NHS: Hinchingbrooke Hospital

Baroness Jolly Excerpts

Thursday 10th November 2011 Lords Chamber

[Earl Howe]

I will, of course, write to the noble Baroness with detailed answers to the first part of her question, which would take too long for me to answer now. I can say that this is a transfer of risk to the private sector. That is why it is a good deal. It is also a good deal in another sense, because patients will still have a hospital in Hinchingbrooke. This is a hospital that in common parlance could be described as a financial and clinical basket case. No NHS bidders were willing to take it on. When the previous Administration left office, only independent sector operators were in the frame to do so. We therefore knew at the last election that there would be an independent sector solution. I think that it is a win-win situation all round. It is good news for Hinchingbrooke patients, and I understand that under normal Freedom of Information Act rules the contract involved will be made available, subject to commercially confidential details being redacted.

[Baroness Jolly]

My Lords, will the Minister please tell the House who was consulted in making this decision and what sort of support was found among the local community and hospital staff?

[Earl Howe]

My Lords, there was extensive consultation, but the important point for my noble friend to understand is that this was a locally led process. Ministers—and, for that matter, civil servants in the department—were not involved in the decision process. The decision was made by the strategic health authority board and the recommendation then came to Ministers. However, I can tell my noble friend that support for this decision has been very widespread, not least among the medical community in the area.

Health and Social Care Bill

Baroness Jolly Excerpts

Monday 7th November 2011 Lords Chamber

[Baroness Jolly]

My Lords, given the hour, I shall be brief. I understand exactly why the noble Baroness, Lady Gibson, has tabled the amendment. I come from the south-west and my GP practice is 25 miles from where I live. The hospitals are 25 or 50 miles away. The noble Baroness and I share that sort of background. The amendment would work in the south-west, the north-west, the north-east, or even north-east Lincolnshire. We have factors of distance, sparsity and rural poverty which are often hidden in poorly measurable clusters.

Before I came here I had a view about policy and legislation being made in a bubble in the south-east and being very metropolitan-based. I had hoped that when I arrived here I would find to the contrary, but I confess that I have not. For a while I was linked with a Defra team and corresponded with a Defra Minister about rural-proofing legislation. It is fair to say that he was not hugely optimistic, but someone really needs to say, “Would it work in a rural area?”. My noble friend Lord Greaves has already started this job on the Bill and has tabled an amendment—and I fear there may be more—about district councils. They play a hugely vital part in areas of rural England that have not become unitary authorities. In one or two areas of the Bill—perhaps in a few more—there are instances where district councils need to be factored in.

Perhaps the Government should have some sort of rural policy champion—I hesitate to use the word tsar. I should be grateful if the noble Earl would give us his assurance that that will happen for this Bill.

[Baroness Thornton]

My Lords, my noble friend Lady Gibson is to be congratulated. I particularly indentify with her remarks about dispensing chemists. As she knows, I supported her on this when I was on the other side of the House, and the issue is close to my heart. She and the noble Baroness, Lady Jolly, have raised a very valid issue and I look forward to hearing the Minister’s remarks.

EU: Economy

Baroness Jolly Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Earl Howe]

My Lords, except in limited circumstances, which must be set out in their contract, primary medical service contractors—GPs, in other words—cannot directly or indirectly seek or accept from any of their patients a payment or other remuneration for any treatment. The prohibition not only relates to treatment provided under the primary medical services contract but extends to any treatment that may be provided to the patient.

[Baroness Jolly]

My Lords, we all agree that the NHS logo must be one of the most trusted brands in the UK. It is currently outside diagnostic and treatment centres which are privately run, so can the noble Earl tell the House whether the Government will issue guidance to any qualified private providers about the use of the logo?

Health and Social Care Bill

Baroness Jolly Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Jolly]

My Lords, I am hugely grateful for the position where we now find ourselves. I am in total agreement with the previous speakers that we need to move this issue on, take back Clauses 1 and 4, use the same sort of language, and bring the matter back on Report. I should like to put on record how I am totally in awe of the work of my noble friend Lady Williams in this regard. We have also been hugely helped by the clear thinking of the noble Lord, Lord Marks of Henley-on-Thames.

While I am thanking people, I should also like to say how much I welcomed the approach of the noble and learned Lord, Lord Mackay of Clashfern. We should recognise the amount of work he put into his amendment. It was useful to take a fresh approach to what was becoming a thorny problem and bring to the House new language to look at, because, for reasons that we have already rehearsed, we were not too happy with the proposals. One of the matters that I should like the Minister to take back with him—here I borrow some language from the noble Lord, Lord Hennessy, which I think he used at Second Reading—is consideration of whether we can maintain the DNA of the Bill when producing the new work that will come before us on Report.

