Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 8 months ago)
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Lord Newton of Braintree
My Lords, perhaps I may intervene briefly, if only to avoid withdrawal symptoms from not having spoken on any day this week. I want to support my noble friend Lord Clement-Jones on the general proposition without wishing in any way to threaten mayhem if we do not get a satisfactory reply. The House is well aware, as I have referred to it on a number of occasions, that last year I went through what turned out to be the trauma of trying to engage in what was technically a takeover, although we presented it as a merger, with the neighbouring health trust. That involved Suffolk Mental Health and Norfolk Mental Health. We finally achieved it on New Year's Day, so I am, so to speak, out of work.
There was a real problem. One got the feeling that the people on the competition and collaboration panel, or whatever it was called, which overlaps quite heavily with the Competition Commission, saw us in much the same category—how can I put this without upsetting anyone?—as two rival sellers of washing detergents. They did not recognise that health is not like that. There were health issues, patient safety issues and quality of service issues that needed to trump the competition issues. I know that we have been told that that will happen, but it is very important to make sure that the machinery will ensure that it happens and that the health issues trump those narrower competition issues. All I seek from the Minister is an assurance that, one way or another, that will be the case.
Baroness Hollins
My Lords, I would like some reassurance that the regulation of competition will improve on the current situation in some circumstances. I do not know whether these amendments, or any existing provision in the Bill, will achieve that. I have a couple of examples about which I feel uncomfortable.
First, I am keen to know whether adequate safeguards are in place for the kind of situation that occurred in Surrey, to ensure that the range of providers envisaged by the Government will be able to compete on a level playing field. I remember the wise words of the economist Fritz Schumacher that sometimes “small is beautiful”. Can the Minister tell the House on what basis it was decided that a £10 million bond would be required as surety from bidders for the NHS contract tendered last year for community services in south-west and north-west Surrey? The winning tender was a private company and the loser was Social Enterprise UK, which is currently providing services to central Surrey but which did not have the £10 million in the bank. That organisation is providing high-quality community services which have been acclaimed by the noble Lord's own department. At the end of its three-year contract, will it simply be taken over by the large private company which has more money in the bank?
My second question relates to the culture within the NHS and medical practice. Since the NHS began over 60 years ago, most doctors have worked primarily in the NHS and used their clinical skills first and foremost for NHS patients. There have been special contractual arrangements in place to ensure that NHS specialists with a private practice do not neglect their NHS patients. I think it is fair to say that specialists with a thriving private practice usually put their extra energy into their private practice. They are not the ones who contribute to managing and developing NHS services, and nor do they usually make much contribution to research.
Let me give the House one example of how the culture within medicine is being encouraged to change. The presidents of many if not all of the medical royal colleges have been invited to a champagne reception and dinner at a posh London venue in a couple of weeks’ time. The invitation comes from a firm of solicitors and the Royal Bank of Scotland, and it states:
“Against the backdrop of challenging economic conditions and massive pressure on the public purse, we are keen to explore how other professions might be able to support your membership and the healthcare sector generally”.
This seems to be a new phase in encouraging and supporting doctors to turn their attention to setting up in private practice, in chambers and in other private healthcare organisations. That is a departure from our history. Is this the direction that the Government hope the medical profession will move in? What safeguards does the Bill contain with respect to competition to protect the NHS?
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 9 months ago)
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Baroness Howarth of Breckland
My Lords, I wish to add my voice to the need for clarification, as raised by the noble Baroness, Lady Finlay, between the services provided by the national and regional boards for rare diseases and conditions. I declare an interest as a patron and trustee of an organisation that deals with children with hypoplastic left heart syndrome and some similar conditions of right heart defects.
As the Minister will know, a recent Safe and Sustainable review has been looking at how those services should be delivered. Obviously the complex surgical procedures need to be carried out in specialist hospitals, but the aftercare very often takes place locally. The Safe and Sustainable review having stalled during the discussion about this Bill, parents are extraordinarily concerned about how that will be taken forward. I say this as an example but it is true of all families who have children or adult relatives with rare conditions that they want to be absolutely assured that the right service is commissioned at the right level, and need to know how that assessment is going to be made. At the moment it is extraordinarily unclear and I think that is why the noble Baroness, Lady Finlay, has tabled her amendment and the other issues have been raised.
All I am seeking is that clarification, partly because I have got to go and tell the parents this weekend at their AGM.
Baroness Hollins
My Lords, I have been reflecting on the amendment tabled by my noble friend Lady Finlay. I declare an interest as one of my daughters has one of the conditions that she mentioned in her speech.
This lacuna must be addressed because the discretionary powers of clinical commissioning groups to apply the appropriateness test provide no assurance for those with these rare diseases. Today’s debate shows that it is essential that this is addressed in the Bill. I hope that the Minister will be able to suggest a way in which perhaps a government amendment might be able to address this lacuna.
Lord Hunt of Kings Heath
My Lords, this is a very interesting group of amendments. They do not entirely fit together but all of them raise important points.
I very much support the noble Baroness, Lady Cumberlege, in her comments about HealthWatch. This is my mea culpa moment about the demise of community health councils. It is clear that having a statutory body with the right to be heard and listened to is very important at local level. Of course, I would link the noble Baroness’s amendment with the desire for HealthWatch England to be wholly independent of CQC, which is another important ingredient in ensuring that the patient voice is heard as effectively as possible.
We support Amendment 96. There has been a persuasive argument about the need to ensure that services for patients with less common conditions are commissioned effectively. We debated these issues on Monday. We know that primary care trusts have often found it difficult to give proper attention to these services. With clinical commissioning groups, this will become even more problematic. I hope that the noble Baroness will be able to pursue that.
I entirely support the noble Baroness, Lady Williams, on Amendment 75. This is a very important statement of principle. I understand the points made by the noble Lords, Lord Mawhinney and Lord Newton. I am sure that this matter will be put to the vote. The whole point about Third Reading is that it can be used for parliamentary counsel to tidy up the wording of such amendments. I do not think that we should let minor technical difficulties get in the way of passing an amendment which has a very important principle. It may be that the noble Earl, Lord Howe, will agree to it. Let us hope so.
My amendments relate to the corporate governance of clinical commissioning groups. On Monday, I developed my arguments when we discussed conflict of interest issues. I do not want to go over the same ground again, save to say that clinical commissioning groups will have a crucial role to play in the new system. They are to be handed billions of pounds by the NHS Commissioning Board to commission services. Essentially, a clinical commissioning group is not an NHS board as we know it. It is a group of small business people—GPs—who will be able to benefit financially from the decisions of that board. I cannot conceive that the Government could be going down this route if they did not want more resource spent in primary care. That must be one of the end results of the Bill. The Government want to spend more money in primary care and to reduce expenditure in acute hospital services, which is a very fair aim. But that means that the board of clinical commissioning groups will be spending public money and placing it in the hands of GPs who also sit round the board of the clinical commissioning group.
