Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Wednesday 30th November 2011 Lords Chamber

[Lord Greaves]

My Lords, in brief response to the noble Lord, Lord Warner, I am not suggesting in any way that the regime should be identical to the local government regime, but that the decision-making body in clinical commissioning groups will be the board. Under the new Section 14A, the board will include lay members and possibly other people. So merely relying upon professional standards and professional systems of discipline will not be sufficient.

[Baroness Masham of Ilton]

My Lords, I spoke on Second Reading of the need for safeguards. These are important amendments. They are safeguards which are necessary. Many people are worried about the conflict of interest.

[Earl Howe]

My Lords, I know full well that noble Lords have some concerns about the potential for conflict of interest in a system of clinical commissioning groups. Those are natural concerns, but I hope to show that the approach that we are advocating has some very specific and robust safeguards within it, which meet the intentions of the amendments in this group.

The CCG constitution provides for dealing with conflicts of interest and specifies arrangements for securing transparency about the decisions of the CCG and its governing body. The governing body must in turn ensure that the group has arrangements in place to ensure adherence to relevant principles of good governance. The CCG’s governing body will have responsibility for ensuring that the CCG adheres to relevant principles of good governance. The Secretary of State can also make regulations for CCGs under Clause 71 of the Bill, which are designed to ensure that in commissioning, CCGs adhere to good procurement practice. These regulations may impose requirements relating to,

“the management of conflicts between the interests involved in commissioning services and the interests involved in providing them”.

These regulations can also confer on Monitor powers to investigate suspected non-compliance. These are the safeguards that the Bill puts in place. My view is that it is unnecessary and indeed undesirable to go further.

Requiring CCGs to adhere to examples of good practice in managing conflicts of interest, such as declarations of interest; or maintaining a register of interests; or the monitoring or registration of hospitality received by members is a temptation, but one that should be resisted. We have got to be very careful about encumbering the Bill and CCGs with inflexible prescriptions as to how CCGs should operate within the statutory framework, or procedure about how they specifically manage potential conflicts of interest. This does not mean that these are not reasonable safeguards. Requiring the governing body to discuss in public choices between potential providers, or publish any decisions made in camera, for example, would remove a necessary discretion around ensuring that sensitive issues, either relating to contract values or performance, or staff matters, were given the appropriate level of confidentiality. I would urge in particular that we do not—as proposed in Amendment 175CC—put restrictions on those from whom a CCG can commission services. Given the importance we attach to ensuring that services are delivered in an integrated way, we cannot afford to cut CCGs off from being able to commission services from local GPs with a special interest, for example, who could deliver secondary care services in a community-based setting.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Monday 28th November 2011 Lords Chamber

[Lord Neill of Bladen]

I make one comment on the amendments, which also goes to the Government’s fundamental philosophy, with which we all agree, that patients should be told about their condition and kept fully informed. My experience in recent years has been visiting hospitals and wards with elderly people in them. You cannot but become aware of the inability of a lot of the patients to understand what it is they are being told or to look after their own notes. There is a danger, if we are not careful, of theory and reality moving apart from each other. There has to be a true awareness of the need to get the relevant knowledge to the right person. Sometimes, it will not be the patient; it will be the patient's spouse, daughter, son or whatever. We should keep that in mind.

[Baroness Masham of Ilton]

My Lords, I add my support to the patient involvement amendments and the HealthWatch amendments. Whose life is it anyway if it is not the patients?’ Patients can now be very much at risk, if they are not involved with doctors, through drugs available through the internet which are counterfeit medicine. I was at a meeting this afternoon and heard from a Minister that the Government had asked China for help, because it is a problem place, and the Chinese are now going to introduce the death penalty for people selling counterfeit medicine on the internet. That is a serious problem. Patients need to be involved; they need to have a voice; and they need to work together with everybody else concerned. Otherwise, they will feel left out and shunned, and that would not be a good thing.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Tuesday 22nd November 2011 Lords Chamber

[Lord Warner]

My Lords, I have added my name to Amendment 99 and to a number of other amendments tabled by the noble Lord, Lord Patel, and my noble friend Lord Harris. I do not want to speak for very long on this issue. I have some inhibition about speaking about this because I do not think that my own party’s record on patient representation was extremely startling. I had to take some of those measures through your Lordships’ House and usually did not get the better of the arguments with the noble Earl on these issues. I accept that the Government have started off pretty well on this issue and that they have a good brand—HealthWatch is quite a good brand. I am an athletics fan, however, and the Government are beginning to look like a 200-metre runner who has moved up to 400 metres but is now starting to run out of steam on this issue in the last 100 metres. What I think has happened is that the money has started to dominate the discussion.

