South London Healthcare NHS Trust

Baroness Gould of Potternewton Excerpts

Thursday 31st January 2013 Lords Chamber

[Earl Howe]

I am grateful to my noble friend and agree with all that she has said. In making this very difficult decision, my right honourable friend’s primary concern has been to protect outcomes for local patients. Indeed, the logic behind these proposals comes from the clinicians themselves, who came together from across London—way before the TSA was appointed—to develop a series of standards for certain conditions. These are based on the simple principle that a critical mass of highly qualified specialist consultants in one place, on a 24/7 basis, available to see patients within one hour and backed up by the latest medical equipment, will give patients better outcomes. At present, no south-east London hospital meets all the emergency or maternity clinical quality standards. Achieving those standards will mean accommodating acute in-patient care across fewer sites. The result will be that people in south-east London will continue to have much better access to A&E and specialist maternity units than the majority of the population in England, and the prediction is that up to 100 lives a year will be saved by this rearrangement of services. My noble friend has raised a very important point because this is about better patient outcomes.

[Baroness Gould of Potternewton]

My Lords, I want to ask the Minister about the next stages and what happens now. I was interested in the paragraph that says:

“It is important to be clear that my acceptance of these recommendations is conditional on Monitor approving the proposals relating to foundation trusts and on my Department negotiating an appropriate level of transitional funding with organisations such as Kings Partners”.

What is the actual process by which Monitor will now do this? When is it likely to report? When is it likely that the transitional funding will be agreed? What is the process if neither of those things is agreed?

[Earl Howe]

My Lords, the noble Baroness asks some extremely pertinent questions. Matthew Kershaw, the TSA, expects to start a new job as chief executive of Brighton and Sussex University Hospitals NHS Trust in the spring. That will happen before South London Healthcare NHS Trust is dissolved. As we move into the implementation phase, my right honourable friend will use powers in the 2006 Act to appoint a new TSA to provide the management role normally performed by the board of directors. That takes care of the mechanics of management, and the person appointed will of course have to have the necessary skills and experience to lead the trust. The TSA worked closely with both foundation trusts and Lewisham Healthcare NHS Trust to develop his proposals. The trusts are eager for the mergers to go ahead to realise the benefits that I have described. All three trusts are now working towards having signed heads of terms in place that agree the principles of the transaction and set the basis for the final deal.

Looking forward, the organisational changes will almost certainly not occur until somewhere between June and October. Having said that, the trust managers will immediately start making the necessary operational efficiency improvements, as indeed I know they are keen to do. The actual transfers of emergency maternity and paediatric services to other sites is planned to happen in late 2015. That will not be immediate, because it is necessary to spend the funds that I have mentioned to expand the capacity of these other acute centres.

[Baroness Gould of Potternewton]

I am sorry to interrupt the noble Earl, but will he actually answer the question about Monitor and the transitional funding arrangements?

Health: HIV Strategy for England

Baroness Gould of Potternewton Excerpts

Tuesday 15th January 2013 Lords Chamber

[Baroness Gould of Potternewton]

My Lords, is the Minister aware of a recent study undertaken on behalf of the British HIV Association on the relationship between women with HIV and domestic violence, which shows that half the women interviewed have shared a lifetime of what is called intimate partner violence—IPV? In the light of that evidence, can the Minister indicate what action is being taken by government to raise awareness of this very serious level of violence against women with HIV and, secondly, whether there will be any routine screening to find out the level of IPV among these women? Furthermore, does he agree that if we had a national strategy for HIV, surely issues such as this and things such as unemployment, as well as other areas, could be taken into account?

[Earl Howe]

My Lords, the noble Baroness raises an extremely important issue about violence against women. There is a great deal of activity in my department designed to bear down on that and I should be happy to write to her about it. On the issue that she specifically alluded to at the end of her question, we think that, as most HIV is transmissible sexually, it makes much more sense to build that dimension into a sexual health strategy which embraces not only HIV but all transmissible sexual conditions.

