strengthening the legislation on this issue because it would be a missed opportunity if we do not strengthen that body of people to help us run the NHS in the coming decades.
Baroness Finlay of Llandaff
My Lords, I will briefly add my support, particularly to the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel. I will draw the House’s attention to the wording, that it is,
“expertise in medical education and training”
that is being asked for, not just medical education, and that the expertise in research is not tied to medicine.
I understand the arguments that HEE must not be too tied or have a board that is too rigid, but if it is to meet the enormous challenges that it faces—and it has come from many, many discussions—to be able to have questions asked at board level about education and training will be essential if we are to have a workforce that can adapt rapidly as new technologies and new ways of providing care come along. It will need to have people with expertise and understanding of the most efficient and effective ways to upskill the workforce in particular areas, because there are enormous unknown challenges ahead.