Health and Care Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Committee stage & Lords Hansard - Part 1
Tuesday 11th January 2022 Lords Chamber

[Lord Patel (CB)]

My Lords, my knee-jerk reaction was going to be, “I don’t agree with what Lord Lansley says”. However, I have put my knee hammer back in my pocket, because I do agree with him about the importance of using outcomes indicators as a measure of the performance of health in patients. In that respect the outcomes framework has always been a good development. Although Clause 4 focuses on cancer—and I hope we do not change that—it is an example of how it can be used for other conditions to improve healthcare.

The noble Lord has also identified one key omission in this Bill, which I hope we can find a way to fill: who will be responsible for making sure that there is continuous improvement and development in healthcare that measures the outcomes? That is not in the Bill. I hope we might find a way to do that, whether through the mandate or other ways. That is all I have to say.

[Baroness Finlay of Llandaff (CB)]

My Lords, I must declare an interest, because a lot of the outcome measures that are now used are in place at Cardiff University. I will expand a little on and support what my noble friend Lord Patel said about outcome measures, particularly for something such as cancer. That is in part because the disease process itself is marching on all the time. It is different from many other diseases, where there might be a chronic condition and other things happen as a result of it. If you do not intervene rapidly with some cancers, you miss the boat and go from being able to cure it to a situation where you certainly will not be able to.

The other group of outcome measures that I do not think we should forget has just now been developed: family-reported outcome measures. That is the impact on the family. We know about the number of carers that there are. There are child carers and many unpaid carers. Having somebody in the family with a disease process, waiting for something to happen and seeing that disease process getting worse and worse in front of their eyes, has a major impact on the health of others and stacks up problems for the future in the health service.

That is why, when I was on the All-Party Parliamentary Group on Cancer, I strongly supported John Baron in all his efforts to look at the one-year survival times in cancer. Looking at outcomes can be far more informative than looking simply at process targets, which is what we have been looking at too much to date rather than looking at the overall impact of disease.

Agriculture Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Committee stage & Committee: 2nd sitting (Hansard) & Committee: 2nd sitting (Hansard): House of Lords
Thursday 9th July 2020 Lords Chamber

[Baroness Finlay of Llandaff (CB) [V]]

My Lords, today’s important debates have been greatly enhanced by the pleasure of hearing the noble Lord, Lord Rooker.

My Amendment 259 is in this important group. I am grateful to my noble friends Lord Patel and Lord Wigley for their support. Chemical weapons were developed in the Second World War and then remanufactured as pesticides, now used in agriculture for around 75 years. In 2013 the Government accepted all recommendations from two important reports. The first was the Bystanders Risk Assessment Working Group of the Advisory Committee on Pesticides. The second report was from the sub-group of the Advisory Committee on Pesticides: the Pesticides Adverse Health Effects Surveillance working group. Both were scathing about the use of pesticides and laid out the dangers. Yet, although accepted, their recommendations remain largely unimplemented.

It is a worrying indictment that 70% of our land is used for farming and almost all of it, except for the 3% for organic farming, is subjected to spraying that is not dose-controlled in any way. In 2014, 17.75 million kilograms of pesticide were sprayed on the land. Carried in the wind, harmful residues have been found several miles downwind. The dangers to health are now recognised. A 2017 report by the UN special rapporteur on the right to food found that chronic exposure to agricultural pesticides was associated with several diseases and conditions, including cancers, and that those living near crop fields were particularly vulnerable to exposure.

The International Panel of Experts on Sustainable Food Systems report describes the unacceptable harm caused by the current chemical farming systems and the energy consumption in the manufacture of these chemicals. It exposes just some of the astronomical health costs externalised by the current system, and states an urgent and overwhelming case for action.

The Lancet Commission on Pollution and Health report on global deaths and chronic diseases from outdoor air pollution, including from the use of pesticides, has the lead author saying that his biggest concern is the impact of the hundreds of industrial chemicals and pesticides already widely dispersed around the world.

I remind all involved in this Bill that the effects are cumulative, because these chemicals often sit in fat stores and are not cleared. The chemicals disrupt the internal hormonal environment; they are endocrine disruptors and make cells more susceptible to mutations, abnormalities and malignancy.

I turn briefly to one of these, glyphosate, used in the weed killer Roundup, which has a large number of tumour-promoting effects on biological systems, including direct damage to DNA in sensitive cells, disruption of metabolic processes and modification to more toxic molecules. Epidemiological evidence suggests correlations between glyphosate usage on crops and a multitude of cancers that are reaching epidemic proportions, including common cancers and lymphoma. In the US, many lawsuits have been brought against the producer Monsanto, which is now part of Bayer.