From these Benches, I repeat that we need a reworked clause with completely unambiguous language that will reflect the duties of the Secretary of State for the 21st century and the new NHS that we are trying to forge.

[Baroness Andrews]

My Lords, I think I can add the support of these Benches to the extraordinary way in which this matter has been resolved. It is a great tribute to my noble friend Lady Thornton, who has led so many of the debates across this House, during which many aspirations have been drawn out, problems identified and voices collected. The Minister responded clearly to what the noble Baroness, Lady Williams, expressed so well: the peculiar trust and confidence that is held in the National Health Service in this country and how careful we must be in our processes to honour that expectation and trust, so that clarity on the legal responsibilities and the future of the NHS is absolutely secure.

Health and Social Care Bill

Baroness Jolly Excerpts

Wednesday 2nd November 2011 Lords Chamber

I make one final comment on integration, but integration of a slightly different kind. The Government are consulting at the moment with a consultation document about the future of social care. I have read that document and responses have been asked for in writing by 2 December. That is extraordinary, is it not? The Government bring forward a new Bill and we are starting the Committee stage, which will probably go on until after 2 December, although I have no idea for how long—none of us does. At the same time, they are consulting on a document about social care. One might think that they would design a new social care system, look at how it needs to be integrated with the rest of healthcare and then come forward with a coherent Bill. Frankly, it is the most extraordinary way of doing anything. It would be the most extraordinary way of running a railway. In my view, it is the most extraordinary way of legislating and the most extraordinary way of running the health service. I hope that the Minister is not too upset by my strictures, which are not personally addressed to him, but an answer does seem to be required as to why these two initiatives seem to be proceeding in parallel with no apparent integration at all.

[Baroness Jolly]

My Lords, I think it is entirely appropriate that integration is included in the Secretary of State’s duty with regard to the improvement of the quality of services. I do not think that anything can improve services more than making them patient-centred, and it is the whole business of integration that will make services focus on the patient. Therefore, we welcome the language. Again, I do not know whether it is in the right place but we welcome the fact that it is there, as well as the definition.

Integration is critical. We have heard about the savings that we need to make, and integrating care is cost-effective as well as being good for patients. I want to talk briefly about social care and the community, and about how the community care too. I come from the south-west, so I will also mention Torbay, which is the jewel in the crown in our neck of the woods. The thing that has worked in Torbay was that when PCTs were set up, the local council decided that, working with the area health board, it did not want a PCT, it wanted to have a care trust. The key to the whole thing was having not only shared governance but a shared budget. There was only one pot of money to fight over and all decisions were made by councillors, non-execs and the executive round the same table. So, in Torbay care is totally integrated.

In Plymouth there is another small integration pilot going on in the DGH whereby many patients from Cornwall go over the border to the acute hospital. Somewhere in the region of a quarter of Cornish patients do not go to Truro; they go to Plymouth. Discharge has historically been a huge problem—bed blocking, Friday afternoons, all the usual sorts of things. It was a joint appointment between the PCT and social services. A social work team was put into the hospital and they liaised with all the right people when discharge was coming along. There was liaison with patients, carers, GPs, social services, care homes, domiciliary, district nurses—the whole thing—to make sure that when the patient was ready to leave the acute service they went to their next port of call and everything was all teed up ready for them to go on. That was effective. It saved time and it was much better for the patient.

I return to the amendments. There is a whole series of interesting additions which are all to be outcomes—but outcomes need measuring. So how do we measure, and what are the indicators for the effectiveness of integration of services, or the equitable provision of care, or the safety of the service? These are good things to achieve and aspire towards but I am not sure how they will be measured. I would like some clarification from the Minister as a general point. Some of the outcomes from the original Bill were added to. How will the success or otherwise of achieving these outcomes be measured and how will it be reported?

Health Authorities (Membership and Procedure) Amendment Regulations 2011

Baroness Jolly Excerpts

Monday 31st October 2011 Grand Committee

[Baroness Williams of Crosby]

Perhaps I may take this opportunity to ask the Minister a couple of questions as well. I am grateful to the noble Baroness, Lady Thornton, for raising this issue with a statutory instrument.

I am delighted to hear that some form of the SHAs will continue in the interim period—I think that they have, on the whole, done a very good job—and that there is a real sense that they can continue to play a significant part in the transition. It looks very much like, with the clustering, we are making a clear transition from where we are to where we are going. I, for one, would not object in the least to their remaining like that.

I have a couple of questions for the Minister. The first is whether he envisages that the regional offices of the NHS Commissioning Board—which, admittedly, we have not yet passed through Parliament—are likely to be very closely aligned to where the strategic health authorities are. Obviously, there is a lot to be said for continuity.