Abortion

Baroness Gould of Potternewton Excerpts

Tuesday 4th December 2012 Lords Chamber

[Baroness Gould of Potternewton]

My Lords, the Minister has answered part of my question, but I shall question him a little further. First, I make the point that of course the law must be maintained at all time. Some of the arguments demonstrate attempts not to keep to the 1967 Act. Is it not therefore important that we stress what it says and maintain in absolute the Act as it stands? Any attempt to water down that Act would return us to the days of backstreet abortions and the deaths that followed them. Does the Minister agree—he mentioned this in his last point—that we should maintain proper, available contraceptive services for all ages? A lot of PCTs are not giving contraceptive services to the over-24s, which is why the abortion rate has gone up in that age group. Does he agree that there should be open access to contraceptive services for all ages and by all methods?

[Earl Howe]

My Lords, I agree with the thrust of the noble Baroness’s two points. In particular, I agree that there should be no departure from the terms of the 1967 Act, which is why the CMO took the trouble to write to all clinics and hospitals, as I mentioned earlier, to remind them of the provisions of the Abortion Act and in so doing to remind them that sex-selective abortions are illegal.

I must correct what I said earlier. I hope I did not give the wrong impression about repeat abortions. My briefing states that in 2011, 36% of women undergoing abortions had had one or more previous abortion. That proportion has in fact risen from 31% since 2001. Twenty-six per cent of abortions to women aged under 25 were repeat abortions, which is quite a high percentage.

Abortion

Baroness Gould of Potternewton Excerpts

Thursday 11th October 2012 Lords Chamber

[Earl Howe]

I fully agree with my noble friend.

[Baroness Gould of Potternewton]

My Lords, further to the Minister’s reply, some time ago the Government set up a parliamentary committee, of which I was a member, to look at counselling for abortion. For some time we have had no idea whether that will go ahead. Can the Minister tell us whether the consultation planned at that time will go ahead? Further, can he indicate the outcome of the review of abortion services conducted by the Care Quality Commission?

[Earl Howe]

My Lords, the department is currently considering the best way to make progress with pregnancy options counselling in the context of improvements to sexual health as a whole. As regards the noble Baroness’s second point, the Care Quality Commission looked into the allegations that were made about the pre-signing of HSA 1 forms and found that a number of trusts were non-compliant. The CQC is working closely with these trusts to ensure future compliance, but we are awaiting the conclusions of the investigations by other agencies, including the police, the GMC and the Nursing and Midwifery Council.

NHS: Public Information and Advice

Baroness Gould of Potternewton Excerpts

Tuesday 12th June 2012 Lords Chamber

[Earl Howe]

My Lords, my noble friend is absolutely correct to highlight the importance of preventing obesity, particularly obesity in the young. He will be reassured to know that the Change4Life Campaign, which we have continued from the previous Government, will include this as a major focus into the future.

[Baroness Gould of Potternewton]

My Lords, in light of the fact that the Minister talked about having a review, have the Government given any reconsideration to the need for a specific national prevention campaign designed to reduce the number of HIV infections? Does he accept that there is a necessity to reduce the increasing level of transmission, not only because it is spreading into non-high-risk groups but also because of the cost of treatment, which is extremely costly indeed? It seems to me that there is no question that the long-term savings would be substantial compared to the cost of a national campaign. Can the Minister also clarify the future of the two current targeted HIV campaigns?

[Earl Howe]

My Lords, I share the noble Baroness’s concern. She has highlighted a major area on which Public Health England and local authorities will wish to focus going forward. This is the great advantage of the architecture that we have put in place, with health and well-being boards responsible for determining local needs and the way in which to address them. Public health awareness campaigns have their place but they are not the total answer. The noble Baroness has drawn attention to the importance of having sufficient treatment facilities, and access to them, available. So, with the support of Public Health England at a national level, local authorities should be addressing sexual health as one of their key areas.