The effect on the developing nervous system and on the adult neurones is not clearly known, but we must take the precautionary principle. Rats exposed to high levels of glyphosate, their offspring and the offspring’s offspring—two generations on—developed malignancy, obesity and birth abnormalities. Neurotransmitter changes occur in rats and mice exposed to glyphosate, and mice display mood and movement changes. Increased understanding of epigenetics suggests that harm experienced by the adult may be handed on by epigenetic factors to offspring not even yet conceived.

I spoke in the previous debate on the theme of future generations and I return to that now. We cannot ignore the cumulative evidence. In my amendment, I suggest an annual report to Parliament on the safety of herbicides and pesticides, taking into account evidence from the analysis of foods that should be glyphosate-free but appear to be contaminated by windborne spray. Neurotoxic effects on pollinators and the damaging effects on human health of these chemicals cannot be ignored.

As we leave Europe, we are free to produce more of our own food for our own market and ensure that our food is safe and of high nutritional quality. We must make also sure that imported food meets our new high standards. Going forward, pesticides need to be designed out of farming systems, for the environment, for health and for the market-ready production of excellent food; hence my amendment.

[Lord Patel (CB) [V]]

My Lords, I want to support the amendment of the noble Baroness, Lady Finlay. Much of what I was going to cover she has covered in great detail, so I will try not to repeat too much.

Pesticides may be metabolised, excreted, stored or bioaccumulated in body fat. The numerous negative health effects that have been associated with chemical pesticides have been mentioned in great detail by the noble Baroness. In the majority of cases, the concentrations do not exceed legislatively determined safe levels. However, these safe limits may underestimate the real health risks, as in the case of simultaneous exposure with two or more chemical substances, which occurs in real-life conditions and may have synergistic effects. Pesticide residues have also been detected in human breast milk samples, and there are concerns about prenatal exposure and health effects in children.

The noble Baroness mentioned glyphosate-based herbicides and the DNA damage that it is known to cause, which may lead to cell deaths and other conditions in cellular metabolism causing disease. Furthermore, the real-life chronic exposure in mixtures of pesticides with possible additive or synergistic effects requires in-depth research. The underlying scientific uncertainty, exposure of vulnerable groups and the fact that there are numerous possible mixtures reveal the real, complex character of the problem. The combination of substances with probably carcinogenic or endocrine-disrupting effects may produce unknown adverse health effects. Therefore, the determination of safe levels of exposure to single pesticides may underestimate the real health effects, ignoring also the chronic exposure to multiple chemical substances.

Care Bill [HL]

Debate between Baroness Finlay of Llandaff and Lord Patel

Wednesday 16th October 2013 Lords Chamber

[Lord Patel (CB)]

My Lords, I shall speak also to the other amendments in my name in this group. I thank the Minister for the government amendments, which go a considerable way towards helping the arrangements for the transition of children to adulthood. My amendments are intended to strengthen that. I thank my noble friend Lady Finlay for putting her name to the amendments.

Amendment 83A is one of a series of amendments which I have tabled with the intention of bringing about better outcomes for young people who need to transition from child to adult palliative care services. These young people are represented by the Transition Taskforce, a partnership of organisations which includes Help the Hospices, the National Council for Palliative Care, Marie Curie Cancer Care and Together for Short Lives. All these organisations support these amendments.

I have spoken previously at other stages of the Bill about the 40,000 children and young people—these are the numbers we are talking about—aged from 0 to 19 in England who live with long-term health conditions, which for most of these children will eventually end their lives and for which they may require palliative care. Medical advances mean, however, that young people with a range of different conditions now live to adulthood—some 10% of the 40,000 children now live beyond 19 years.

Good planned transition, when it works, changes the lives of these young people. Unfortunately, for the majority that is not happening. I will give the example of one young girl, Lucy Watts, who is 20 years old, and has Ehlers-Danlos syndrome, which means that Lucy has a number of inherited conditions which were diagnosed by the time she was a teenager and is unable to eat normal food. Her system does not digest food and she is fed intravenously all the time. While she is able to sit up for a few hours a day, Lucy spends most of her time in bed. Lucy’s mum, who has a full-time job, carries out the majority of her care and all of her day-to-day medical care.

However, Lucy is fortunate, because her transition to adult service was excellent because there was joint working between children’s and adult services over the course of a whole year. That is the important point. It takes a long time for transition arrangements to be put in place for these children. Lucy is quite a feisty young lady. She said:

“Transitioning from children’s to adult in the medical and social world is a huge step ... The people involved in my care have been very supportive and were brought in before I started the transition”.