The conflict of interest amendment in the name of the noble Baroness, Lady Barker, which the noble Earl accepted, was very weak and does not provide the kind of assurance that we require. I have to say to him that there will be trouble in the future with clinical commissioning groups in this area. The proper safeguard would be for clinical commissioning groups to have a proper board. Proper boards in the public sector usually ensure that there are a majority of non-executives, people who are appointed independently, who can make sure that the public interest is protected. We have the extraordinary proposal that we are guaranteed only two non-executives on the board of clinical commissioning groups. We are not even guaranteed that one of them will be the chair of that clinical commissioning group. Looking over all the corporate governance difficulties in this country in the past 20 years, can noble Lords imagine that any of those inquiries would endorse the kind of governance arrangements that the Government are putting forward for clinical commissioning groups? I say to the noble Earl, Lord Howe, that I just wonder how long it will be before the first group of members is prosecuted for corruption. This is an open invitation for corrupt action. The Government show no signs of understanding or realising what difficulties they will put the whole service in by these proposals.
I have put forward a number of amendments to put in place proper corporate governance protection. I also believe that the constitution of clinical commissioning groups should be subject to approval by your Lordships’ House. In relation to primary care trusts, orders go through. I do not see why the same thing should not happen to clinical commissioning groups. I also endorse everything said by the noble Lord, Lord Patel, about quality payments. It is absolutely abominable that quality payments could be made to clinical commissioning groups where those payments end up in the pockets of individual GPs. That money ought to go into the commissioning of services. Again we see the conflict of interest. There is so much potential for conflict of interest between commissioning decisions in the public interest and commissioning decisions which are to the financial advantage of the members of the clinical commissioning group.
Finally, Amendment 118 would remove the quality premiums altogether. This is very much a probing amendment. I am content to support the noble Lord, Lord Patel, in his argument that, if quality payments are to be made, they should simply be put back into the commissioning pot.
Baroness Finlay of Llandaff
My Lords, this is a clear example of an iatrogenic condition, very often originating in primary care. When patients have presented with insomnia, instead of being taken through the more complex and time-consuming aspects of sleep hygiene and possibly talking therapies to discover the cause of their insomnia, a prescription has been given all too quickly and readily. If we are looking at responsibility falling back to clinicians in primary care, it seems inordinately sensible that the clinical commissioning group should consider its responsibility to provide support to patients who end up with an iatrogenic problem.
I can see that the Government may feel that this is a very specific amendment targeted at a very specific area, but the guidance that needs to go out to clinical commissioning groups on their responsibility for the behaviour of all those prescribing on their patch may well deal with some of the principles behind this amendment and ensure that the necessary services are provided to patients who, completely inadvertently, fall foul of taking the drugs that they were prescribed and as they were told to take them.
Baroness Hollins
My Lords, I pay tribute to the work of my noble friend Lord Sandwich, who has done so much to raise awareness of the often unmet needs of people whose addiction originated in a legal prescription. There is some progress in training doctors—for example, in undergraduate medical education with a new national curriculum on substance misuse. This guidance provides learning objectives on rational prescribing and iatrogenic addiction. The fact that such a curriculum is only just being introduced shows the need for the attention of clinical commissioning groups to be brought to this issue.
There seems to be a special responsibility on the National Health Service to provide better care for people affected by medical prescribing practice, and I hope that the Minister will be able to suggest how such a responsibility could be emphasised in the Bill.
Baroness Thornton
My Lords, I intend to make only two remarks. We have a great deal to get through tonight, so I shall exercise great self-discipline. I think that I will come in at under a minute and a half.
The noble Earl needs to be commended for his determination and hard work in this area. We think that it is an important issue. This is a growing problem and the noble Earl makes very reasonable requests, for which he has widespread support. I agree with the noble Baroness, Lady Masham, in that I fear this problem may get worse before it gets better, but I hope that the Minister will have good news for us about it.
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 9 months ago)
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Lord Faulks
Before the noble Lord sits down, could he confirm that, since the Compensation Act 2006, an apology is no longer deemed to be an admission of liability?
Baroness Hollins
My Lords, I support the amendment, particularly because it draws attention to the point that often patients experience prolonged psychological harm after an incident, something that is not well understood across the whole of the medical field. Such psychological harm is often overlooked. However, there is plenty of evidence that an honest and prompt apology can do so much to help the person and their family going forward. It is fair to say that delaying a response is very much like denying a response. The timeliness of a response is critical.
Lord Turnberg
My Lords, As someone who taught medical students for many years that it is very important to be absolutely open and candid with your patients, and that, if something has gone wrong, to explain it in full to the patients and their relatives—explaining that that is not necessarily an admission of guilt in some way—I am very keen on the sort of sentiment that is being expressed in this amendment. I am particularly keen on the GMC imposing on doctors the duty of being open. I am all behind the sentiments of this amendment. I have some anxiety, though, about how this can be put into law. How can you legislate for someone to be candid? How will it work? How do you know that someone has been candid or not? There is a great deal of subtlety about this candour and about putting it into law as a duty on every occasion. I am slightly apprehensive about the amendment, even though I support everything about the principle.
Lord Owen
My Lords, I rise to speak because I am a little troubled. It looks as though the Minister will object to this amendment. Of course, we are speaking in advance of knowing what he is going to do but I should like to give two or three reasons why I very much hope that he accepts the amendment.
First, using the term “social care” in the Bill means that expectations will rise. Those expectations have not been fulfilled and, to be honest, they could not have been. Nevertheless, it was a good idea to try to point to the fact that this was about more than NHS care or healthcare. We all know—it has been said many times in our debates—that there is no way that we can look at the narrow definition of the health service; it has to be broader.
The other powerful argument which I thought the noble Baroness was going to make is that this is a cultural change, and that needs to be re-emphasised at every stage as part of an educative process. Let us take the national Commissioning Board. This is a new body and the person who has been appointed to chair it is an academic lawyer—a person of great distinction. I am not objecting to the fact that it may be somebody with not very long experience of the health service. Nevertheless, a lot of hopes are vested in that Commissioning Board and to draw attention to it in a more declaratory way in this Bill is very important. It needs to know and see in clear terms in the Bill that this is part of its remit. I take great notice of what has been said about the reluctance of local authorities to respond to this. Were we having a debate involving local authority services, I would raise that, too. For a very long time I have believed that in the 1948 Act a great mistake was made in not pooling together local authority health services and welfare and social services in a comprehensive package. As everybody knows, there was a very deep debate inside the then Labour Government between Herbert Morrison and Aneurin Bevan.