Health: Clinical Commissioning Groups

Baroness Gould of Potternewton Excerpts

Thursday 26th April 2012 Lords Chamber

[Earl Howe]

My Lords, I do not accept that. CCGs will be subject to rigorous safeguards that prevent conflicts of interest affecting their commissioning decisions. Each CCG has to maintain registers of interest. They must have a governing body with lay members on it and other non-GP clinicians who will oversee the arrangements for governance. Each CCG must make arrangements set out in their constitution to manage conflicts and potential conflicts of interest. And the NHS Commissioning Board, as part of its overseeing role, will be responsible for making sure that every CCG has arrangements to manage potential conflicts of interest. So we do not see these problems arising in practice.

[Baroness Gould of Potternewton]

I should like to probe the Minister a little further in response to that. While he says that CCGs have to have a register of interest, how are they going to be monitored to make sure that actually happens? How will the register be kept up to date so that conflicts of interest cannot arise in the future? And what actions might be taken when a conflict of interest is proved?

[Earl Howe]

My Lords, the watchword in this context is transparency in that the governing body of a clinical commissioning group will usually meet in public. There will be provision for the health and well-being board of a local authority to challenge decisions made by the clinical commissioning group in its annual commissioning plans. In general, if anyone has a concern about a conflict of interest, or indeed a perceived one, it is open to them to refer the matter, first to the CCG and, secondly, to the NHS Commissioning Board itself.

Health and Social Care Bill

Baroness Gould of Potternewton Excerpts

Wednesday 29th February 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, the noble Lord, Lord Fowler, was chairman of the House of Lords Select Committee on HIV and AIDS. Other members included the noble Baronesses, Lady Tonge and Lady Gould of Potternewton, and me, all of whom are in their places tonight to support the amendment. There is support across the House.

We found that there was a serious problem with people who became HIV positive and were living in England but did not qualify for free medicines. As the noble Lord, Lord Fowler, said, this is a public health problem. If people are HIV positive but do not know it, they can be a danger to others, by infecting them, and to themselves, as late diagnosis is a big problem and very expensive.

Infections are going up but someone on medication is less infectious. HIV/AIDS is an infectious disease. Other people with infectious conditions are given medication, and it is only right and wise that people who are infected with HIV and are living here should receive free medicines. HIV has not gone away—it is still increasing—and I hope that what we hear tonight will be confirmation of what we have heard in the press.

[Baroness Gould of Potternewton]

My Lords, I had a long speech prepared but I have decided to reject it on the grounds that what we will hear tonight will be sound common sense. At the end of my speech on Second Reading I said that we would expect sound common sense, and all the indications are that this will happen. I sincerely hope that that is the case. I am going to make a very short contribution tonight—possibly the shortest I have ever made in your Lordships’ House —and make two specific comments. I have argued and campaigned for this change for many years and, as I say, I hope that I will be able to say thank you.

Not only is this a health issue that will protect the public and bring HIV treatment in line with other infectious diseases—it will save valuable NHS resources in the long term. Principally, however, it is absolutely wrong to discriminate against any section of the community, as has been happening since this rule was first brought in in 2004. There is no question but that universal access, which this regulation will introduce, will be very important in ultimately reducing the cost to the NHS and in making it easier to have early diagnosis, thereby reducing onward transmission and guaranteeing hospital treatment if that is required. No deterrent should be put in the way of reducing transmission and treatment. I hope that that will now cease.

I hope, finally, that the concept of HIV tourism has been accepted as the myth that I have always believed it to be. I hope I am right in saying that I can genuinely thank the Government for a change to this rule. I dread the thought that the Minister is going to stand up and say the wrong thing now—I hope that that is not the case. I also want to thank those HIV organisations that, along with me and others, have campaigned for this change for many years. It has been a long and hard battle trying to persuade people that what we are asking for is, in many ways, not a big issue, although it is for those who are affected by it. Again, I can only say thank you, given that we are perhaps going to get regulations that will change that.

[Baroness Finlay of Llandaff]

My Lords, I did have a speech prepared in support of this amendment, based on the Welsh experience. However, after being woken by the “Today” programme telling me about a debate that we had not had—or that I thought I might have perhaps slept through—and announcing how the Government had responded in a way that I could not recall, I decided simply to bin my speech and live in hope. That is how we all are at the moment. We await the Government’s response to the amendments.