Lucy’s case demonstrates how important it is for young people and families that their transition is planned well in advance of their 18th birthday and why our amendments to stipulate a timeframe for a child’s needs assessment are so important.

I very much welcome the fact that the Government have amended the Bill to ensure that when it appears to a local authority that the child or their carer is likely to have needs for care and support after the child becomes 18, the local authority must assess them. I appreciate, too, the Government’s stated position that the needs of very young people are different and that their care needs can change between the ages of 14 and 18 in a variety of ways. However, our amendments would provide flexibility by ensuring that assessments could be initiated before the age of 14 if requested by the child or parent or if it appears to the local authority that an assessment is necessary and appropriate. Local authorities would have until the age of 16 to assess the child’s needs. They would not be prevented from reassessing a young person if their needs changed before they reached 18. They would also enable local authorities a period of two years to assess the child’s needs in cases where their care needs become apparent only after the age of 14. Without these important thresholds, it is feasible that a local authority may leave it too late to carry out a child’s needs assessment.

Setting the age threshold for a child’s needs assessment at 14 is also based on the existing statutory requirement for every young person in year 9—that is, aged 14 to 15—with a statement of special educational needs to have a transition plan. Our amendment would ensure that transition planning correlates with that requirement and reflects best practice in exemplary palliative care services in England. It is entirely reasonable that some young people with life-limiting conditions, including those with conditions such as Duchenne muscular dystrophy and cerebral palsy, could be expected from an early stage to live beyond 18. Assessing and planning for their future needs should therefore begin at the age of 14. Our amendments would ensure that this is the case without disadvantaging young people with other disabilities, which is the concern that was expressed. The Bill already stipulates that where a local authority deems a child’s assessment not to be in the best interest of the young person or the young person does not consent to being assessed, an assessment will not take place.

Amendment 89B, which is a long amendment, corrects the anomaly of the transition and the duty on local authorities. While the Bill currently makes provisions to enable local authorities to carry out a child’s needs assessment, there is no duty on local authorities to use the assessment to create a transition plan for the young person. Amendment 89B would ensure that, if a child’s needs assessment finds that a young person is likely to need health or social care when they reach adulthood, a statutory five-year rolling transition plan should be prepared by the time they are 16.

The amendment has a number of other important features. It would ensure that children, parents and carers were involved in the transition planning process and that transition plans are maintained until the young person reaches the age of 25, which 10% of these children would probably reach. Further, one of the provisions included in the Children and Families Bill is to introduce an integrated education, health and care plan—or EHC plan—for young people who have special educational needs. This will include many—but, crucially, not all—young people who need palliative care. Where a young person stays in education or training, they will be eligible for an EHC plan until the age of 25. I recognise that an EHC plan could fulfil the functions which I intend the transition plan in my amendment to fulfil. An optimal position would be for EHC plans to be available to all young disabled people up to the age of 25—but that is not the case. Our amendments will provide similarly joined-up transition provision for young people who need palliative care but do not have SEN.

Amendments 93A, 94A and 94B would amend and address the carer’s needs. In considering young people who need to transition from children’s to adult services, it is also important that we address the needs of those who care for them. I welcome the Government’s aspiration to do so and the amendment that the Government have already tabled to strengthen the Bill. However, as with the clauses relating to planning for young people’s needs on transition, we need to go further in order to ensure that planning for carers also happens in a timely fashion. Amendment 93A would introduce an age threshold of 14 at which a local authority would be duty-bound to undertake a child carer’s needs assessment.

I hope that I have persuaded the Minister that his amendments, excellent as they are, need a bit more tweaking to make it possible to streamline the process of transition of children to adulthood. My amendments merely help to do that. Some children may of course begin to need long-term health or social care after they are 14. In such cases it may not be reasonable to expect a local authority to complete a child carer’s needs assessment before the child reaches the age of 16. I hope that the Minister will be persuaded enough to add to his excellent amendments a few more to fulfil these needs. I look forward to hearing his response.