There is also another debate about decentralisation and centralisation. That has been with us all these years. In the very early 1960s I wrote a book about a unified health service. When I was a Minister, there was a great deal of animosity within the medical profession at the thought of working closely with local authorities. It is amazing how that has changed. There is now a readiness in the medical profession in particular—nurses have always done it—to work across these things. I shall make no more points, but I hope that the Minister will accept this amendment. With all the reservations that have been put down, nobody should believe that this legislation will have a very big impact on social care anyhow, but pointing it in the right direction at this moment would be helpful.
Baroness Hollins
The amendments have particular relevance to mental health and learning disability services. In speaking in this debate, I declare an interest as a past president of the Royal College of Psychiatrists. I shall focus my comments on commissioning integrated care.
I remember that in the early 1980s, when I was newly a consultant, we had jointly commissioned services. They worked effectively and provided a very accessible way of developing integrated services. I shall talk briefly about the work that the Royal College of Psychiatrists has already done to support integrated commissioning since the Bill was first mooted. The joint commissioning panel on mental health was launched in April 2011. It is led by the Royal College of Psychiatrists and the Royal College of General Practitioners. It is a collaboration of 15 other leading organisations, service users and carers with an interest in mental health, learning disabilities and well-being across health and social care. It draws on expertise from across the statutory, voluntary and private sectors.
It has already produced guides on primary mental health care and liaison mental health services, which is relevant to the comments of my noble friend Lady Young about integrated care for people with diabetes. My interest here is integrating mental health care into the diabetes pathway. The panel is working on both commissioning guidance: on what is needed; and on practical commissioning tools—how to do it. The practical how-to-do-it tools have been developed with strategic health authorities, thus providing important support to the emerging and new NHS structures. They will be ready in 2013.
The joint commissioning panel on mental health is an example of an existing strong and practical partnership, which brings together the whole mental health sector with government to develop and implement integrated high-quality care and interventions. Incidentally, it is hard to understand why professional organisations leading this work were excluded from the Prime Minister’s recent summit on implementation, given this real focus on that issue. Mental health can so easily be forgotten along with other complex services when physicians, surgeons and politicians are debating health rather than mental and physical health. I am interested to know the Minister’s views on whether this cultural change needs to be in legislation. Some of the experience gained in jointly commissioning mental health services provides very good learning for services traditionally seen as providing stand-alone health episodes—good learning that could be used to develop integrated services in other areas of healthcare.
The Earl of Listowel
In rising briefly in support of the amendments, I pay tribute to the Government for their contribution in this area already. This is a personal view, but in my experience the best professionals will find a way through against all odds and against the system to work together in partnership to improve outcomes. What the Government have been doing with the social work workforce in terms of raising the threshold of entry to social work, the additional support for newly qualified social workers and the review by Professor Eileen Munro on child and family social workers is a welcome part to this. I hear again and again from people on the front line that an obstacle to integration is continual structural change. When disciplines have stability and can grow together they can learn to work in partnership effectively. Finally, I welcome the building of capacity in the social work workforce, which will assist with the question of better integrated working.
Health: Smear Tests
Baroness Hollins Excerpts(12 years, 9 months ago)
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Earl Howe
My Lords, inoculation is not being offered to boys as part of the national programme. As I am sure the noble Lord knows, the aim of the programme has always been to prevent cervical cancer in women. Clearly, the best way to do that is to vaccinate girls and young women. However, these vaccines can be purchased privately and health professionals should exercise their clinical judgment when prescribing products for specific indications.
Baroness Hollins
My Lords, will the Minister explain what efforts are being made to ensure that uptake of both vaccination and cervical screening is good among girls and women with learning disabilities, particularly given their low awareness of the risk of cervical cancer and the high rate of sexual abuse among this population?
Earl Howe
My Lords, as ever, the noble Baroness raises an extremely important point about those with learning disabilities. I will need to write to her because my brief does not contain an explicit reference to them. However, I feel sure that the work to which I referred earlier—the strategic trial—will incorporate work to embrace all sections of the female population. I will write to the noble Baroness about that.
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 9 months ago)
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Baroness Hollins
Baroness Hollins
My Lords, I rise to speak to Amendment 26A and the others in this group on behalf of my noble friend Lord Ramsbotham, who was unable to stay until this hour tonight. My noble friend was first going to explain, and apologise to the House, that the amendments, as handed to the Public Bill Office, included the word “communication”, which somehow turned into “communization” during the printing process. My noble friend was then going to thank the noble Earl for his letter, which he received on Friday, and invite him to confirm to the House what he said in that letter about the healthy child programme. The letter said that the programme,
“provides regular opportunities after birth for the parents and the health visitor to review together a child’s development, health and wellbeing including any concerns about speech and language skills”.
My noble friend was very glad to note that the Department of Health and the Department for Education and Skills are working together to ensure that the two-year to two and a half-year review that is part of that becomes an integrated review covering both health and education, which he assumes is to be compulsory. He also noted the work that was being done within the public health outcomes framework to inform decisions on services and support. However, accepting all that, he noted that, in her final report, the communication champion recommended that the Government should fund local professional development for early-years practitioners to enable them to assess and support children's communication and language development within the revised early-years foundation stage framework that is part of the public health outcomes framework. There is a possible shortfall, so my noble friend would like to ask the Minister whether that includes training of health visitors, who will make initial assessments, and a halt to the reduction of speech and language therapists, whose numbers were reduced by 3 per cent in 2010-11. Their follow-up is crucial to successful post-assessment development support. Equally crucial is that health and well-being boards understand that speech and language development not only underpins literacy development but is at the heart of the Government's proposed revisions to the early-years foundation stage framework. My noble friend seeks the Minister's additional assurance that assessment and follow-on action are properly integrated.
Speaking now for myself in support of these amendments, I have had personal experience in my family of a child needing the specialist help of speech and language therapy to be able to acquire sufficient language for day-to-day communication. The battle to provide adequate speech therapy for pre-school and indeed for primary schoolchildren has been ongoing for many years. I know that my noble friend Lord Ramsbotham was not proposing to test the opinion of the House, but I beg to move this amendment tabled in his name.
Baroness Northover
I would refer the noble Baroness to the public health outcomes framework and the way that this will be included in that. The framework is very widely drawn and I hope that the Opposition will generally welcome that. It builds on the work that they themselves did and I hope that they recognise that.
I think that I have covered most of the issues that were flagged up. I reiterate that we appreciate enormously the commitment that noble Lords have paid to this area. We know how important it is; it sets the foundation for what happens later for many of these children. On the basis of that, I hope that the noble Baroness will be willing to withdraw the amendment.
Baroness Hollins
My Lords, I know that my noble friend was extremely grateful for the letter from the noble Earl, Lord Howe, on this matter. Communication is fundamental and screening is critical. We know that early intervention is effective. I am disappointed that the Minister did not confirm whether there would be a halt to the reduction of speech and language therapists. I beg leave to withdraw the amendment.
Baroness Hollins
Baroness Hollins
My Lords, I shall speak also to Amendments 55 and 238. My noble friend Lord Rix sincerely regrets that he could not stay this evening as his wife is unwell.