The noble Earl also mentioned the need for flexibility, on which we could not agree more. Perhaps I may ask specifically whether one could raise the question of March 2013 not being a final date. There has, as we know, already been some softening of the original timetable as a result of the Future Forum and the listening exercise, which I think was broadly very much welcomed, partly because it enabled the new system to keep some of the quite distinguished and very experienced staff from the past. The noble Earl had the kindness to say that one of the problems is how one maintains experienced and well qualified staff. The more the transition can copy the strategic health authority structure, the more likely it is that we will be able to retain some of those very qualified and experienced staff. We know that quite a few of them have been lost and that the NHS could do with not more being lost. Is there any prospect of greater flexibility about the timetable, which was strongly supported by the Future Forum?

The second question is a more specific one about SHAs. As the noble Earl knows, SHAs have a large part in education and training, which is still a major area of uncertainty until the education and training legislation comes forward. Under Regulation 2.2 of the 1996 regulations, there was a specific commitment that where a strategic health authority contained medical or dental schools, a member of the authority would come from that background. They specifically stated that he or she should come from the background of education in the medical or dental school that was part of the strategic health authority. Will that be respected in the new circumstance? That would clearly be helpful in addressing future education and training issues.

My last question is a broader one about the Government’s feeling that there was no need for an impact assessment. I confess that I am a little worried about that, because the clubbing together of membership has certain possible impacts. Lastly, as the noble Baroness properly mentioned the issue of the involvement of HealthWatch, will there be an insistence that at least one member of the cluster should be someone with a background on the health and well-being boards—in other words, representing the HealthWatch interests—in the decisions of the new cluster groups?

Let me say loud and clear that all of us regard the cluster groups as a good development; I did not want to quarrel with that. Our questions cluster around the cluster, rather than concerning the cluster itself.

[Baroness Jolly]

My Lords, I will add to the points raised hitherto. I welcome the emphasis on continuity, but I wonder whether there is an opportunity to think whether we are closing the door completely on appointing new non-executive directors. We are moving into a new world with a new mindset and culture. If we are going to retain non-executive directors currently in situ in SHAs, will that opportunity be lost? I should like that to be clarified.

We must not lose sight of the fact that these are enormous organisations geographically. From one end of Cornwall to the other end of Kent is further, distance-wise, than from London to Edinburgh. There are issues about representation on boards. There must be complete understanding of the different issues in metropolitan, rural and urban settings. That will be critical for any board.

Also, does the noble Earl have any figure for what the savings in management costs might be? I seem to remember that when this was done for PCTs and they were all enlarged to become coterminous with local authorities, management savings were promised but not delivered. What is the size of the savings that we hope for? Have the Government factored in the risk with all of this?

[Earl Howe]

My Lords, I am grateful to noble Lords for their questions, which I will try to deal with in order. The noble Lord, Lord Beecham, asked about the extent to which the new bodies will be subject to local authority scrutiny. There is no change to the existing arrangements for scrutinising SHAs. All 10 SHAs still exist. They must meet their duties as set out in legislation.

The noble Lord also made a good point about geographical representation, geographical balance and the spread of local knowledge. What we tried to achieve with the ring-fenced competition, to which I referred, across the geographical boundaries of each cluster was to arrive at a point where we had as much geographical representation as was practicable. The chairs of individual SHAs who were not appointed as cluster chairs were invited to become vice-chairs so that corporate knowledge could be preserved.

Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2011

Baroness Jolly Excerpts

Monday 31st October 2011 Grand Committee

[Lord Collins of Highbury]

I have received a warning that I must not repeat myself, so I shall try to start from where I left off, which was highlighting the CQC report on out-of-hours services arising from the Daniel Ubani case, which highlighted that we have a nationwide problem. Delaying the requirement to register for a further year means that a lot of the issues that need to be addressed by proper monitoring of compliance will not be.

My other questions relate to which organisations are covered by the regulation. The estimate was about 230 organisations. Does that include the co-operatives such as SELDOC, established in south-east London? Is it simply those organisations separate from GPs? There is an issue about high-risk out-of-hours services stemming from provision within GP services by the use of locums employed directly. I would appreciate clarity about the risk assessments. What concerns me most is that within a 12-month period, the Care Quality Commission will be required to get in to 9,000 organisations, but the Government have given it 12 months to deal with about 230. Having been on the commission’s website and seen the processes and procedures, and the advice being given to primary health services, I think we have a difficult job ahead of us.

I leave my remarks to those few specific points. On the extension of out-of-hours—I must not say out-of-office services, that is my trade union background coming out—the flexibility of the provision of services by primary health services is most important. People are reverting to organisations that do not have their medical records or knowledge of their conditions because they have to work and cannot get to a surgery within its opening times. I know from personal experience that even booking a medical appointment can be extremely difficult. You have to do it within a particular time frame. With those concerns, I leave my remarks.