[Baroness Finlay of Llandaff (CB)]

My Lords, I am most grateful to my noble friend Lord Patel for the way in which he has introduced our amendments. I greatly welcome the Government’s amendments in this area of transition. The reason that our amendments are written as they are is because this group of children are different to adults who are terminally ill. They have life-limiting conditions, but their prognosis may be years. However, during that time they know that they will deteriorate, as do their parents. We are therefore looking at completely different timeframes, and with completely unpredictable prognoses, except for the likelihood that they will live through into adulthood. Some of them, of course, live surprisingly long periods of time and may live several decades into adulthood. They tend to have the inherited disorders of metabolism. They are a different cohort from those who have terminal illnesses such as cancer. There are also those children who, for example, have had very severe sudden injuries, such as a severe head injury, and then develop epilepsy, which can then become so severe that it is life threatening. Many of the children also have learning difficulties and educational needs.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Tuesday 13th March 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I speak in support of what has been said by the noble Lord, Lord Warner. There is real anxiety that people will be frightened to admit to and report errors, if they feel that that could threaten, in any way, the contracting of the service that they are working in. Who in the new system will be responsible for rolling out training that has come from the cataloguing and analysis of problems, and how will the lessons learnt in devolved nations be fed into the system for the UK as a whole. Indeed, how will lessons learnt in England be fed out to the devolved nations?

[Lord Patel]

My Lords, I speak as somebody who has been involved with the National Patient Safety Agency for longer than the noble Lord, Lord Warner, as a Minister, or the noble Lord, Lord Hunt, as its chairman, as I chaired it for four years. What is important is that the National Patient Safety Agency, as it is currently, has been unable to be effective. It has not been effective because it is not mandatory to adopt, implement or use the learning produced from the reports it receives from all healthcare providers on systems failures that may cause harm to patients. I hope that the Minister will reassure us that whatever the new arrangements are, the learning produced from systems failures will be implemented, or will be expected to be implemented.

I do not know whether the Commissioning Board is the ideal place for it—I understand that it is taking over the group that looked after the analysis of the reports. Therefore, it will be its task to disseminate all the learning that comes from it. The actual collection of information or data will be outsourced on a contractual basis to Imperial College. Perhaps the Minister will comment on that. The important issues are that the information on systems failure is collected and that the lessons learnt are available to all those who commission and provide healthcare. They must be implemented.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Monday 27th February 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, this is another group of amendments that relate to the process of commissioning. Their aim is to ensure that commissioners have regard to all the expert advice needed to make informed decisions about commissioning services for patients, particularly complex services that operate across the care pathway. Amendment 65, which is primarily in the name of my noble friend Lord Patel, further aims to ensure that safety information is shared with everybody who needs to know about it.

The groups of particular concern to be consulted go beyond medicine and nursing; the wording in the amendment is “local clinical specialists”. They will be linked to their own specialist group and specialist society and will be expected to be completely up to date with advances in their field, enabling the most modern, up-to-date and cost-effective care to be brought down to a local level. They also address allied health professionals.

We have spoken remarkably little about the contribution of allied health professionals in our debates so far, and they have not featured on the face of the Bill. Physiotherapists form the largest group of allied health professionals. I declare an interest as president of the Chartered Society of Physiotherapy. As a group, they are very used to representing other allied health professionals; and, as a group , allied health professionals are very used to understanding the role and contribution of each other, such as occupational therapists, speech and language therapists and so on, groups that are small in number but have a very important contribution to make. One of the reasons that they become so important in these new processes of a care pathway is that, if we are expecting more patients to be looked after in the community, we have to do a great deal to increase the independence of individuals.

The physiotherapists and occupational therapists are par excellence the people who will maintain or re-establish mobility and be able to discharge patients from hospital. I know from my own clinical practice that all too often we are waiting for the physio or the OT to provide the essential input that makes the difference between a patient remaining an in-patient or being able to get home, particularly where they have mobility problems. Physiotherapists also have a role in mental health and can be very important in establishing mental health improvements as well as just physical health. It is with that background that they have been featured in these amendments as a group of allied health professionals, because, sadly, many doctors and nurses do not really understand the major and very cost-effective contribution that these healthcare professionals can make. I beg to move.

[Lord Patel]

My Lords, I shall speak to two amendments in my name, Amendments 65 and 66. They are very simple. They regard the information on the safety of services provided by the health service. I particularly want to address the issue about patient safety.

Amendment 65 refers to the information provided. The Bill says that the Commissioning Board will provide information to those whom it “considers appropriate”. I do not know why the Commissioning Board must decide who it considers appropriate; my amendment merely lists all the organisations providing healthcare to whom the information must be provided. Patient safety incidents occur mainly because of systems failure. I can give many examples, from wrong-side surgery to wrong infusions, wrong medicines reconciliation and wrong injections in the wrong side—such as a spinal injection when a particular material must not be injected spinally. Because it is a system failure, if such a patient safety incident occurs in one hospital, it is likely to occur in another. So the information must be provided to all healthcare providers and those who train doctors and nurses. I do not understand why it must be that the board must make information collected on patient safety incidents available only to those whom it “considers appropriate”.