The three amendments tabled by my noble friend to this Bill have been placed together in this one group. I welcome this opportunity to speak to them. Noble Lords will be aware that these issues were raised during the Committee stage of the Bill. My noble friend recently met the Minister to discuss the matters that I am about to raise in relation to people with a learning disability. It is appropriate for me to declare an interest as a psychiatrist specialising in learning disability and also because my son has a learning disability.
To be fair to the Government, it could be argued that the broader issues which these amendments attempt to resolve could have been addressed by the National Health Service many years ago. However, my noble friend and I are using the opportunity presented by this Bill in an attempt to tackle them now. The first amendment, Amendment 37, aims to ensure that health services for those with the most complex needs are commissioned by the NHS Commissioning Board. Concerns were expressed about this issue in Committee. We seek assurances that health services for those with the most complex needs, particularly people with profound and multiple learning disabilities and people with complex needs whose behaviour challenges services, will be commissioned centrally by the NHS board. This amendment would ensure that the NHS Commissioning Board has oversight in this area, including the co-ordination and commissioning of specialist services or facilities for this particular group of disabled people. Any assurances that the Minister may be in a position to provide on this matter would be welcome.
The second amendment tabled in the name of my noble friend, Amendment 55, concerns the importance of collecting data on the experience and outcomes encountered by all patients in the NHS. Where a patient has a disability, it would also ensure a breakdown of disability by impairment type. In Committee, the Minister informed the House that his department is working with the NHS information centre to explore the extent to which indicators in the NHS outcomes framework can be disaggregated to show impairment types, which we would both welcome. However, if the information is not collected at source, clearly there will be limits to which this can be achieved. The Minister also stated that the Government's NHS information strategy aims to cover this issue too, when it is published later this year. Any additional assurances that the Minister is willing to give about what steps the Government will take to ensure that data are collected at source would be welcome.
The third and final amendment, Amendment 238, concerns the provision of independent advocacy services for people who are in the process of making a complaint against the NHS. For those who are unfortunate enough to encounter it, the NHS complaints system is flawed and ineffective. We welcome the Government's proposal for local authorities to make appropriate provision to support people in the complaints process through the use of advocacy services. However, there is a risk that advocacy support could be started and then halted some time before any conclusion to an ongoing complaint has been made. In Committee, the Minister emphasised that local authorities would have the discretion to provide independent advocacy services, consistent with their legal obligations, as they deem appropriate. My noble friend is particularly concerned that such discretion could leave many families without the on-going advocacy support that they need. Is the Minister able to provide my noble friend with any comforting words on that matter? I beg to move.
Baroness Thornton
My Lords, it is important that the Minister can give us some satisfaction in answer to the remarks made by the noble Baroness, Lady Hollins, particularly in view of the tireless pursuit of these issues by the noble Lord, Lord Rix. This small suite of amendments aims to start at the top as it talks about the Secretary of State’s power to require the board to commission services including for those with profound and multiple learning disabilities. It then puts a duty on the board to reduce inequalities, which will involve collecting data on the experiences and outcomes of patients with these disabilities. It also sets out that there should be no upper limit on the length and type of advocacy support that must be provided by local authorities. Therefore, it aims to provide a suite of amendments that address the whole system and the interventions that will be necessary to provide the right framework under the new regime for some of the most vulnerable people in our country.
It was interesting that, on a more general matter concerning children and the Bill, the NHS Confederation deputy policy director, Jo Webber, said recently that the Government's plan to recruit 4,200 extra health visitors by 2015 was leading to a loss of staff in other vital roles in some areas. For example, many established and successful children's health teams are being rearranged or in some cases disbanded simply to employ more health visitors. Ms Webber’s report claimed that the Government should replace the health visitor target with one that focused on the outcomes for children rather than on the numbers of staff in place. That was a very wise remark.
I turn to the children with the most complex difficulties and the question of how under this framework they will receive appropriate assessment and treatment that will address their individual needs. At best, there will be problems with the transition to the new system, and if there are gaps in the service for vulnerable children and learning-disabled patients who perhaps have GPs with limited experience, and doubts about how GP consortia will react to the situation, that is an issue of great concern. Historically, there has been an imbalance whereby people with learning disabilities have lost out when compared with those, for example, with mental health problems—who have also lost out. Therefore, how this group of children and young people are catered for will be a way of testing whether these things will work at all.
Baroness Hollins
My Lords, I am grateful to the Minister for emphasising the Government’s wish to improve outcomes for the group concerned in these amendments. I am pleased that current plans are to define these services through regulations. On behalf of my noble friend Lord Rix, I thank the Minister for their recent meeting at which I understand these issues were discussed in depth. I know my noble friend was very pleased to have that opportunity. I would like to pay tribute to him for his careful and persistent work to improve access to healthcare for people with learning disabilities. I shall look forward to seeing the information strategy in April and seeing just how far the information is going to be able to identify the needs that my noble friend and I are concerned about. I beg leave to withdraw the amendment.
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 11 months ago)
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Baroness Hollins
My Lords, I would like to add to what my noble friend Lady Murphy has said by commenting on a couple of amendments in this group which concern the need for the tariff to be able to reflect and adapt to the requirements of people with complex needs. I am thinking particularly about people with learning disabilities who may need additional time to be devoted to them because of their conceptual or communication difficulties, or other disabled people who may require reasonable adjustments to be made in order for them to use a service. I think also of people with mental health problems using hospital services such as maternity services. The provision of maternity care is hugely complicated by the presence of people with an enduring mental illness. The need for the tariff accurately to reflect and encompass these needs poses quite a challenge.
Baroness Tonge
My Lords, I rise to ask a question rather than to make comments. I am rather confused about how tariffs work. I am thinking particularly of sexual and reproductive health services. Therefore, I support Amendment 292A tabled by the noble Baroness, Lady Gould.
Sexual and reproductive health services are currently provided by general practitioners and clinics directly commissioned by primary care trusts. They can be family planning clinics, youth counselling clinics or genitourinary medicine clinics. Under the new system, GPs will presumably carry on providing sexual and reproductive health services and abortion counselling services, although I am unclear exactly how they will be remunerated in the future. Those GP services are very variable. Some GPs provide a superb service while others provide a very bad one. Some do not provide certain services at all so it is common for patients to go to clinics in their area which have been provided by the primary care trust.
Under the new health service, local authorities will commission and provide sexual and reproductive health services and abortion counselling services as well as HIV prevention services, but not the treatment, although I do not want to go into that now. They will be responsible for those sexual and reproductive health services. However, I am puzzled by the following matter. Currently, if a patient does not like their GP or finds that the GP does not provide the service they want, they can go to a local clinic. However, because of political or religious arguments within a local authority it may have made those services a very low priority, or perhaps does not provide them at all. It seems to me that there is nothing to compel local authorities to provide certain public health services. If a patient cannot get the relevant services from a GP or does not like them, and cannot go a local clinic because one is not available, can they go to a clinic in another local authority where they are not resident? This could be a problem for many patients all over the country, particularly young people who tend to go to different areas for their services where perhaps they are not known or the doctor does not know them. So I am very concerned.
