Health and Social Care

Baroness Jolly Excerpts

Wednesday 5th June 2013 Lords Chamber

[Earl Howe]

The noble Lord hits upon a point of central importance. The outcomes framework clearly sets out where the different parts of the health and care system share responsibility for outcomes and support joint working in the way that I have described. However, we are committed to developing a measure of people’s experience of integrated care for use in the outcomes frameworks. That is a work in progress. Meanwhile, a place holder was included within both the NHS and adult social care outcomes frameworks when they were refreshed in November last year. We have highlighted the development of this measure in the public health outcomes framework, so I hope to give the noble Lord further news in a few months’ time.

[Baroness Jolly]

My Lords, within local authorities, public health is responsible for reducing local health inequalities, particularly in areas of non-communicable disease. For those, the solutions are often long term, so would my noble friend explain how success can be measured and incentivised in the short term?

[Earl Howe]

Again, my noble friend asks an extremely good question. The year-on-year success of public health interventions to address non-communicable diseases, for example, will be measured through the public health outcomes framework. The department will incentivise some of the indicators in the public health outcomes framework through the health premium incentive scheme. Some of the indicators that will be selected may contribute to prevention of non-communicable diseases.

Care Bill [HL]

Baroness Jolly Excerpts

Tuesday 21st May 2013 Lords Chamber

[Baroness Jolly]

My Lords, I thank my noble friend Lord Howe for explaining the parts of the Bill so clearly in his introduction to this debate. I also thank the government Care Ministers—the previous one, my right honourable friend Paul Burstow; and the current one, Norman Lamb—for championing the Care Bill and the work of the Dilnot commission.

As the Minister has already explained, this Bill brings all previous legislation together for the first time, and is based on the well-being principle but also on the funding cap to protect those from catastrophic costs, the higher means test, the inclusion of rights for carers assessments, the portability of care and the mechanism to protect the care market.

The decision to manage this Bill differently from the Health and Social Care Bill was wise. Not only was there extensive consultation on the White Paper, but the Bill was based on the Law Commission report that itself had consulted widely. It is worth mentioning that we on the scrutiny committee looked at Part 1 so that the new Part 2 and the sections added to Part 1 should get close scrutiny in Committee.

The committee had members who are hugely experienced in the world of care, and was chaired by the previous Care Minister, my right honourable friend Paul Burstow. We took evidence from a wide range of stakeholders, and without exception they were full of admiration for the work of the Bill. However, as noble Lords would expect, they had areas in their own field that necessitated extra work. When we looked at what the report should say, we had a strong evidence base and deliberated long and hard about any deletions, omissions or just plain amendments to the draft Bill. Those recommendations, which were included in the report that was published, were to make a good draft Bill better. I therefore really welcome the Bill, but there are some areas where more work needs to be done. There are some unintended consequences, and some minority groups need assurance that the Bill will meet their needs.

This is not the time for detail, but areas that have received full coverage and early attention are young carers, adults caring for children, and the transition in service provision. The Law Commission felt that this Bill is the vehicle to place legislation for the assessment and meeting of their needs, but in winding up on the third day of debate on the humble Address the Minister was very clear that there is no place in this Bill for young people: that it is an adult Bill. Will he explain how the Government intend to meet this real need? If he does not have the information at the moment, will he please write to me and place a copy of the letter in the Library?

A third of the adult population who receive care are of working age. Many are in work or mobile, and many aspire to work. I would be grateful if, before we get to the parts of Part 1 about funding, the Minister will meet me to look at areas where the sector is anxious that their needs will not be met, resulting in failure to cope, leaving employment and subsequent isolation and depression. This was articulated most clearly in the report released last week by the All-Party Parliamentary Local Government Group and the All-Party Parliamentary Disability Group, entitled Promoting Independence, Preventing Crisis.

There are other sizeable but hidden populations who feel that the provisions of the Bill do not meet their needs. Before Easter, there were two all-party group commissions: one on dementia and autism and the other on BAME communities in old age. As I have said before, details are for Committee, and I am sure that my noble friend Lady Browning, whose expertise in autism is far greater than that of many noble Lords, will follow this up.

One of the scrutiny committee recommendations was about free care at end of life. Marie Curie Cancer Care has done a financial assessment of this policy, and the cost works out at £32.2 million a year. This will support the families of some 40,000 people who have care needs and are on the register, and will be just over £800 per individual. I note that the Government think that this has merit and that it can be implemented without a change to legislation. Will the Minister confirm that discussions are in hand on this and give some indication of a timescale, or has the proposal found the long grass already?