My next amendment has to do with subsection (3), which says:

“The Board may impose charges, calculated on such basis as it considers appropriate, in respect of information made available by it under subsection (2)”.

Why must it charge? If it charges, we do not get the gains from the lessons learnt from patient safety incidents.

The two amendments are quite simple. I do not understand why it is not clearer.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Monday 13th February 2012 Lords Chamber

[Lord Patel]

My Lords, here we go again. I wish to speak to today’s first group of amendments—Amendments 13, 16, 62 and 106—but, before doing so, I thank all noble Lords who have put their names to the amendments. Many noble Lords wanted to put down their names to Amendments 13 and 16 in particular but were unable to do so. However, I thank them all for supporting these amendments.

Perhaps I may start in reverse order. Amendment 106 would impose a duty on clinical commissioning groups in respect of training and education. This matter was debated on the first day on Report and the Government produced Amendment 104 to the same effect. Similarly, Amendment 62 puts a duty on the NHS Commissioning Board in relation to training and education. As the Government have brought forward Amendment 61 to achieve exactly that, I shall no longer speak to Amendments 62 and 106. I can now move on to the proper business, as the House has quietened down.

I apologise that Amendment 16 is badly worded and has some rather deliberate mistakes. Much of it was debated in the context of a second group of amendments moved on the first day of Report last week, and I shall not labour those points.

There are three key issues that we might explore further in relation to this amendment. The first is the establishment of Health Education England as a special health authority. I have no doubt that the Minister will be able to reassure us about the timing of that. Secondly, there is the issue of funding the education and training of the healthcare workforce. That budget will be held by Health Education England. The role of the respective regulators, professional organisations, universities, higher education institutions and so on has already been discussed. The Minister accepted that they have an important role to play, but it is important to establish that the postgraduate deans will continue to perform their current role. The third key issue is the role and authority of the local education training boards. They will not be controlled by employers, and employers will not have a right in statute to chair local education training boards.

Those are the key issues on Amendment 16. I can now turn to my key amendment, and I emphasise the word key—Amendment 13. This amendment tries to encompass all the issues that we discussed in Committee and last week on Report. As noble Lords may remember, I tabled some amendments on education and training and the Minister was sympathetic to several of them. They alluded to the responsibility of all those who provide health services or care or who make any provision for health services to pay regard to education and training. I have tried in this amendment to bring all those amendments together in a simplified way. I now have an admission to make. At an earlier stage I tried a slightly different amendment on the Minister—Amendment 12—which I then withdrew. However, I hope that he finds it acceptable now as I think that it encompasses the matter in a much simpler form.

What is this amendment about? It states:

“Any arrangements made with a person under this Act for the provision of services as part of that health service must include arrangements for securing that the person co-operates with the Secretary of State in the discharge of the duty under subsection (1) (or, where a Special Health Authority is discharging that duty by virtue of a direction under section 7, with the Special Health Authority”.

The purpose of the amendment is to ensure that any person providing services as part of the health service has a duty to co-operate with the Secretary of State in the discharge of the duty in new Section 1E of the National Health Service Act 2006 to exercise his functions so as to secure an effective education and training system, or with any special health authority which is discharging that duty. The amendment would achieve that by requiring commissioners of health services to include a duty of this kind in their commissioning contracts. The amendment applies to all persons commissioned to provide services as part of the health service, including NHS services commissioned by the board and public health services commissioned by the Secretary of State or local authorities. This is consistent with the powers of the Secretary of State that we discussed previously.

The amendment seeks to ensure that all providers of services commissioned as part of the health service, including NHS and public health providers as well as private alternative providers, have a duty to co-operate with the Secretary of State in the discharge of his duty to ensure an effective system for education and training. The duty will apply equally to Health Education England when it is created as a special health authority with responsibility for health education and training. Perhaps the noble Earl will confirm that that is likely to happen by June 2012. It would also require commissioners to include a duty for providers to co-operate on education and training when they issue commissioning contracts.

Since we last discussed the issue, the Government have set out their intention for the new education and training system. I welcome that. I am pleased to see that there will be a national system for education and training, and that Health Education England will be established as a special health authority. However, it is important that we secure a future for education and training through the Bill—hence my amendment—and that the necessary connections are made with other national bodies and with local service commissioners and providers. It is important that all providers of NHS-funded services participate in the planning, commissioning and provision of education and training. They are responsible for delivering front-line NHS services and therefore have a key role to play in supporting local education and training boards—and I mean supporting, not controlling. One previous issue of concern was how the budgets would be used.