Could the Minister please say how these services will be affected if no national tariff is set on public health services? How do we know that local authorities will not only provide services for sexual and reproductive health but accept people from other local authorities for treatment? It is a very important question for many people in this country.
Health: Neurological Conditions
Baroness Hollins Excerpts(12 years, 11 months ago)
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Baroness Hollins
My Lords, I am grateful for briefings from the Spinal Injuries Association, and from my daughter, who has tetraplegia, and to the Motor Neurone Disease Association. I am also glad to participate in this debate, which allows for deeper thought about the needs of people with neurological conditions than is possible in the lengthy debates around the Health and Social Care Bill, and indeed the Welfare Reform Bill.
I have learned, and am still learning, about the disabling barriers that people with different impairments encounter, both as a doctor working with disabled people over the last 30 years, and also as the mother of two adult disabled children. I am convinced that policy will not be effective if the social model is not fully embraced as part of the foundational principles underlying legislation. But some needs are medical, and require highly specialist expertise. I would like to draw attention to the fact that medical research into neurological conditions is grossly underfunded.
It would also be remiss of me not to mention the importance of attending to the emotional and mental health needs of patients with neurological conditions. I am thinking here particularly of newly spinal cord-injured patients. It is not just the obvious psychological adjustment to a new impairment, and all the learning required to keep well and to reintegrate into society. We should remember that many people acquire spinal cord injuries during a failed suicide attempt and there may be an underlying mental illness which also requires active treatment. It is the partnership between medical and social agencies working with the disabled person that will best meet that person’s needs, and the needs of their family, while recognising each person’s right to respect for their private and family life, as provided by Article 8 of the European Convention on Human Rights.
In 2009, the NHS published an updated National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, for use in England with revised eligibility criteria. In paragraph 79 of the framework, explicit mention is made of the Coughlan ruling under which a person with a high-level spinal cord injury or similar health need is entitled to continuing healthcare funded by the NHS. The purpose of the continuing healthcare assessment is to establish whether an individual’s care needs are primarily health related or social in nature. This is done by measuring the totality of their care needs according to their nature, intensity, complexity and/or unpredictability, and gives rise to the concept of a primary health need. These assessments are done at the time of initial diagnosis, they are reviewed regularly and there may be a reassessment when a person’s needs have changed.
For many people, securing continuing healthcare funding is fundamental to enhancing their prospects in rehabilitation and their prompt discharge, and thereafter in the community in reducing the likelihood of complications requiring hospital readmission. However, outcomes for individuals seeking continuing healthcare are very uneven and unpredictable across the country—a classic postcode lottery.
A primary cause for concern is the lack of quality clinical input into these assessments from professional practitioners with experience of spinal cord injury and of the patient in question. Often, no opinion is even sought when assessing patients in the community. A detailed and insightful clinical assessment from a spinal cord injuries centre consultant carries significant weight, but is all too often a key missing component. In the community, in particular, the patient is frequently left to persuade sceptical assessors, and when declared ineligible, to battle the bureaucracy of the primary care trust alone.
Unfortunately, there are an increasing number of appeals by people with tetraplegia who are being found ineligible for continuing healthcare funding, although those who appeal are often later found eligible. For people with some neurological conditions the award of continuing healthcare funding will be welcomed, but for others it will not. Consider someone with spinal muscular atrophy, which is a degenerative condition. For much of that person’s life, any support needs will be considered primarily social in nature and, appropriately, funded by the local authority. Increasingly, people are receiving direct payments to employ their own personal assistants. However. when a person’s condition leads to them needing more intensive support, such as being on a ventilator or needing a personal assistant 24 hours a day, some social services departments are asking the local PCT to pick up the funding under CHC rules.
Some people, including some with spinal cord injury, do not want to move on to continuing healthcare funding when their condition deteriorates because they will no longer be allowed to employ their own staff—personal health budgets allowing this are not yet available. The Secretary of State has announced that personal health budgets will be rolled out in 2014 subject to the evaluation of the pilots, and I think that will be welcomed.
There has been quite a lot of talk also about the need for a change in the law to allow people to take their support package with them if they move area, and indeed my noble friend Lady Campbell, who sadly cannot be here for the debate today, has had the first reading of a Private Member’s Bill to introduce a right to portability of support. However, I suggest that portability is not just a matter of geographic portability but should also apply to a change in the funder from social services to health, and vice versa.
Case law—and here I mean the Coughlan criteria—clearly indicates that if you have tetraplegia, you should be eligible for continuing healthcare funding. But many PCTs have been resisting their responsibilities and refusing to honour the Coughlan criteria. Some PCTs, such as Norfolk, have apparently sought to introduce a blanket requirement that anybody receiving complex medical care and considered to be at high risk will no longer receive continuing healthcare in their own home and will have to move into nursing home care, because it is thought to be cheaper.
Rehabilitating people with spinal cord injury in the community requires a positive and active engagement with friends, family and the wider community. It requires an integrated, collaborative, and joined-up approach by the NHS and the local authority, in which recovery is understood as being as much about removing social barriers as about medical treatments. It may require, for example, disabled facilities grants to adapt living accommodation, and the installation of environmental controls. It requires financial support to pay for the extra costs of living as a disabled person.
One of the biggest worries for someone with a spinal cord injury is the risk of pressure ulcers, and the absence of ulcers is usually down to good care. It does not require health professionals to deliver this care, but it does require specially trained personal assistants working under the direction of the spinal cord-injured person. The cost of treating pressure ulcers to the NHS and to the individual is very high.
Prevention must be the priority, but that requires that people with spinal cord injury are well trained and can train specialist PAs to support them. If they go into hospital for medical treatment, it is critically important that their personal assistants continue to support them in hospital, working alongside the clinical team whose job is to attend to the reason for the clinical admission. However, some people with spinal cord injury find that their personal assistants are not allowed to accompany them to hospital and so leave hospital in a worse condition. I would like an assurance from the Minister that the Government support the continuing involvement of personal assistants in the personal care of someone with a spinal cord injury who is in an NHS hospital.
The most obvious addition to a person's daily life is a wheelchair. We have already heard something about wheelchairs. An adequate, well fitting wheelchair is of critical importance in enabling somebody with spinal cord injury, motor neurone disease or another neurological condition to participate in their local community. The current wheelchair service is too slow to respond to the needs of someone with, for example, motor neurone disease. Some people wait as long as two years after the need for a chair has been agreed. Half of those with motor neurone disease die within 14 months of diagnosis. I have heard that some people do not receive a wheelchair in their lifetime because of the unresponsive nature of the wheelchair service. I know that the Motor Neurone Disease Association would like to become a provider of wheelchair services to get round this problem. I hope that the Minister will endorse that aspiration and that it will not be disadvantaged in competition with larger commercial providers.