I also recognise here a favourite Department of Health word—hosting. There are two phrases that used to worry me as a Health Minister: “the NHS family”, which was usually an excuse for doing something foolish; and “hosting”. The danger of hosting is that, for what seemed to be perfectly good reasons, you put one organisation in the maw of another organisation whose culture is fundamentally different from the needs of the organisation being hosted. The real danger here is that there is no obvious similarity between a regulator and a patient representative organisation.

I will give the noble Earl just one example where the Government would do well to pause and think. If you are the parent of someone with a learning disability who is in a home which has mistreated and abused them and the regulator has let you down, or you perceive that the regulator has let you down, you are not going to be very pleased to find that the regulator is the very same body that is hosting the national body representing patients. That is a real example, not a phoney example. I think that there could be many such cases—and we will have a debate on Dilnot and social care on Thursday. However, there are some serious problems in the funding and quality of some of our social care institutions. The regulator is going to have a tough time in these areas over the coming years. It is a mistake for HealthWatch England to be hosted, in effect, by the regulator. Given the size of the NHS budget, the Government are spoiling their ship for a ha’porth of tar, to use a corny phrase, by not finding the money to fund this body adequately, so that it can stand on its own two feet and be secure and independent, and so that it can be allowed to be seen to be secure and independent by the patients who will put their trust in it.

I shall end on the point made by the noble Lord, Lord Harris, about ring-fencing. I can give the noble Earl a good example of where the Government have tried to do the right thing. They tried to put some extra money into social care that would go down to local authorities to improve the volume and quality of social care, but they did not ring-fence it. It was the best part of £1 billion, out of the £2 billion increase in social care funding. We now have a lot of people who thought that that was a jolly good idea. However, as it was not ring-fenced, the Government will not get any credit for it. It has gone into local budgets, but we do not know where. If you talk to any director of adult social services they will tell you that one of the problems was that the money was not ring-fenced, so they cannot reassure the Government that the money has gone to the purposes for which the Government sent it down the conduit to the local authorities. There is a very real danger that the same will happen with the HealthWatch money that will go down to the local level. I strongly support these amendments.

[Baroness Masham of Ilton]

My Lords, I spoke on this subject at Second Reading, and I want to go back in history for a few minutes. I remember that when the community health councils were closed down, the noble Earl, Lord Howe, and I felt strongly that the health forums which were put in their place should be independent. If a local healthwatch organisation is linked too closely to its local authority, it will be difficult for it to be able to speak out if it finds that both health and social care facilities are not up to scratch. What happens if they disagree with the CQC? Patients often need help, so an independent body would be much better to help them with their problems. It is vital that HealthWatch is adequately funded to do a useful job, otherwise it will fail. Perhaps I may give an example concerning a rural area. What happens if there are not adequate funds for the payment of members’ travel expenses? That has been found with the local LINks. I hope that the Minister will give this serious consideration.

[Baroness Cumberlege]

My Lords, I have listened to the debate, and some powerful arguments have been put forward for an independent HealthWatch England. However, I am not sure that that is the right answer. The noble Lord, Lord Harris, said that he feels that the Bill is setting up the new arrangements, and of course he is right. However, when one is setting up new arrangements, it is a good idea to look at what has happened in the past. Looking back to the confederation of CHCs, one sees that it never actually made an impact. I think that that was probably because the initiative for setting up that body came from the CHCs themselves, and so the confederation had no formal legitimacy, no clout and few resources.

--- Later in debate ---

[Lord Walton of Detchant]

I have a short but, I believe, relevant question for the Minister. As he is aware, a medical charity called HealthWatch has existed for some years. I have the honour to be a patron of it. Every quarter it produces incisive commentaries on health matters that are not always totally in line with government policy. Has the department been able to work out some kind of mechanism by which any potential confusion in the public mind between the charity and this body, which is to be created under this Bill, can be avoided?

[Baroness Masham of Ilton]

My Lords, I want to ask the noble Baroness, Lady Cumberlege, about her safeguarding amendments, which are very interesting. Would she not also put down a safeguarding amendment about the funds? Jobs will not be able to be done unless funds are safeguarded.

[Baroness Cumberlege]

I will think about that. Having dealt with the Treasury in the past, I know how difficult it is to get anything ring-fenced. However, the noble Baroness’s suggestion is very interesting and I will take it on board.