[Baroness Jolly]

I should like the Minister to clarify one point. Out-of-hours services providers need to register a year early if they are not in the practice of treating patients from outside their area. Can the Minister clarify the situation regarding itinerant or travelling workers? Where I come from, huge swathes of people come in to pick strawberries, daffodils or whatever. They certainly do not register. I am not clear whether the out-of-hours providers would treat them as temporary residents. What is the case in those circumstances? Would GPs who currently provide services in Cornwall in a co-operative be required to register a year early?

[Baroness Williams of Crosby]

My Lords, I, too, have a couple of questions. I very strongly support my noble friend's question about itinerant or temporary workers. In addition to the people about whom the noble Baroness, Lady Jolly, spoke, there is also the Traveller community, which does not stay permanently in a single place, as we know from the Dale Farm episode. I am very concerned—I am sure that others in the Committee are, as well—about the position of mobile workers whose life involves moving from place to place, and about where they will be picked up by the providers.

My second question concerns the position of out-of-hours services. The General Medical Council has raised many concerns about out-of-hours providers who are not familiar with the English language, let alone some of the other languages that we have in this country. Will there be additional requirements for out-of-hours service providers above the basic medical requirements that they will have to meet?

I should know the answer to my third question, but I confess that I do not. However, I am sure that the Minister does. When providers are registered, are the lists of those who are registered made available to local HealthWatch committees, local authorities and Parliament? That is very important. Transparency is almost invariably the best form of inspection.

Finally, with regard to the CQC, we all know—as the noble Lord and the noble Baroness, Lady Thornton, said—that it has been under heavy pressure. My question is: will the practice of non-notified inspections, as well as notified inspections, continue? I note that the Secretary of State referred to this just a couple of weeks ago in respect of the investigation of complaints about the treatment of elderly people when he called on the CQC to do an immediate inspection.

I have one final point. I do not expect the noble Earl to reply if he does not want to. The most effective form of inspection is by protecting whistleblowers. All of us are aware that whistleblowers are a very effective form of informal inspection. It was whistleblowers who came up with the terrible Winterbourne story. Are there any means of protecting whistleblowers, especially among NHS staff, from being forced into retirement or sacked? Among all possible forms of inspection, NHS staff are most likely to be able to alert the system too bad or poor standards. Have we given consideration to the possibility of protecting whistleblowers among NHS staff? I am sure that our colleague from the trade unions would be sympathetic to that idea.

Health and Social Care Bill

Baroness Jolly Excerpts

Tuesday 25th October 2011 Lords Chamber

[Baroness Murphy]

My Lords, one cannot help but be moved by the commitment of the noble Lord, Lord Hennessy. In view of the public discussion that has gone on outside this Chamber, we all welcome a recommitment to the principles of the NHS constitution. But I have a number of really serious concerns about the amendment as it stands. For a start, remembering back to the 2009 Act, the whole point about the NHS constitution is that it was not just a set of airy-fairy principles, it concerned how those principles were to be put into effect. To extract these crucial principles, which along with the noble Lord, Lord Hennessy, I wholly support, and put them separately at the beginning of the Bill is to confuse the issue and, I think, to leave us open to further legal challenges over what the NHS is about. The NHS constitution stands; that it must stand is reiterated in the Bill, and therefore we should not seek to water it down in any way.

The second part of the amendment again does not quite reflect what we have tried to do, as we discussed the development of this Bill, to ensure that the NHS is about improving quality. It is not about accepting quality, equity, integration and accountability as is; it is about continuous change leading to improvement. Again, I think that that is not reflected in subsection (2), which is very confused, and I really do not understand the phrase at the end, “not the market”. What does that mean, and how does it relate to the,

“person or body performing functions”?

The third subsection, about the primacy of patient care, is crucial. We want to see the primacy of patient care throughout the Bill. Again, however, as it stands, the amendment would rule out structural and financial reorganisations, for example to improve the formula for allocation of resources to local clinical commissioning groups. It would rule out the decisions that we want local groups of commissioners to make regarding reconfiguration. It would stultify the development of an improved health service. I really think that that is confusing.

As for the Nolan principles, I think that all of us would say that they are crucial. But they are in the Bill as it is, as they were in every NHS Act recently. Standards in public life are something that everybody who is in public service must be committed to, and they are in employees’ terms and conditions of service. These are desirable things, and I am very sympathetic to the desire to make a comprehensive statement of the commitment of all sides of this House to a universal and comprehensive NHS. However, this amendment is not it.

[Baroness Jolly]

My Lords, I do not intend to take an awful lot of your time with my comments. I agree with many comments made by my noble friend Lady Williams, and I share the anxieties expressed by the noble Baroness, Lady Murphy. To a certain extent I am bemused, because we have a perfectly good NHS constitution. It has been said that it is only three years old and indeed it is. It was a result of the work of the Labour Peer the noble Lord, Lord Darzi, and involved a huge cross-party effort. This is to be commended. This amendment does not match it in breadth or scope.