It is also important that local employers should provide the highest-quality clinical placements. These placements are an essential element of the education and training process for doctors, dentists, nurses and other healthcare professionals. They give them hands-on experience of their profession or specialty through the delivery of health services in the NHS. It is important, if we are to continue to develop high-quality clinicians and health professionals, that these placements are continued. In the past, there was a tendency when budgets were tight to cut the placements. That is why I make this comment.

My amendment covers all these issues and therefore makes the Bill stronger. It is in the true spirit of revising the legislation that I move it. I was told last week that I misread the signals given by the noble Earl when I pressed my amendment. In order that I do not do so again, I ask him, if he is not minded to accept Amendment 13—although I sincerely hope that he will be, because it makes the Bill clearer—to give me clear signals that he is prepared to talk about this and bring it back at Third Reading if necessary. However, I sincerely hope that we will not go that far and that he will be persuaded to accept the amendment. I beg to move.

[Baroness Finlay of Llandaff]

My Lords, my name is on two amendments in this group. However, in large part they were covered by the government amendments that we accepted on the previous day of Report. Amendment 13 is particularly important. In our last debate on education and training, we spoke about the need to thread education and training as an infrastructure like scaffolding through the Bill. Carrying on with another analogy, Amendment 13 acts like a superglue that holds all the bits together. We need to make sure that education and training run through every provider, whoever they are. We cannot have some people saying, “Fine, we will have a contract and use staff who have been trained by the NHS but we will not have any obligation toward education and training”. It is within NHS services that the vast bulk of training occurs, although valuable experience can be obtained elsewhere.

The other question the Government need to ask themselves if they are thinking about turning this amendment down, but I hope they are not, is whether they can honestly say that there is anywhere that is fit to provide a service but is not fit to share its knowledge and skills with those who are in training in any part of the discipline. This is not only about specialist education and training but about increasing the knowledge base and skills at every level throughout the system.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Monday 28th November 2011 Lords Chamber

[Lord Patel]

My Lords, I support the amendments tabled by the noble Lord, Lord Warner, to which I have added my name.

First, I will speak very briefly about innovation and procurement. I also contributed to the report by the Science and Technology Committee on procurement. The public sector could learn a lot from the private sector about using procurement to drive innovation. Perhaps the Minister can comment on this. The NHS is a huge organisation that uses about £20 billion-worth of procurement a year and if that was done in a co-ordinated way, it could drive an immense amount of innovation within the NHS.

My second point is about how to drive innovation into clinical care. There are lots of examples I could give, but I will give one from my own specialty. It took us 20 years to take the learning from research into the kind of treatment to be given to the mother in premature labour that would considerably reduce the incidence of respiratory distress syndrome, which causes a lot of harm and death in neonates, and embed that into practice. There are lots of examples of such innovations not being embedded into the NHS and we need to look at ways of doing that faster.

My third point is how to use tariffs to drive innovation. If I as a provider will not be given a higher tariff if I drive innovation or innovate a different way of providing the service, and all that will happen is that the tariff for procuring my services as a provider will be less the following year, there is less incentive for me to use innovation in clinical care to improve patient care and also to make it cheaper.

The fourth issue is about an innovation fund, which I support. Together with the Wellcome Trust, the Government have an innovation challenge fund that asks for tenders in particular areas of innovation. The one I know about is in reducing infection rates. Innovation funds of this kind will drive further innovation; for example, in the United States Medicaid and Medicare have a joint innovation fund to drive improvements in healthcare. So I support that amendment.

[Baroness Finlay of Llandaff]

My Lords, I rise to speak briefly to Amendment 129ZA, which is really a probing amendment. I hope that the Minister will be able to explain what these “prizes” are that are referred to in the Bill. The Explanatory Notes do not really help. They talk about the Bill providing for,

“the NHS Commissioning Board to make payments as prizes in order to promote innovation in the provision of health services”,

and that:

“Innovation will originate primarily from the actions of commissioners and providers but it is intended that the NHS Commissioning Board will take a lead role in promoting it”.

The changes should bring about continuous improvement and innovation often happens outside the main NHS. Indeed, in my own discipline, end-of-life care, the innovations have happened by and large in the third sector, particularly in care in the last 48 hours of life. In some ways, this is where these organisations, the different hospices and those working with them, have felt freed up to pilot different ways of doing things which have subsequently been adopted within the NHS.