We have examples of other consumer groups being very effective within their parent organisation. I think in particular of NICE, which has done a lot to get views on its work from the general public. The Council for Healthcare Regulatory Excellence has also done that.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Monday 14th November 2011 Lords Chamber

I hope very much, therefore, that the Government accept the amendment and undertake the review that it suggests, so that we might take matters forward and relieve them of a burden which reduces nobody’s profits but does reduce the capacity of the sector to provide a better and wider-ranging service to the people whom it seeks to serve, and in whom we all have an interest.

[Baroness Masham of Ilton]

My Lords, how could one not accept this amendment?

[Earl Howe]

My Lords, I begin by saying that I completely understand the seriousness of the issues raised by the noble Lords, Lord Patel of Bradford and Lord Noon, and others noble Lords. The noble Lord, Lord Patel of Bradford, suggested that part of his purpose was to ensure that this issue remained on the government agenda. Let me assure him that the issue is very firmly on the Government’s agenda, and I am pleased that we are having this debate today so that I can outline exactly what we are doing.

Before I turn to address the amendment, I think it would be helpful if I briefly laid out the Government’s view of the role of the voluntary sector in the NHS. We firmly believe that voluntary sector organisations have a strong and often crucial role to play, due to the experience, expertise and insights that they can offer to commissioners and the system more widely. I of course acknowledge and pay tribute to the valuable work performed by Sue Ryder and numerous other charities, including most especially hospices. We recognise that they can play a vital role in delivering innovative, high-quality user-focused services in their local communities, along with improved outcomes for patients and increased value for taxpayers. We also acknowledge, as Amendment 46 highlights, that taxation treatment is one potential barrier to voluntary sector organisations’ entry into the provision of NHS services and to their increased involvement in those services. Access to capital is another. We are very keen to explore ways to overcome these challenges. The department is discussing this, as part of a wide range of issues, with voluntary sector providers of NHS-funded services.

When I was preparing for this debate, I asked whether the Treasury was looking at these issues, and the answer is that it is. I understand that Treasury officials are already working with representatives from the voluntary sector to explore the value added tax treatment of charities supplying the NHS, taking into account the legal limitations and the potential complexities around possible solutions. We are keen that they should make speed over this. However, the introduction of an artificial one-year timetable, as this amendment proposes, would limit the scope for a full and thorough discussion and consideration of this issue. I cannot commit to that limitation. However, I emphasise that we are very keen to work at possible solutions as fast as we can. It is a complex issue. My noble friend Lady Barker pointed us towards some of those complexities.

It is worth my repeating a general point here. The Government are committed to fair competition that delivers better outcomes and greater choice for patients and better value for the taxpayer. We want to see providers from all sectors delivering healthcare services. We have not the least wish to favour one type of provider over another. Indeed, as a result, and to ensure that the Secretary of State, Monitor and the Commissioning Board do not confer preferential treatment on any type or sector of provider, the Government have introduced amendments to Clauses 144, 59 and 20, inserting a new section, Section 130, into the National Health Service Act 2006.

We know very well that the voluntary sector plays a strong role in bringing the voices and experience of patients, service users and carers to the work of improving services, often reaching individuals who are excluded or who cannot access mainstream services. The voluntary sector brings advocacy and information to support individuals to exercise choice and control over the services that they access. These are major prizes, and we wish to capitalise on them. Opening up services to greater choice, for example, through “any qualified provider”—as was pointed out by the noble Baroness, Lady Finlay—allows for greater involvement by social enterprises or voluntary sector organisations. To a great extent, this is already happening.

Listening to noble Lords, I felt that there was a great deal of consensus around those points. There is a shared feeling across the House that charities have a key part to play in NHS provision, that the current VAT rules can act as a barrier and that this needs to be looked at very closely and urgently. I completely agree with that, and I would like to reassure the noble Lord, Lord Patel of Bradford, that we will ensure that this taxation issue continues to be considered urgently, as we develop work on a fairer playing field for delivering NHS services. In establishing Monitor’s new functions, the department and Monitor will continue to consider these issues and the priorities to be addressed.

The noble Baroness, Lady Armstrong of Hill Top, asked in particular what comfort there is in this Bill for the voluntary sector. She quite rightly mentioned the Future Forum in highlighting the work of the sector. The noble Baroness will be aware that the forum gave a very strong endorsement to the Bill’s creation of a bespoke provider regulator, Monitor, in order to oversee a level playing field. Such a commitment to a fair market was and remains a comfort to the voluntary sector. Of course, we acknowledge that more needs to be done, and that includes the ongoing work at the Treasury.