Another issue of real concern is the lack of palliative care provision for people with motor neurone disease. This is entirely unacceptable. If there is any condition for which excellent palliative care is required, it is motor neurone disease. In Southampton, for example, there is no palliative care provision for people with motor neurone disease. The association is calling for widespread availability. Can the Minister confirm that palliative care services for people with motor neurone disease will be included in the pilot work associated with the current review of palliative care?
For all these conditions there are concerns about how services will be commissioned in future. Will the Government issue guidance on when services should be commissioned jointly for these complex but relatively rare conditions? I am talking about commissioning both at the acute stage and in the longer term for people with complex neurological conditions. The NHS Commissioning Board and clinical commissioning groups will of course need to recognise the difference in commissioning for people with spinal cord injury—normally a fairly static long-term condition, with the prospect of somebody in their 20s living to 70—and for people with a deteriorating condition such as spinal muscular atrophy. What is not clear in discussions on the Health and Social Care Bill is where responsibility for commissioning continuing healthcare will lie in the future. The Minister's response to this question would also be welcome. Certainly, risk sharing between several clinical commissioning groups will be needed to make locally funded continuing healthcare a viable prospect.
With respect to spinal cord injury, does the Minister agree that specialist treatment in spinal injury centres leads to the best chance of recovery and rehabilitation in both the medical and social meanings of the words; that the decline in the number of people with spinal cord injury being admitted to spinal injury centres is to be deplored; that people with spinal cord injury should be treated in such centres both acutely and over their lives, as they need to be readmitted for complications from their spinal cord injury to be managed and treated; and that the National Spinal Cord Injury Strategy Board, which is to be nationally commissioned in future, should also be involved in ensuring that continuing healthcare is appropriately commissioned?
Health and Social Care Bill
Baroness Hollins Excerpts(13 years ago)
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Lord Turnberg
My Lords, I will speak to Amendments 103, 104A, 106, 135A, and several of the others in this group. Clause 20, new Section 13M, highlights integration of services as something the Commissioning Board should “exercise its functions” to secure,
“where it considers that this would—
(a) improve the quality of those services”.
That is all well and good, but by itself it seems insufficient. Integration is of course difficult to pin down. We have heard quite a bit about that this evening, and I will not repeat those remarks. I know what I mean by integration, so I will give you my particular understanding, for the purposes I want to talk about, using the term to mean a seamless service for those patients, usually elderly and with multiple diseases, who need both hospital and community care, and flit between the two.
It is unfortunately the case that the integration that is needed between health and social services has seen so many failures and been so elusive, despite many wasted words. We have an opportunity here to correct these failures, so I was somewhat disappointed when the Minister said in the debate on 2 November, when we were discussing the role of the Secretary of State, that the Government were,
“not in the business of dictating the processes”—
and that—
“integration is neither a necessary nor a sufficient condition of a good outcome”.—[Official Report, 2/11/11; col. 1334.]
Surely if integrated care is a good thing—and I think few will deny that—then we must give a lead on how it might be achieved. We cannot ignore the process, and must at least try to see what conditions are necessary for successful integration. We should not go around simply saying it is a good thing, without showing how it might be achieved.
There are many examples out there that we can build upon. We are not entirely in uncharted territory. The noble Baroness, Lady Cumberlege, mentioned Assura Cambridge and services in Torbay in our last debate, and other noble Lords spoke of Kaiser Permanente, Northern Ireland, personal health budgets and information sharing, as valuable means to an end.
We also have the excellent report from the Nuffield Trust, Integration in Action, that analyses successful integration being carried out in four places across the world, including in Scotland. We are not working in a vacuum, and we could and should take advantage of all this information, and incorporate some of those ideas in the Bill without waiting for yet further work.
Of course, not everything can or should be put in the Bill, but we should see where we can strengthen it, by including more pointers to how we can improve the present, very unsatisfactory, position. Let me give some examples, leaning heavily on the Nuffield Trust report. First, the Commissioning Board should point the way by developing commissioning for bundled payments, and local tariffs for key conditions. I think that is possible. At the moment, fees for service for episodes of hospital care, as we have heard, work against integration with community service. That is something that the board should seek to redress quickly.
Secondly, we should design the national tariffs that we have heard about, which incorporate a full care pathway across the health and social service divide. Monitor and the board should work together to develop a pricing strategy that provides the incentives for integration. They should also develop ideas about how outcome measures, which are admittedly difficult to quantify when we are talking about a complex system like integrated care between hospital and social care, can be used to promote integration across the whole pathway of care. Contracts based on those measures can encourage providers to respond to the need to integrate. There is nothing here that obviates competition between providers, which I am sure will please my noble friend Lord Warner.
We will come later in the Bill to Monitor, but it too should link improvements in outcomes, including the patient’s experience, to the way it regulates integration. Then, there are several measures that clinical commissioning groups and local authorities should be encouraged to develop by the Commissioning Board. One huge area is of the improvements we desperately need in the flow of information between hospitals and community. Too often we rely on phone calls on the day of discharge, which is inefficient and fails most of the time. We should have an IT system which allows information to be shared across the divide. It only requires a competent programmer to produce the programme, and a safe system for preserving patient confidentiality and data protection. I am sure that that is not beyond our capacity.
There is also the need for joint funding and integrated governance arrangements, which we have had some discussion about. This is much easier said than done, but it can be done. We have seen it in action here and there and we must spread the good practice.
There is also the need for people to make the whole thing work on the ground: for example, liaison officers whose sole responsibility is to ensure that patients pass seamlessly across the divide, and nurses and doctors who move without constraint from one sphere to another. The example of specialist district nurses is a good one. They follow patients from hospital to the community and back, and are very much appreciated. Unfortunately, they are a threatened species and are disappearing, largely because neither the NHS nor local authorities will fund them. We must get around that problem.
Of course, much of what is needed depends on a change in the mindset of those working at the coalface in hospitals and the community. If through the Bill we can change the conditions from those that inhibit collaboration to those that encourage it, we can begin the process. The amendments bring a greater sense of the need to focus more strongly and urgently on the duties and responsibilities of the board in putting integration more firmly on the map as a way of improving outcomes. I support them strongly.
Baroness Hollins
My Lords, I will speak to Amendment 203A in my name and those of my noble friend Lady Finlay and the noble Lords, Lord Patel of Bradford and Lord Patel. I will speak also in support of Amendments 135C and 135D, tabled by my noble friend Lady Finlay.