We are now in Committee and it is not sensible of us to prolong the debate. We have many, many days yet to go and we really need to move on and get on with the Bill. However, I want to finish by thanking the noble Baroness, Lady Thornton, for her compliments about our conference motions and the way in which our policy is made following votes by our members at conference. The second subsection of this amendment came from a motion to our conference last spring. We wanted the NHS to work for patients and not providers and as a result of this and the Future Forum deliberations, this was acknowledged. Furthermore the Monitor duties were changed to reflect this so that they now are about the promotion and protection of patient care. I really feel that we need to move on and get on with the Bill.

[Baroness Donaghy]

My Lords, I support this amendment for three reasons. I will be brief, bearing in mind the comments made by the noble Baroness, Lady Williams.

First, in a Question in the House today, the noble Lord, Lord Low of Dalston, asked for an inquiry into the nature and extent of commercial lobbying of Ministers. If it is considered bad now, I have a great fear that it will be an even bigger problem when we get to the commercialisation of the National Health Service. As a former member of the Committee on Standards in Public Life and a former acting chair, I regard it as a reassurance to have reference to the Nolan principles in this amendment. More importantly, I think that it will be a reassurance for the members of staff who work in the health service.

I want to draw the Committee’s attention to two of the most important parts of the principles: openness and accountability. We have already seen—certainly in my experience as a non-executive director of a foundation trust until a couple of years ago—phrases such as “commercial confidentiality” creeping into discussions about how we conduct our health service. How much more will that phrase creep in when the kind of proposals in this Bill become an Act?

Currently, research and knowledge are shared by the medical profession, both nationally and internationally. If you are involved in any way in higher education and medical research, you will see how important that is for the advancement of medicine generally. Unless we embed these principles in the amendment, I fear that they will be under threat and the efforts of our medical profession will be compromised.

--- Later in debate ---

[Baroness Emerton]

My Lords, I rise as the one nurse here. The debate so far is music to my ears but it would be even more so to the professions. When the Bill was published there was great concern and great disappointment that we had to wait for education and training to come as a further step in the White Paper and after this Bill. They see, as I think every professional here sees, that education and training is a fundamental basis for ensuring the primacy of patients.

This Bill gives an opportunity to look at the future of health and social care and to bring in integration and holistic care, as was pointed out at Second Reading. To do that, we have to look at the education and training of all healthcare professionals, and the holistic approach from primary to secondary and tertiary, back to primary and community care, and to work alongside social care.

One of the things that we particularly need to address is the commissioning of the workforce in the future. The noble Lord, Lord Warner, has mentioned the strategic health authorities. I am sure that we all have comments against the strategic health authorities, but one of their functions was to engage in workforce planning. At the moment, it does not seem at all clear how the commissioning will be for the future workforce of healthcare professionals. This will be a great issue that needs to be addressed urgently because we all know that education and training is a three or four-year process—longer for doctors. It will need to be addressed immediately.

I want to support the amendment tabled by my noble friends Lord Walton and Lord Patel, proposing an overarching responsibility for the Secretary of State. I am sure that we will have certain other amendments, which have been already mentioned, and future debate. I would just say how urgent it is that we get something in the Bill to reassure the professions that education and training are essential for the primacy of patients.

[Baroness Jolly]

My Lords, it seems that we are now getting an outbreak of agreement that there should be a duty on the Secretary of State regarding education and training in the Bill. This is to be welcomed.

The noble Lords, Lord Mawhinney and Lord Kakkar, put it really well, and I will slightly paraphrase what they said. The delivery of high-quality patient care is absolutely predicated on quality training. It is also critical, however, that standards are set, maintained and monitored, not only for doctors and nurses—we have heard a lot today from very eminent doctors—but for allied health professionals.

There will, however, be a plethora of local healthcare providers: some within the NHS and some outside. We are anxious to ensure that the local responses to the delivery of training will meet these standards. We hope that proper checks and balances will be put in place to give some sort of national oversight on this. The noble Baroness, Lady Finlay, alluded to this in her remarks. I was going to carry on by giving a couple of examples about the need for co-ordination across providers and talking about these independent treatment centres. I will refer only to phase 1 and not to phase 2; we will have got it right by then.

There were complaints, certainly in my local district general hospital, that doctors were seeing only quite complicated operations and not standard ones. It was to do with hips there, and we have already heard about elbows or shoulders elsewhere. Similarly, the noble Lord, Lord Winston, cited hernias and I have a hernia example, which I shall not share with the House.