The intention of this Bill is to rationalise a confusing morass of Bills and measures to give clarity to local authorities, providers and, most importantly, those in need of care and their carers. In Part 1, the main thrust is the individual, not the system. It is based around the well-being principle in Clause 1 and the cap on funding to give assurance about catastrophic care costs. Both the cared-for and the carer will be entitled to an assessment and a care plan, whether they are a self-funder or not, and there will be a requirement to provide information about care options.

Part 2 was added to redress some of the problems that arose from the Mid Staffordshire Hospital scandal, to ensure that information is available in a readable and usable way to detect failure earlier, and to clarify actions in the event of failure. I am sure there is room for debate on this in Committee, too, but on balance we welcome the clause in Part 2 and hope that the further information referred to in yesterday’s deposited Statement on the joint Monitor/CQC approach to their new role and the development of ratings will be in time for the Committee debates on this part. Can the Minister assure the House that that will be the case?

Additionally, Part 3, on Health Education England and its Health Research Authority, is now hugely improved on the formulation in the Health and Social Care Bill, and is welcomed by the sector.

Of course, the economic situation in which we find ourselves is not the easiest, and I welcome the proposed delay—or perhaps I should say the pause—in Committee so that we can address the issues in Part 1 in the light of the spending review. I am sure none of your Lordships needs telling that the higher the level for eligibility for social care, the more will fall on the NHS. Let us hope that the Chancellor understands that point, too.

This will need modelling carefully, and I hope we will see some of that detail. Of course, it is worth knowing that were the CCGs and their health and well-being boards to work together as hoped integrating services, prevention would be increased, gaming would be reduced, and care would be delivered in an appropriate way by the appropriate body.

However, the Bill gives a sustainable and coherent framework for care in the future, some level of security about the cap for those with high care costs, and a method of dealing with hospital failure, including an early warning system. It comes with a warm welcome from these Benches.

Health: Cancer

Baroness Jolly Excerpts

Monday 20th May 2013 Lords Chamber

[Earl Howe]

My Lords, I agree, and I am confident that over the years ahead we will see a much greater emphasis on stratified medicine, particularly if we can relate treatments to genomic data.

[Baroness Jolly]

My Lords, everyone—families, statisticians, managers and, indeed, researchers—wants accurate death certificates. What are the arrangements to monitor the recording of death as part of clinical governance?

[Earl Howe]

My noble friend has raised a very live issue because consultation will begin shortly on the Government’s plans to reform the governance relating to death certification. The proposed reforms will simplify and strengthen the process for death certification by appointing local medical examiners to provide independent medical scrutiny of the cause of death for all deaths not subject to coronial investigation. The medical examiner will improve the accuracy of information recorded on medical certificates of cause of death because the process will include a review of medical records and consideration of the circumstances leading to death.

NHS: GP Dispensing

Baroness Jolly Excerpts

Thursday 16th May 2013 Lords Chamber

[Earl Howe]

I am sure that the noble Lord is as aware as anyone of the balance that has to be struck here. A GP’s primary purpose is to provide comprehensive medical care and treatment to his or her patients. More than 90% of prescription items are dispensed by pharmacies, which is what most patients expect. However, we must have arrangements to enable patients who live in rural and more remote areas to access medicines more easily. I think the noble Lord will understand that the arrangement for some GPs to provide dispensing services has always been the exception rather than the rule. I do not think there is an appetite on anyone’s part among the professions to reopen these arrangements.

[Baroness Jolly]

My Lords, these GP-dispensed services come at a cost, but as someone who lives in a rural area I am very glad of it, because it saves me a 12-mile round trip. However, the cost of a practice-based prescription will be apportioned to the CCG in two parts: the actual cost of the medicine itself and disbursement costs. Does my noble friend expect that the disbursement cost mechanism will be looked at again in the light of GPs running CCGs, where, of course, every penny will count towards the care of the patient?

[Earl Howe]

My Lords, those particular technical matters will always be looked at very carefully to ensure that the right balance is struck. It is open to commissioners to propose a change in the arrangements. If a new pharmacy applies to open, and that could affect GPs dispensing to patients in a rural area, we would fully expect there to be consultation with patient groups and the public. There is a mechanism to ensure that that process can take place.