The Bill seems to favour the commissioning of services through the any-qualified-provider model rather than being concerned primarily with commissioning an integrated model of care. Amendment 203A would introduce a duty on clinical commissioning groups to commission multiple providers of health services competing to deliver a section of the care pathway only where they can demonstrate to the NHS Commissioning Board that the approach is beneficial to patients. Integrated care pathways are particularly important in complex, long-term conditions such as serious mental illness or challenging behaviour, for example in someone with learning disabilities who is also on the autistic spectrum.
There have been attempts in the NHS to deliver integrated care pathways, with varying degrees of success. The introduction of a plurality of providers in mental health services in recent years is already showing signs of fragmenting complex care pathways in some instances. The disaster of Winterbourne View is just one example of how commissioning one provider to deliver part of a pathway without planning, commissioning and co-ordinating the whole of an integrated pathway can be an expensive and tragic mistake.
The further introduction of competition between providers has the aim of reducing the cost of provision while maintaining and improving the standard. This is a noble aim on which we may all be able to agree. However, commissioners must evaluate whether the aim is being achieved, recognising that care pathways vary hugely in different conditions and even for different patients. The variety of provision needed means that we cannot easily—if at all—prescribe a rule to cover all situations. Of course, the health service exists to serve patients, not providers. It is in this light that we must consider proposals to introduce competition between providers, and it is because of this that the burden of proof must be on those who favour increasing competition to show that doing so would benefit patients.
The risk is that many providers will compete to provide more profitable parts of a pathway, cherry-picking the parts they would like to offer, perhaps only to the least complex patients, thus leaving unmet the less easy to cost and define but still essential parts of the pathway. The importance of an integrated care pathway cannot be overestimated. The comfort patients take in knowing that their entire provision is being dealt with in a coherent, joined-up way may be put at risk under an any-qualified-provider system. As always, it is the most vulnerable patients whose needs may remain unmet.
Health and Social Care Bill
Baroness Hollins Excerpts(13 years ago)
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Baroness Hollins
My Lords, I support the amendments of my noble friend Lord Rix. He made reference to people with learning disabilities and in particular expressed concern about people with complex needs. I should like to say a little more about people with learning disabilities who have challenging behaviour. It is estimated that as many as 40 per cent of people with learning disabilities may present behaviours that are challenging to family and other carers. These behaviours can be so intense and frequent as to have a major impact on the quality of life of the individual and their families.
People who present severe behavioural challenges are among the most disadvantaged and marginalised individuals in our society and are at much greater risk of exclusion, institutionalisation, deprivation, physical harm, abuse, misdiagnosis and exposure to ineffective interventions. Their carers are subject to physical harm, psychological ill-health, physical ill-health and to an increased burden of care and financial consequences. It can also have an impact on their employment prospects and quality of life.
Commissioners, policymakers and providers all face escalating costs and risk undermining national policy. Providers face high staff sickness and turnover, service breakdown, scandals and exposés such as the recent “Panorama” programme about Winterbourne View in Bristol and previous scandals in recent years in Cornwall and Merton and Sutton.
Back in 1993, Professor Jim Mansell emphasised the need for commissioners of health and social care to work together to provide good support and services for this group of individuals. He recommended locally based, individualised packages of care. He suggested that the environments where people are cared for should be skilled and capable of maintaining support for the long term. He revised his report in 2007 for the Department of Health and made the same points because insufficient progress had been made. He and others, such as the Challenging Behaviour Foundation, have made it very clear that large institutional provision is not the answer, yet many people with learning disabilities have care packages commissioned within such institutional care, mainly in the independent sector, funded by the NHS and by social services. These placements are often far from home. They have little guarantee of high-quality, skilled care and are vulnerable to the kind of restrictive practices that have been revealed time and again in a variety of high profile exposés. This care is often very high cost, as well as not delivering good outcomes for people.
A recent publication entitled There Is an Alternative, published by the Association for Supported Living, makes a strong argument for local, community-based support, saying that it is more successful and cheaper than specialist in-patient provision. However, for that to happen requires vision, commitment and a will to make it happen. It cannot be achieved without the will of effective local commissioners, a will that must be expressed in decisions to invest in local community-based services, rather than to farm out problem cases to expensive out-of-area placements—what in the world of learning disability we know as the “crisis Friday afternoon very expensive mistaken placement”. Most successful supported living services have their roots in commissioners' decisions to invest in that service model, acting on sound demographic knowledge of the communities they serve and the needs and wishes of the people with learning disabilities who live within them.
I am sure that health and well-being boards will have an important role in thinking about the needs of their population with learning disabilities in that way. However, it is clear that there need to be good lines of accountability in future. There is a worry that local clinical commissioning groups will not be able to commission adequately when specialist services are needed. They will have to be able to address a comprehensive local strategy that can deliver early intervention, timely and skilled professional expertise and support, competent and high-quality providers of individualised support and services, flexible crisis intervention services, such as psychological therapies, which are very underdeveloped for that group of people, and psychiatry, which can build the support required for each individual—real individualised care. The numbers of individuals are relatively small but they can be very high cost if the services are not planned well.
It is essential that the needs of this group of individuals are specifically considered within the new commissioning arrangements. I always say that if we can get it right for people with learning disabilities and complex needs, we can get it right for everybody else. There may be an argument for looking to the National Commissioning Board to take this overall responsibility without compromising the need to find ways to ensure local responsibility—the delivery of creative, flexible and local solutions to meet the needs of individuals and families within their own communities. This is quite a challenge, which is why I have gone to such lengths to explain the problem faced by this complex group of people. I ask the Minister to comment on how such services might be commissioned in the future.
Lord Newton of Braintree
My Lords, perhaps I may intervene briefly in support of the general thrust of the amendments without necessarily saying that I agree with every dot and comma. I also agree, not least, with the remarks of the noble Baroness, Lady Hollins. The noble Lord, Lord Rix, and I have known each other for quite a long while in the field of learning disabilities and, indeed, through my role many years ago as Minister with responsibility for disabled people, so I am happy to lend a sympathetic word on this point.
I ought to declare an interest in that several times I have told the House that I am the chair of a mental health trust. Of course, mental health trusts often deal with learning disabilities as well, as indeed does the health trust that I chair, although happily last year it transferred most of its residents on old-style campuses to Suffolk County Council for a more complete version of genuine living in the community and community care, and I am rather pleased that we did that.
We need to recognise that, although there are overlaps—the word “co-morbidities” is used in one of the amendments—between mental illness and learning disability, they are not the same, and we need to make sure that we take particular and appropriate account of the needs of learning disabilities in all this. I hope that the Minister will be able to assure us that that will be the case.
Health and Social Care Bill
Baroness Hollins Excerpts(13 years ago)
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Baroness Williams of Crosby
Perhaps I may add a few words on an aspect that was touched upon only a moment or two ago by the noble Lord, Lord Lucas—the role of people who act as whistleblowers, particularly regarding patients who, for one reason or another, are not capable of standing up for themselves, are perhaps in institutions where they get little attention paid to them, and are not much listened to. They would be heavily dependent on the willingness of NHS staff to blow the whistle when bad standards are being allowed to continue.