With this Bill, there is a wholesale need for a total change of culture within the NHS about the way we work. If we put patients at the centre it will create a huge need for training. It will be one-off training in the first instance but it will also need to be ongoing. This is something that I had hoped the Future Forum might be considering as part of its deliberation.

We are assured that the Government are keeping deaneries in place at present, but we share the anxiety of some of the royal colleges about their future. I have to repeat what others have said—and I heard it only this morning: there really is anxiety about this second Bill. The first assurance was that it would come in the next Session but now organisations are worried that the delay might be even longer. Therefore, we need something from the Minister that will help to focus people’s attention and give them confidence that things are in place.

I have spoken to universities and other providers of training. They need reassurance and certainty, too. They need to plan their staffing and, in this, they form part of the health economy. It is in no one’s interest to destabilise them. Can the Minister offer such reassurance on this?

We welcome the duty for Monitor to have regard to the need for high standards in the education and training of healthcare professionals. How will this interact with the potential for insufficient caseloads, in some circumstances, to train new healthcare professionals properly? How will national oversight of education and training be carried out to ensure higher quality? All these areas need to be teased out further, and we will come back to them on Report.

We all acknowledge the critical need for training and for standard setting. Can my noble friend give the House some reassurance that he will look at these issues again and, where possible and appropriate, consider regulation as a way of moving some of them forward in advance of the Bill?

[Lord Alderdice]

My Lords, I do not wish to repeat what other noble Lords have said very eloquently, but there are one or two issues which have not been referred to, to which I wish to draw attention. First, I pay my own tribute to the noble Lords, Lord Walton of Detchant and Lord Patel, and indeed other noble Lords who have kept fighting the good fight on education and training.

It is important, however, that we see this in as broad a fashion as possible. I am a doctor but I intend to speak mostly on non-medical education within the health service, since it has not, perhaps, received as much attention as it might. Like everyone else, I will undoubtedly speak from my own experience, which is, perhaps, a little different because it is in psychiatry and the psychological services. That is not just about treating patients; it is often also about training doctors in communication skills and the capacity to understand the psychological aspects of disease.

The noble Lord, Lord Hunt of Kings Heath, knows that I am not a recent convert to this question of trying to get regulation of psychotherapists and counsellors so that they can properly become part of an overall healthcare system.

Health and Social Care Bill

Baroness Jolly Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Jolly]

My Lords, we have heard well-argued speeches, as we would expect, from my noble friend Lord Howe and from the noble Baroness, Lady Symons, the Opposition Front Bench health spokesman—

[Noble Lords]

Thornton!

[Baroness Jolly]

Apologies to the noble Baroness, Lady Thornton. I have that name written down but the wrong one came out. They have provoked thought. At the debate on the Future Forum, called by the noble Baroness, Lady Wheeler, before the conference recess, I flagged up many of my concerns with this Bill, but time did not allow me to share them all. I fear that I will have the same problem today, but I am sure that my noble friends on the Benches behind me will be happy to fill in any gaps I may leave; in particular, areas of inequality, mental health, and the role of Monitor in competition and integration.

For the record, my areas of concern which I flagged up in that debate were the accountability of the Secretary of State—this needs to be right from the beginning and completely unambiguous, and he or she needs to be hands off and responsible at one and the same time; the need for clarity within the local government and clinical commissioning groups and democratic accountability; the role and status of the director of public health within local government, which will be critical and will need work; and the need for clarity about education, training and workforce development within local government.

I am delighted that this Bill is designed to promote integrated care—acute and community services working as one with social care. The patient and carer must be totally woven into these new networks and clinical senates. In future, patients and carers should not have their care packages worked out in isolation.

As I was working out how I was going to come up with this speech, I realised that it is nine months to the day since I was introduced to this House. In the maiden speech I made two days later, I told the House about my time on various NHS trust boards. From that time, I offer your Lordships an example of why the Secretary of State must be hands off.

We needed extra capacity to deal with cataracts in my area and made the appropriate arrangements through a local hospital. Before this could be finalised, we had the project pulled and replaced by a new treatment centre, run by the private sector, which would also offer terminations and endoscopic diagnosis. This would be based in a new build—not particularly where patients wanted to go—and we were given patient target numbers not only to meet but to pay for whether they were met or not. We did not need all that provision and it was in the wrong place. We respectfully told the powers that be that we were happy with our original solution, thank you. We were then told, in very blunt language, that it would happen with or without our decision, and that if our board did not approve it, another would be found that would. So that is a result of the Secretary of State with a power to intervene. Fortunately, under this Bill, this proposal would come before Monitor and the privately run hospital would be deemed not to be in the best interests of local patients and it would not proceed.

I must have sat through hundreds of board meetings, not to mention audit committees, clinical governance groups and remuneration committees. They were all about the structure of the NHS. There were times, as we discussed systems and processes, that the patient never got a mention and was certainly rarely there at the table.