Health: Stroke Care

Baroness Gould of Potternewton Excerpts

Monday 13th February 2012 Lords Chamber

[Earl Howe]

My Lords, not for the first time, we learn from Newcastle how to treat patients.

[Baroness Gould of Potternewton]

I, too, refer to the debate that we had recently on stroke. The Minister greatly praised the work of an organisation called Connect. I declare an interest as my daughter is a director of it. It is a third-sector organisation which works across the country but mainly in rural areas. Connect and many other third-sector organisations are worried that, in light of the squeeze on local authority and NHS budgets, their funding will cease and this wonderful and vital work will be lost.

[Earl Howe]

My Lords, we are well aware of the issue raised by the noble Baroness. Indeed, it was raised during the listening exercise last year. PCT commissioners are identifying all their clinical contracts as part of a stocktaking exercise and over the next year will be using the information collected to identify those contracts that are due to transfer to the new commissioning organisations next year. We will work with both providers and commissioners to ensure that there is a smooth transition and continuity of care for patients and service users.

Health: Stroke Care

Baroness Gould of Potternewton Excerpts

Monday 30th January 2012 Lords Chamber

[Baroness Gould of Potternewton]

My Lords, there is no question that the 2010 national stroke strategy has heightened the knowledge of stroke across the country, but there is still evidence of gaps in long-term provision.

I will concentrate on aphasia, which is an outcome, among others, that my daughter still suffers from 15 years after having a stroke. Aphasia can take the form of people not being able to speak at all or having only a few words; others can no longer read, write or use numbers. All the evidence shows that services are not planned with the needs of people with aphasia in mind.

There are currently about 250,000 people in the UK with aphasia. However, statistics are notoriously difficult to collect. This is illustrated by the findings of the Care Quality Commission. Only 7 per cent of adult social services departments reported including people with aphasia in designing stroke information. Eighty-one per cent of PCTs have not tried to estimate how many people with aphasia live in their area. All this is further compounded by the fact that communications disability is not a recognised disability and so is not monitored. People with aphasia are invisible. A simple solution would be to monitor how many people have aphasia at the time of the stroke, at discharge from hospital and when under the care of social services.

Key to the provision of services for people with aphasia are the voluntary bodies, and I want to refer to one specific organisation, Connect, of which my daughter is a board member. Connect is a charity for people living with aphasia, which offers information and support for carers and health professionals. Crucially, it recognises people with aphasia as experts and as such has pioneered innovative ways of working in partnership with people with aphasia. It aspires to enhance and extend statutory service provision once statutory services end and offer the opportunity to re-engage with life beyond services. This is in addition to the provision of a statutory workforce and a passionate and highly skilled workforce of volunteers supporting service development and delivery. At the same time it aims to reduce costs for national services by reduced visits to the GP as a result of improved mood, greater self-esteem and increased social participation as well as reduced dependency on speech and language therapy, enabling earlier discharge from statutory services.

It is not all about specialist rehabilitation, important as that is, but sometimes about low-cost, accessible, creative, peer-led activities such as drop-in, befriending and awareness provided by a third sector organisation. However, real support is required to help organisations such as Connect and the Stroke Association continue to provide these vital services in the long term. Stroke is not a one-off event but a life with complex disabilities.

Health and Social Care Bill

Baroness Gould of Potternewton Excerpts

Tuesday 13th December 2011 Lords Chamber

[Lord Butler of Brockwell]

My Lords, I shall speak to Amendments 288H and 291A, in my name and the names of the noble Lords, Lord Newton of Braintree and Lord Turnberg. The amendments are related. Like other amendments in this group, they relate to the tariff—that is, the remuneration which a healthcare provider receives for a healthcare service. The amendments to which I am speaking are designed to facilitate the introduction of new treatments made possible by the development of new technology. When an innovative treatment requires a new procedure code or an updated healthcare resource group classification, a new code can take up to three years to be implemented and a new healthcare research group can take up to six years to develop. Meanwhile, NHS trusts cannot be remunerated for potentially useful and cost-effective improvements made possible by new technology.