Emergency Services: Paramedics

Baroness Jolly Excerpts

Wednesday 15th May 2013 Lords Chamber

[Earl Howe]

My Lords, the issue here is that they were not unqualified, as I tried to convey. All ambulance trusts in the UK allow student paramedics to work unsupervised, but only after they have had nine months’ operational experience and have passed both a written exam and a clinical practice observation by a qualified assessor. In this case, the London Ambulance Service accepts that, despite their qualifications and experience, the crew did not act in accordance with their training.

[Baroness Jolly]

My Lords, there are also volunteer first responders, trained with a minimum skill set and working with ambulance trusts across England. Will my noble friend tell the House who keeps the information about their deployment and how they are monitored for quality outcomes?

[Earl Howe]

I think that my noble friend is referring to first responders, who should be integrated into the clinical governance structure of all ambulance trusts. The outcomes will be assessed for all calls regardless of who attended the calls in the first instance. A first responder is just that—further ambulance staff would always be sent to a call. In rural areas, these staff can often get there first and provide immediate help, so the use of those people is a matter for local decision.

NHS: 111 Telephone Service

Baroness Jolly Excerpts

Monday 13th May 2013 Lords Chamber

[Earl Howe]

I take the noble Lord’s point. That is why the 111 service has been created; there is no doubt that there was a very confusing landscape in which people did not know who to call out of hours, and they did not necessarily have the telephone number of the out of hours provider in their area. The 111 service is designed to simplify all that, and across the vast bulk of England people are getting a good, if not fantastic, service. Unfortunately, in two areas of the country, the south-east and the south-west, we are still seeing problems arising, and those are being gripped.

[Baroness Jolly]

My Lords, the out of hours services, the ambulance services, A&E and these 111 services need to work in a harmonious and co-ordinated way for the good not only of the patient but of the service as a whole. Will the Minister reassure the House that the 111 service will be part of the review of urgent and emergency services being led by Sir Bruce Keogh?

[Earl Howe]

I am very glad that my noble friend has raised that issue. Sir Bruce Keogh is indeed looking across the piece at urgent and emergency care services, and that will include the way in which 111 is working.

National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013

Baroness Jolly Excerpts

Wednesday 24th April 2013 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, the hour is late and many of us are extremely keen to hear from the Minister. He took a brave decision in withdrawing the original set of regulations, and now we have these laid before us. Many people have posed questions and I hope that he will address them all head-on in his summing up. The lead question that has been asked tonight is why there is a such disparity between the centre here and how it is interpreted out there. Therefore, what will the Government do to make sure that there is no panic about challenges, that this does not become a lawyers’ charter and that integration works in the best interests of patients? Clause 2 suggests that it should take precedence over Clause 5 and that integration is key, because it will secure the best services for patients today and those of tomorrow. We have education, research and training in the Act and these also need to be secured for long-term stability. I suggest that we now need to hear from the Minister.

[Baroness Jolly]

My Lords—

[Noble Lords]

Minister!

[Baroness Jolly]

My Lords, many noble friends have already addressed the main issues of the debate and I do not intend to delay the House for long. I will confine my remarks to guidance—currently in preparation by Monitor—the role of Monitor in the process, and what the effect would be if the Prayer to Annul by the noble Lord, Lord Hunt, were successful. When we had our first meeting with the Minister about our concerns, we expressed our anxiety about the language. Laws they may be, but they did not have to be impenetrable and we improved the situation with the second draft, in particular, Clause 2 and Clause 5. I thank my noble friend Lord Clement-Jones.

The key issue, which my noble friend Lord Howe picked up earlier, is that we insisted that the guidance needs to be absolutely clear and unambiguous. It is written by Monitor, but it is signed off by the Secretary of State. We said that it needed to be a product not just of Monitor’s work, but also of various stakeholders’.

It also needs to contain a worked series of case studies so that people could see how things pan out in certain situations. During the Recess, the Secretary of State and my honourable friend the Minister, Norman Lamb, met some of the stakeholders and I understand that further meetings are in hand. But, of course, there is an open consultation as well. This has meant that the guidance is not published with the regulations. That is seriously to be regretted. However, if the end result is a workable set of guidelines with real case studies, time is the price that has to be paid.

What of Monitor’s other role, that of regulating and policing contracts? Until 1 April, much of NHS commissioning covered by procurement law was undertaken by PCTs. That meant that a supplier could take a PCT to court if they lost a contract unlawfully, and seek compensation and damages. That could be a waste of time and taxpayers’ money, damaging in one way or another to patient care.