By their own admission, the Government want to put the patient at the centre of the NHS—“No decision about me without me” is a laudable and catchy strap line. We welcome that, but I fear that at times this patient is still sidelined. Care will have to be taken to embed a serious culture change.

I fear that this Bill, as it stands, has areas which are about process; engineering the system for desired outputs and outcomes while Mrs Smith or Mr Patel is forgotten. Just how much within the Bill needs looking at again from the perspective of individual care and not making the individual fit what is being designed?

There are three distinct areas for patient involvement. First, at the time of a consultation with a professional they need to be involved in their care plan and look at any options. There is evidence—there has been a lot said today about evidence—that 75 per cent want involvement and that if they become involved they do better. Incidentally, that goes some way towards reducing health inequalities. This needs to start upstream and it needs to be built into commissioning.

Secondly, we can look at a patient as an expert patient, offering insight and refection in how their experiences can help the care of others, as can patient organisations. Again this needs to be built into the commissioning process, into senates and into local networks. Finally, as a member of a local healthwatch or HealthWatch England, these replaced the old LINks groups and, as yet, do not have a sufficiently robust structure with the ability to challenge. Here I disagree with the Minister. They do need more clout.

We are faced with two amendments to the Motion, one tabled by the noble Lord, Lord Rea, and the other by the noble Lord, Lord Owen. I will take them separately and explain why I am not supporting either. First, on that of the noble Lord, Lord Rea, as a Liberal Democrat I know only too well that many areas of this Bill, for the most part, fall outside the coalition agreement, which I voted to support in May 2010. In fact, it drives a coach and horses through the agreement. This leaves us the opportunity on these Benches to revert to our manifesto and policy document in deciding amendments. When I arrived in this place, the Bill was already printed and starting its passage through the other place. History will tell us whether there was a Blue Peter here's-one-I-prepared-earlier moment and who the main players were. I expect it to be silent on the matter of wire coat hangers, cereal packets, and sticky-backed plastic.

It is the Government's Bill and it is not without fault. One of my early lessons here was that it is our role to improve and not to reject Bills. We need to take those faults and work to take them out. As a junior member of the coalition, I have found Ministers' doors have been open, and there has been a willingness to listen and engage. I welcome the invitation of the noble Baroness, Lady Symons, to work together in the interests of the public and the NHS.

[Noble Lords]

Thornton.

[Baroness Jolly]

Thornton—I beg your pardon. It is the first time I have made that mistake. You know who I mean. I apologise to the noble Baroness, Lady Thornton. I welcome her invitation.

Next, the amendment of the noble Lord, Lord Owen, is more nuanced, but puzzling. The noble Lord calls for those issues raised by the Constitution Committee report dealing with powers and responsibilities of the Secretary of State to be extracted and given to a Select Committee to work on while the remainder remain within the House in Committee in this Chamber. Thanks to the hard work of the noble Baroness, Lady Thornton—I have it right—in pulling together a really well attended series of fascinating seminars about all aspects of this Bill, followed by a similar series arranged by noble Earl, Lord Howe, the opportunity to question think tanks, Royal Colleges and senior civil servants was made available to all Peers and was taken up by many. Peers are well informed about this Bill and are able to deliberate, scrutinise and amend in the usual way—in a Committee of the whole House. This is the general custom and I see no reason to do otherwise.

I ask noble Lords to reject both amendments. Let us get on with doing what we are praised for doing worldwide: scrutinising difficult and complex legislation as a House, with a view to producing a better, workable Bill.

NHS Future Forum

Baroness Jolly Excerpts

Thursday 15th September 2011 Lords Chamber

[Baroness Jolly]

My Lords, I thank the noble Baroness, Lady Wheeler, for securing this timely debate and for her thought-provoking speech and I thank the noble Lord, Lord Ribeiro, for his speech. I believe I speak for all my colleagues on these Benches when I say that we welcomed both the listening exercise, a process to which we contributed enthusiastically, and the report of the NHS Future Forum. We also welcome the Government’s commitments to implementing the bulk of the Future Forum’s recommendations. However, there are three broad areas—I think we shall revisit these three areas throughout the debate—on which I would appreciate further clarification from the Minister, in particular on accountability, local government involvement, health education and workforce planning.

First, it is important for the functioning of the NHS as a whole to get the Secretary of State's duties and powers absolutely right. We on these Benches have long advocated the devolution of power away from Whitehall wherever possible; and the Secretary of State should not be able to micromanage the health service. But there is a balance to be struck. The Health Secretary must remain ultimately accountable to the electorate, through Parliament, for the system as a whole; and, on the other side of the coin, he or she must have appropriate powers to intervene where the system has broken down.