There is a huge need for more health services research and for good, qualitative methodology. My only anxiety about the word “prizes” being in the Bill is not that I do not want innovation to happen—I desperately want innovation to improve services for patients—but that I want to make sure that innovations are also properly evaluated; that they are piloted, evaluated and audited in the long term. It is terribly easy for people to have great flashes of inspiration and great ideas but they might not necessarily roll out appropriately across all aspects of the health service. Many of us have seen innovations that seem to be excellent in one setting but when they are rolled out without adequate support and training, mistakes are made and problems arise.

I had the privilege of chairing the commission into medical generalism, and our report noted the shortfall in both funding in primary care and in researching ways of delivering primary care to common conditions. We welcomed the National School of Primary Care Research and the recognition that more funding was needed, but we urged the MRC and other funders to create a dedicated funding stream for clinical research in primary care as it is difficult to secure funding. I hope the Minister will explain what these “prizes” are and say that they will in no way detract from the much needed research funding to really evaluate innovations and innovative ideas, particularly in primary care.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Monday 28th November 2011 Lords Chamber

[Lord Patel]

I am grateful to the Minister for those comments and am greatly encouraged.

[Baroness Finlay of Llandaff]

I add my thanks for the Minister’s remarks. I look forward to seeing amendments which thread education and training through all parts of the Bill with duties on everybody at every level.

Health and Social Care Bill

Debate between Baroness Finlay of Llandaff and Lord Patel

Tuesday 25th October 2011 Lords Chamber

[Lord Patel]

My Lords, my name is added to this amendment along with that of the noble Lord, Lord Walton of Detchant. He has alluded to the need to include this amendment in the Bill. I consider that not only do we need it but that it is not strong enough. We may have to consider making it stronger. I say this because it is important to indicate on the face of the Bill that the Secretary of State has the responsibility to promote and secure a high-level of education in the whole of the workforce that delivers healthcare. I use the example of medical education and training but that applies equally to the training of nurses and other health professionals who are also regulated.

The current system of medical education and training—a model that is copied by many other countries and is widely respected—has evolved over many years. It is not something that was planned overnight and then executed. It has delivered well trained doctors who have improved healthcare. The system is complex and its essential relationships with different organisations and responsibilities are well documented. Only about 18 months ago, legislation was introduced which further changed the regulatory mechanisms for the training of doctors and nurses by making the General Medical Council the sole regulator of doctors’ training from entry to medical school to the day they retire, including postgraduate training, continuing professional development and revalidation. If we tinker with this, we run the risk of fragmenting it and making it inconsistent.

As my noble friend has already mentioned, under the GMC we have postgraduate deans, the royal colleges, the deaneries, undergraduate deaneries and the local hospitals where doctors are trained. These work together in a complex relationship to deliver high-quality medical education and training. The Department of Health has issued a consultation document, Liberating the NHS: Developing the Healthcare Workforce. Some of its proposals have caused a great deal of concern. If those proposals are implemented we run the risk of damaging what has been built up over many years. Adopting a localised approach to education, training and workforce planning to meet the short-term needs of employers will destroy the national training for a national workforce that has been developed over a long time.

There are many other concerns; for instance, the lack of clarity over the role of Health Education England. How will it hold education providers and commissioners to account? There are serious concerns about the continuing role of postgraduate deans, a very important group of people in the delivery and quality assurance of medical education and training. Uncertainties about the role of postgraduate deans are already leading to concerns about managing the recruitment of doctors into training in 2012. There is a lack of information about what part local skills networks will play and about the risk of serious damage occurring to workforce planning, and a lack of clarity about their governance and accountability. The training of doctors also includes training in research methodologies, as the noble Lord, Lord Walton, mentioned. Development of academic doctors is crucial. We already have a problem with recruitment to academic medicine. Therefore, training in research methodologies, postgraduate research and higher degrees in research is crucial. None of these is included in the Bill. They are not included because, we are told, there will be a second Bill. It might even be called the social care and health Bill as opposed to the Health and Social Care Bill. However, we are waiting for the responses from Future Forum, which is considering this. Then we will have the Government’s response, despite the fact that they have indicated that all the proposals in Liberating the NHS: Developing the Healthcare Workforce will need to be implemented by April 2012—the time is rather short. Perhaps the Minister will indicate when we are likely to see this Bill related to education and training. If there is not a satisfactory answer, we may have to consider putting a framework for medical education and training in this Bill.