After 1 April, PCTs, which could be ordered to do anything by the Department of Health, were replaced by CCGs, which could not. If we want to continue to keep the NHS out of the courts, something needs to have the same power over CCGs in relation to procurement as the Department of Health had over PCTs. That something is Monitor.

However, Monitor is not a body under the control of the department. Instead, it is directly under the control of Parliament. Instead of the department being able to tell Monitor to continue to enforce the PRCC—principles and rules for co-operation and competition—Parliament must do it for Monitor. Thus we arrive at the furore around the Section 75 regulations—Parliament’s way of telling Monitor to enforce the PRCC within the NHS. The regulations, like the PRCC, reflect the overarching requirements of EU procurement law.

I now come to a point that was picked up by the noble Baroness, Lady Hollins. In the general debate until today, much has been made of the opinion of this or that lawyer. Often, any one lawyer gives an opinion that reflects the view of whoever instructs them. We end up with as many views and opinions as we have lawyers. Therefore, with due respect to noble members of that profession, we need to inform our own opinions on this debate.

Without these regulations, all we have is EU competition and procurement law and the courts. There is no direction about the nature of services to be commissioned, and CCGs are completely unprotected and unsupported. What the regulations are not is a signal that the NHS is up for sale. The NHS will still be free to all at the point of need.

The purpose of these regulations is twofold. First, they are a legally binding tool, along with detailed guidance, to be used by the CCGs and NHS England when commissioning the best possible services for their patients and facilitating an integration of those services—services which put patients first. The regulations enforce that patient care is about competition and they outlaw cherry picking and vested interests. Secondly, to put it bluntly, they are to keep the NHS out of the courts. When we decide whether to support this Motion or not, those two conditions are precisely what we would do well to keep in mind.

[Baroness Masham of Ilton]

My Lords—

NHS: ECMO Machines

Baroness Jolly Excerpts

Monday 22nd April 2013 Lords Chamber

[Earl Howe]

I shall certainly take that idea away with me, but I think that there is broad consensus among the medical community that the key to success with ECMO is getting the patients connected to the equipment quickly. Although it is a moving scenario, all the evidence so far suggests that ECMO confers no benefit if some hours have elapsed since the cardiac arrest.

[Baroness Jolly]

My Lords, services that need ECMO machines would currently, in the new world, be commissioned by NHS England. Will my noble friend explain to the House what role, if any, the department now has in commissioning such services?

[Earl Howe]

My Lords, the department itself no longer has a role in commissioning highly specialised services. NHS England is implementing a single operating model for the commissioning of 143 specialised services. That replaces the previous arrangement whereby 10 regional organisations were responsible for commissioning specialised services and, to be frank, there were wide variations in the standard of those services. The new operating model represents a significant change to the previous system and should result in better outcomes.

NHS: Out of Hours Service

Baroness Jolly Excerpts

Tuesday 26th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, in some parts of the country confidence has been lost in out-of-hours services. The NHS Commissioning Board takes over next week, so what can it do in terms of commissioning smartly to regain the public’s confidence in these services?

[Earl Howe]

We have known that out-of-hours care has been in need of reform for some considerable time. The much strengthened commissioning arrangements that we have put in place, including the national quality requirements that I mentioned earlier, will enable that to happen.

Mid Staffordshire Foundation Trust Inquiry

Baroness Jolly Excerpts

Tuesday 26th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, I thank my noble friend the Minister for repeating the Statement. I am sure that many noble Lords will welcome, in due course, a full and spirited debate on this issue. Will my noble friend clarify which of the recommendations that are being adopted will require primary legislation, what the timescale might be and what the mechanism might be for that?

We welcome my noble friend’s remarks on the duty of candour but, as with all these things, the devil is in the detail. My question is about the chief inspector regime in general. We are going to have a chief inspector of hospitals so it would seem sensible to have a chief inspector of social care. Will we then need a chief inspector for public health and another one for mental health? Is that the way to have all the bases covered?

[Earl Howe]

My Lords, it is a little early to say what legislation we will need, but I can tell my noble friend that we can deal with the duty of candour by secondary legislation. It may be that many of the follow-up actions to Francis can be done without any legislation at all. However, primary legislation would appear to be the obvious route when statutory roles are to be changed.

With regard to the chief inspectors, the only firm decisions we have taken so far are to appoint a chief inspector of hospitals and a chief inspector of social care. We are looking at the merits of a chief inspector of primary care but we need to make sure that there is a genuine issue that needs to be addressed by way of a chief inspector role rather than leaving the CQC to perform its role in the normal way. Further details will be forthcoming at an appropriate time.