Therefore, I am pleased that the Secretary of State will now have an express duty,

“to secure that services are provided in accordance with this Act”,

rather than, as hitherto, merely to,

“act with a view to securing”,

their provision. This wording ought to ensure that the Secretary of State will continue to be accountable to Parliament for what goes on in the NHS, while also recognising that day-to-day operational control rests with clinicians and managers.

I welcome, also, the clarification of the Secretary of State's powers of intervention in cases of substantial failure, and in particular the requirement that he or she be transparent in publishing the reasons for any such intervention. Set against these powers, the Secretary of State also has an express duty to promote the autonomy of other actors and players in the health service. This is a laudable duty, because it militates against political meddling. However, can my noble friend reassure me that this duty will not hamper the Secretary of State’s power to intervene when necessary in cases of failure? If there is a chance that it might have that effect, will he consider appropriate amendments to ensure that the right balance is struck?

Secondly, I am delighted to see local government attracting a greater role in the health service under the Bill. Assuming that the provisions are properly fleshed out and implemented, there is another opportunity here to press the localism agenda that is common to both parties in the coalition. The new health and well-being boards represent an opportunity to put more power in the hands of elected local representatives and their communities and so bring health and social care together in a meaningful way, but even after the Government’s amendments, the Bill leaves almost all the detail of this to regulations. Will this House have sight of the draft regulations before the end of Committee in your Lordships’ House? Will the regulations, in particular, detail appropriate outcomes, incentives and levers so that health and well-being boards are able to ensure that the integration of health and social care services actually takes place in their communities? What will happen, for example, where a clinical commissioning group and its health and well-being board cannot agree on the contents of the joint strategic needs assessment or health and well-being strategy? What recourse will there be where a clinical commissioning group strays significantly outside the provisions of the relevant local assessment or strategy? The duties of consultation and co-operation set out by the Government’s amendments are welcome, but I am concerned that they do not go far enough. There will be some situations where the health and well-being boards will need to have real teeth in order to get the job done.

Bringing public health back into the purview of local authorities is a hugely welcome development. I am glad to see that local authorities will be required under the Bill to appoint a director of public health, but can my friend reassure the House that directors of public health will be sufficiently senior and independent? They will need to have sufficient tools and resources at their disposal, financial and otherwise, to hold local authorities to account and make sure that they take their public health responsibilities seriously. In particular, will the department require each local authority to establish the post of DPH at an appropriate level of seniority, reporting directly to the chief executive? Can the public be confident that they will be adequately qualified? Will the Minister consider including this in the Bill, or at least setting it out in regulation or guidance?

Finally, education and training formed one of the four headline areas tackled by the Future Forum in its report, but is more or less absent from the Bill. While we welcome the retention of the functions of postgraduate deaneries within the NHS, the current system of medical education and training is overly complicated and was in need of reform well before the Bill appeared. However, given the impending demise of strategic health authorities, there is a danger that the existing system may disintegrate before anything can be set up to replace it. The Future Forum recommended, and the Government accepted, that Health Education England ought to be established as soon as possible with a clear mandate. I would be grateful if the Minister would update the House on progress so far on setting up the new system and the likely timetable for completing this work.

The Future Forum also recommended that education and training should be confirmed as a vital part of the core NHS, rather than established as a separate system. In the Government’s response to the Future Forum report, we were promised,

“an explicit duty for the Secretary of State to maintain a system for professional education and training as part of the comprehensive health service”.

This does not appear to have been implemented in the Bill as it stands. Will the Government bring forward an amendment in Committee to make good on this commitment?

We also understand that employer training networks—which, thanks to Future Forum, will now be known as local education and training boards, LETBs—are in the process of being set up. We welcome the move to bring healthcare providers more into the process of education and training. Will the Minister reassure the House that these organisations will be required to operate transparently and will be properly scrutinised by Health Education England?

As a result of the Government’s response to the Future Forum report, we now know in broad terms what the arrangements will be at local provider and national level, but can the Minister tell the House how strategic regional workforce development, hitherto carried out by strategic health authorities, will be carried out under the new system?

This has been a timely debate that has given us all plenty to think about at our party conferences. I will take the opportunity to update the noble Baroness, Lady Wheeler, on what will happen at the Lib Dem conference next week. There will be a debate on Wednesday in prime time, immediately before the leader's speech. In addition to that, our Minister will hold an open surgery. There will also be a Q&A session in the conference centre. There is no secrecy here. In addition, all parliamentarians involved in health will be available at a plethora of fringe meetings. I am more than confident that our membership will take every opportunity to engage us in debate.

I return to this one. I am sure that the House will agree that the issues of accountability, integration and education are critical to the smooth running of the NHS. We look forward to working with the Minister on these issues when we finally go into Committee later this month.