In Germany, an intermediate step has been developed, under which providers can apply for an on-top payment while a new code is being developed. This is known in Germany as the NUB system, although I hope that noble Lords will not ask me to say what NUB stands for. These amendments provide for a similar “innovation tariff” to be provided in the United Kingdom, to allow for providers to be remunerated for an innovative procedure on a temporary basis while a new procedure code or healthcare research group is being developed.

These amendments are in line with the Government’s Strategy for UK Life Sciences, which was published last week, but are not already covered by it. I hope therefore that the Minister will give sympathetic consideration to the introduction of arrangements of this sort to facilitate the introduction of health improvements made possible by new technology.

[Baroness Gould of Potternewton]

My Lords, I shall speak to Amendment 292A. As it stands, Clause 114(11) will have a negative effect on the provision of sexual and reproductive health services. This arises from the transfer of sexual health commissioning, along with public health, to local authorities.

Clause 114 requires Monitor to publish “the national tariff”, but an amendment put down by the Government in the other place inserted subsection (11), which specifically exempts public health services from the national tariff. As sexual health services are set to be a public health responsibility, it will mean that genito-urinary medicine and sexual and reproductive health services will be excluded.

Sexual health professionals are deeply concerned by the impact that the absence of a national tariff may have on the provision of sexual health services. There are a number of providers of sexual and reproductive health services in the community and many are funded by a payment-by-results tariff system, commissioned by PCTs. The Bill as it is now drafted makes it very unclear how those services can expect to be commissioned by local authorities. Without a national tariff, the expectation at best would be to have a local tariff implemented, based on a national tariff. At worst, providers will return to a system of block contracts.

--- Later in debate ---

The noble Baroness, Lady Gould, took us to the subject of sexual health. I thank her very much for setting out her concerns so eloquently. Public health is indeed an area that deserves our consideration, and I am sure that the noble Baroness would agree that we discussed this subject at some length in previous debates. However, let me be clear that the purpose of the national tariff is to facilitate the fair reimbursement to providers for NHS services only. It would be inappropriate for Monitor and the NHS Commissioning Board to impose public health tariffs on local authorities. I see no reason why Monitor and the NHS Commissioning Board could not provide expert advice to Public Health England or local authorities on implementing a current tariff or—

[Baroness Gould of Potternewton]

The difference between sexual health and most of public health is that sexual health provision crosses local government boundaries, otherwise you will restrict any form of open access, which is absolutely essential in providing proper and effective treatment and care for people who need sexual health services. That has to be taken into account. Identifying sexual health provision just in terms of local government areas will make all the work that has been carried out over the past few years to provide better services disappear rapidly.

[Earl Howe]

My Lords, I appreciate those points and I was coming to some words of comfort for the noble Baroness. Not only could Monitor provide technical advice to Public Health England, provided that that was resourced and managed through the framework agreements and the memorandum of understanding between the two organisations, which would be a given, but Public Health England and local authorities could develop their own tariff, if that is what they wanted to do. I understand the noble Baroness’s concern about the underfunding of sexual health services and that the mandate may not set out enough on that score. Her amendment is clearly a way of ensuring that public health services—particularly this type of service—have an agreed cost attached to them that cannot be varied by local authorities, unless they adhere to the rules around variation. I understand all that. However, what the noble Baroness proposes would significantly increase the remit of Monitor and the NHS Commissioning Board and cut across the roles of local authorities and Public Health England. I will, of course, reflect on what she said, but there are probably mechanisms to deliver the kinds of objectives that she is aiming for.

Also on the subject of sexual health services, my noble friend Lady Tonge made some important points. I completely agree with the importance of the issue she raised. It would probably be best if she allowed me to write to her in response.

My noble friend Lord Clement-Jones proposed in his Amendment 292ZA that Monitor should include variations to prices for individuals who experience disadvantage or who have complex needs. While I am sympathetic to his intention, this is already provided for in the broad provisions in Clauses 114(4) and 117(1). In addition, the inclusion of “must” rather than “may” would not provide Monitor with flexibility on when to specify variations and rules.