One thing has always worried me about the NHS. As a parliamentarian of many years’ standing, I have received many letters from junior members of NHS staff asking me to look into some aspect of a hospital or care home in which they work, and almost invariably saying at some point in the letter, “I dare not do this myself because my job would be at risk”. This is a very serious aspect of the amendment of the noble Baroness, Lady Masham, but we have not talked about it very much at all.
I tend to favour the idea proposed by my noble friend Lord Mawhinney for having an element of mediation, as well as an element of court behaviour, in the way in which we deal with such cases. However, it rests on us all to give high priority to thinking of the ways in which we can protect whistleblowers and distinguish the genuine whistleblowers from those who are complaining merely about their personal position. For example, if we included private as well as NHS hospitals and care homes, the kind of position that the noble Baroness, Lady Oppenheim-Barnes, talked about—she described a terrible case with regard to her daughter—would not arise so readily.
I ask the Minister to say something about the view that mediation is one way forward, as well as court cases. At least as importantly, perhaps he can say whether the General Medical Council or others would now seriously consider protection for whistleblowers within NHS staff, who are often the most effective inspectors that we can find—much more effective than people with no clear knowledge of the way in which medical and health services work.
Baroness Hollins
Perhaps I may raise a couple of issues that have been touched upon. The first is that I do not know how far the consultation that is looking at the duty of candour will tease out the role played by whistleblowing. I should like some clarification about that.
The General Medical Council’s document, Good Medical Practice, in paragraph 31, makes it clear that doctors must be honest and open and act with integrity. I mention that because my noble friend Lord Walton spoke about the GMC’s role and said that he was not sure how far the medical defence unions currently adopt the same approach to encourage doctors, when they are aware of an error, to be open and honest. I decided to telephone my medical defence union before this debate and ask it for its current advice. It said that it refers doctors to Good Medical Practice and reminds them of paragraph 31, which states that they must be honest and open and act with integrity. I hope that the House will be reassured to hear that.
In my experience, a culture of openness and honesty leads to a culture of learning. That point has been made by a number of noble Lords. We should not be afraid of the idea that apologising will in some way lead to a greater culture of litigation. It is certainly my experience that being open and apologising does not necessarily imply negligence; it reflects the fact that something harmful has happened and that the lessons from mistakes must be learnt from in order that other people will not be harmed by the same mistakes in the future. That is what this is really about.
Lord Winston
Does the noble Baroness not agree with me, however, that this is not what this is about? The problem is that any persons providing healthcare—someone who is seeing a patient but is not concerned with the original treatment—would be required to be open and candid. The problem with that is that it is likely to be highly dangerous and damaging to patients in that situation, as extensive medical experience over many years has shown to the many people trying to do an honest and open job within the health service. The matters of each case have to be looked at on an individual basis.
Baroness Hollins
I absolutely agree with the comment of the noble Lord, Lord Winston. Commenting on another practitioner’s practice and making judgments is fraught with error. That is why it is important when looking at the duty of candour to understand the role that whistleblowing plays. A great deal more could be said but it is extremely dangerous to make assumptions about another person’s practice.
Lord Warner
My Lords, I was not intending to intervene in this debate, but after listening to the discussion I want to remind the Minister of the many happy hours that we spent taking the NHS Redress Bill through this House six or seven years ago. Can he tell us the extent to which some of the measures in that Act may or may not have helped to deal with some of the concerns that have been expressed in this debate, because that legislation was an attempt to give patients more satisfaction without going to court and to encourage a greater culture of openness and apology on the part of the NHS when it made mistakes?
Baroness Armstrong of Hill Top
My Lords, I seek only to intervene briefly on this. The whole issue of how to tackle inequalities in health is an extremely complex and difficult one. When I was a Member of Parliament, I looked forward to receiving from the department reports on a regular basis on how inequalities had been addressed and how health had improved throughout the constituency. What was clear was that the more effective our public health interventions were, such as on reducing smoking, the more difficult it was to tackle inequalities. The people who automatically responded best to those interventions were those on higher wages, with better qualifications and who were likely to be in higher class groups than those in the poorest parts of the constituency. That could always be seen clearly in those reports. The amendments that support better information are very important because clinical commissioning groups in particular are not well placed instinctively to tackle inequalities. It is generally not part of the training of GPs to look at these issues and work out how to address them.
We have already discussed the second issue today, and it is important—the issue of access. Unless we open up access much more sharply to the disadvantaged we will not have a chance of addressing inequalities. The noble Baroness opposite talked about homelessness. I have discussed this issue with the Minister on a number of occasions, and I am not content that the Bill deals with it adequately. It is not fair to ask clinical commissioning groups to address this issue. Sometimes they will simply be too small to do so. Also, homeless people tend to be fairly mobile, so in London they will cross authority areas. From my experience in the north-east of England, a single PCT—or what will now be the smaller clinical commissioning groups—does not have the people available properly to offer the sort of services that are needed to open up access effectively to those who are not normally registered on a GP list.
I am also concerned that clinical commissioning groups may be responsible for areas with poor GP coverage and there will be a need to bring in salaried GPs. It will need someone other than a clinical commissioning group to address the issue of GP shortages—and it is always the poorest areas which have the poorest access to GPs. It is an issue that continues to have to be addressed time and time again. I was pleased when the last Government introduced many more salaried GPs, but we have to keep on top of that agenda.
I also support the amendments that look to the responsibilities of the NHS Commissioning Board. There will be occasions when the board has to come in specifically to address inequalities in a range of ways. I am not sure that it is really geared up to do that at the moment. But because I certainly do think that clinical commissioning groups are not going to be able to do this on their own, and indeed it would not be appropriate for them to address some areas of clinical commissioning, it is very important that the department, the Secretary of State and the Commissioning Board think about how they are going to do this effectively.
Baroness Hollins
My Lords, I particularly welcome the amendments which are designed to strengthen the duty to reduce health inequalities between people and communities, the emphasis here being on inequalities not between “the people of England”, but between individuals as well as groups. I draw attention to this because in 2008 the Department of Health drew up a policy on health inequalities, and I sat on the group which developed it. I was pleased when the document was published in June 2008 because it talked about the group that I am interested in, which is people with learning disabilities. I shall read out a short paragraph from the executive summary because it makes my point very nicely:
“Progress on health inequalities will be judged against how public services treat especially vulnerable groups. The recent Disability Rights Commission report made it clear that people with learning disabilities often receive a poorer level and quality of service from the NHS. If services and health outcomes are improving for people with learning disabilities, they are likely to be improving for other groups at risk of health inequalities”.
The report goes into some detail about the importance of measuring the improvement in health inequalities for particularly vulnerable groups. That is a good measure to measure progress in the NHS.