[Baroness Finlay of Llandaff]

My Lords, I have two amendments in this group, but noble Lords who have looked at them will have noticed that they are almost identical. One of them has inverted commas in it. At this point, I ask the Committee to discount Amendment 8B because the inverted commas do not mean a great deal. However, I would like to take a moment out to pay tribute to those in the Public Bill Office, where this drafting error occurred, and I know exactly why. They have had unending patience, have been infinitely polite to everybody who has gone up there and have provided impartial advice when under enormous pressure. So if this is the only mistake they have made with my amendments, they have done amazingly well.

I would now like to quote from the report from Future Forum by Steve Field. In it he pointed out:

“The professional development of all staff providing NHS funded services is critical to the delivery of safe, high-quality care but is not being taken seriously enough”.

I am glad to see that the Government have also decided to put down an amendment providing that we should state on the face of this Bill the importance of education and training.

Amendment 8A is almost exactly the same as Amendment 6 except that it adds the words, “a nationally co-ordinated system”. The reason is that currently, the standards are set by deaneries, the royal colleges, the universities and the regulators. At the other end from the high-profile degrees and specialist competencies from the royal colleges, there are qualifications such as the NVQs, which have been used for training healthcare assistants. There has recently been much debate about the standard of healthcare assistants, but I think there is a foundation there that could be built on to raise standards across the board. However, it needs to be nationally co-ordinated rather than have lots of odd little bits of training in one particular area, because otherwise when staff transfer, the organisation of management of another area believes that they are adequately trained, when actually there is no national benchmark for that competency. That is why I put in the words “nationally co-ordinated”.

I turn to the amendment put down by the Government. I hope that the Minister will explain how those deaneries and those national co-ordinating bodies that set standards will link in. Will the national Commissioning Board and the clinical commissioning groups have to consider education and training in everything that they do? If they do, the deaneries will have a national planning function in conjunction with the royal colleges and specialist societies which set specific competency standards. I also wonder whether this government amendment, which talks about the health service in England, takes consideration of the NHS in Wales and Northern Ireland. If it does, how would that happen and, if it does not, what arrangements have been made with the devolved Administrations?

I should also ask whether the Secretary of State has a comprehensive duty. Will the national Commissioning Board and clinical commissioning groups have a duty to include education and training when deciding contracts and making commissioning decisions? If they do not do build in education and training right across the piece, will an appeal go to the Secretary of State?

In proposed new subsection (1) of the Government’s amendment, there is mention of,

“provision of services as part of the health service”.

Given the nature of the health service as we see it developing, am I right to understand that that would include all private providers, all voluntary sector providers and all public health and health protection arrangements? Am I right that any provider which does not then provide education and training would need to prove why they were exempt from providing it, if they have a contract for a specific service?

We heard earlier about the independent treatment centres and the sense that they had milked off some healthcare services but had not undertaken training and education. We hear now about specialist trainees in some of the disciplines. Orthopaedics is a clear example whereby a lot of shoulder and knee surgery is not being done in their training environment, so the trainees are not adequately exposed to the range of operations. Indeed, an orthopaedic surgeon contacted me about how she was crowded out in theatre by trainees desperate to watch her carry out a shoulder operation simply because they had not seen that operation done—whereas previously they had broader experience.

If the clinical care of patients is contracted out to private sector or voluntary sector providers, the clinical experience associated with providing that care, if it is high quality, will provide a fantastic education and training opportunity. If we are truly developing a healthcare workforce that will be comprehensive for the needs of the nation, it does not matter who owns the building or the service where that patient is being treated. If that is really high quality, there is much to be learnt. In all the years when I have asked patients if they minded students, postgraduates or whoever being present, there have been only two occasions when patients have said that they would prefer them not to be there—and they were for very understandable reasons. Everyone understands the need to educate and train, and the majority of patients understand that if the person looking after them is also teaching they are being held to account by the group that they are teaching.

Those are some of my questions to the Minister when he comes to speak to his amendment. I ask the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath, whether they see the use of the word “comprehensive” as a duty on the national Commissioning Board and clinical commissioning groups, and whether, when they talk about delivering NHS services, they are intending that private providers and public health are included.

My final point is: whichever of these amendments is agreed—and I have a sneaking suspicion that mine will not be top of the polls; but that is the way it tumbles—the different providers, whoever they are, need to contribute to the cost of education and training. I suggest that when determining a tariff, those who do not contribute to education and training on a particular part that they are providing should not receive the full tariff because they will be ducking out of part of the ongoing responsibility to secure the nation’s health.