I move on to the amendment of the noble Lord, Lord Davies of Stamford, who argued the case for competition on price, and I listened with interest to what he had to say. Let me explain what we are seeking to achieve. Overall, we want a system of fixed prices, set locally or nationally, that would ensure that competition was based on quality and patient choice, not on price. Only in specific circumstances could the prices determined by the tariff be varied. These flexibilities would not allow price competition but would rather, as I have indicated, prevent cherry-picking, allow innovation and secure continued access to services. Put simply, the flexibilities would be allowed only where the effect was to improve the efficiency or quality of services provided.

The Government made amendments to the Bill in another place to make clear that the tariff would not be a maximum price. That is vital to avoid perverse incentives for providers to cut costs at the expense of quality. That is entirely different from the competitive tendering scenario to which the noble Lord, Lord Davies, referred. In that scenario, whereby services would be outside the tariff, it is quite reasonable to evaluate bids in terms of best value, not the cheapest price. Guidance published by the previous Government made that clear. I think that we are closer together than perhaps the noble Lord appreciates, but I am grateful to him for what he said. However, he will know that it was the firm view of the NHS Future Forum that competition should be based essentially on quality rather than on price alone. There is of course a danger that we have a race to the bottom if we go too far down that road.

My noble friend Lord Clement-Jones in his Amendment 294M made some telling points. While I am sympathetic to some of them, I can reassure him that agreements for local modification of tariff prices under Clause 122 are intended not to introduce price competition but to sustain the provision of essential services. For example, a local modification may be necessary to sustain provision of A&E or maternity services in a less populated area. It would be inappropriate to remunerate all providers of an essential service at a modified tariff rate without assessing their circumstances on an individual basis.

The noble Baroness, Lady Finlay, in her Amendment 294BZA proposed that it be explicit that Monitor, in establishing the national tariff, have regard to differences in costs of patients incurred by providers and differences between services provided. Clause 116 makes clear that when developing the draft tariff for consultation, both the NHS Commissioning Board and Monitor should have regard to the differences in costs of patients incurred by providers and differences between services provided. However, that amendment raises a valid point around whether Monitor should have regard to these differences when publishing, as well as when drawing up, the national tariff. I can tell the noble Baroness that this issue will be given consideration to determine whether further clarity is necessary in this area.

I now return to Amendment 292ZA, tabled by my noble friend Lord Clement-Jones. He raised the issue of cherry-picking, which we define as something that occurs when providers undertake only the more simple interventions for less complex patients but are paid an inflated price, based on higher average costs. I hope that my noble friend would agree with that definition. Under the proposals in the Bill, Monitor would ensure that the price paid to providers was accurate and reflective of the services delivered. A comprehensive tariff with more reflective prices will prevent cherry-picking. In particular, Monitor and the board would need to consider among other factors the impact of variations in the range of services provided by different providers and the differing needs of the patients treated. My noble friend again asked why the Competition Commission should be used, and again my answer is similar to the one I gave him earlier. The commission is an expert independent body with experience in considering matters such as this—unlike the OFT.

I now turn to Amendment 294AA, tabled by the noble Lord, Lord Warner. It would duplicate what is already stated in this clause, whereby Monitor must send a notice to other persons as it considers appropriate, which may include other clinical groups. Clause 59(8) makes explicit that Monitor must obtain appropriate clinical advice to enable it effectively to discharge its functions. Clause 116(1)(c) provides that Monitor must notify other appropriate persons of the proposed national tariff, which may include other clinical groups. Monitor must publish its consultation containing the draft tariff.

As regards Amendment 294BA, the share of supply percentage that triggers a reference to the Competition Commission will be considered in secondary legislation and agreed through the affirmative resolution procedure. The share of supply percentage would ensure that providers of a service made up of only a few providers would still be able to object to a proposed national tariff and therefore trigger a reference for independent adjudication.