With those remarks, although I am sure that I have not completely satisfied the noble Lord, Lord Patel of Bradford, I hope that I have given noble Lords the sense that we are onside with this issue and shall be pursuing it with as much urgency as we can. I therefore hope that I have done enough to persuade the noble Lord to withdraw his amendment.

--- Later in debate ---

Finally, I come to some probing amendments concerning the number of staff to be employed by the national Commissioning Board and the staffing. I should like to hear from the noble Earl something about the size of the NCB and what its regional and local structure is likely to be, remembering that it will hold the contracts of thousands of practitioners. My understanding is certainly that it will hold the contracts of all GPs because it is deemed that presumably the local clinical commissioning groups cannot hold the contracts of the GPs who are members of the clinical commissioning groups. Clearly, if the Government’s proposals are to streamline decision-making, then finding that the national Commissioning Board becomes an absolutely huge organisation with thousands of people employed will rather detract from what the Government seek to do. It would be very helpful if the Minister could give assurances about the cost of the NCB.

[Baroness Masham of Ilton]

My Lords, I should like to go back to Amendment 50 and, in supporting this amendment, to tell your Lordships that during the deliberations of the House of Lords Select Committee on HIV and AIDS this very subject came up. It was felt to be essential that a public health specialist should sit on the Commissioning Board. Also, I feel that he or she should be the link between the NHS and the local authorities. Public health needs to have a high profile. It is vital to have someone who understands the problem of sexually transmitted infections—in which we lead Europe—as well as PVL MRSA, which is a community-type MRSA, food poisoning and epidemics such as flu. It could be possible for somebody who was interested only in obesity and exercise to be put on the board. Our public health is vital.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Wednesday 9th November 2011 Lords Chamber

[Lord Darzi of Denham]

My Lords, I enter the debate speaking as a professional working in the health service, but also as someone who has had the opportunity and privilege of serving in government. I might know something, therefore, about the accountability of driving quality and improvements. I also had to learn fairly quickly about the accountability in this democracy and the accountability, as the noble Lord, Lord Mawhinney, put it very clearly, about the expenditure of the health service.

I will use the example of a piece of work that I had the privilege of leading. Many noble Lords in the Chamber helped me through it. It was a review of the London healthcare services, called Healthcare for London: A Framework for Action. I led this piece of work with 150 clinicians, in addition to 100 Londoners—members of the public and also patients. The work took place in 2006, after a formidable amount of expenditure and growth in the expenditure of the NHS. As someone who worked and lived in London, looking at the quality of some of these services, the case for change was quite striking. Thirty-one organisations in London were providing stroke services but none of them was meeting the international guidelines and standards for stroke services. One-third of our primary care providers were single-handed and patient satisfaction was well below the national average.

I will put inequality in health on one side, but there are inequalities in healthcare not far from this building. If you take the Underground from Westminster to Canning Town, you will find that life expectancy there is about eight years worse. Those were striking issues that had to be dealt with. The question is who deals with that important issue—the accountability for quality in improving and changing services. That was a fairly long, democratic process. It had very important principles. It had to be clinically led, locally owned and evidence-based. We made a strong pledge: if change is to happen, an alternative needs to be described to the local population and patients before such change happens.

A year later, a significant amount of public consultation ended in an agreement to drive those fairly radical changes in a city that is competitive globally, whether considering its financial services, its scientific output or its universities. That was 10 years after another review by my noble friend Lord Turnberg in the same city, trying to address the same challenges facing us back in 1996-97.

I could not agree more about accountability. I say that having had the privilege of serving in government. Ultimately, accountability has to rest with the Secretary of State. It is important to recognise that. However, I support the noble Baroness, Lady Cumberlege, to a degree. I will mention the K factor. I am not sure how many noble Lords have heard of the K factor. It was well before “The X Factor” was invented. The K factor refers to Kidderminster, where something interesting happened. There was a significant change in a little hospital, for which the whole driver was quality and improvement in facing the challenges of that local health economy. A local MP lost his seat and was replaced for a decade in the other House by a retired physician, who is no longer there. The K factor created a huge amount of sensitivity within the political world—in all political parties in this country. The noble Lord, Lord Mawhinney, was a brave man to throw out the person who came to challenge him about that reconfiguration. I was not the Secretary of State; I was the most junior Minister; I was starting on the learning curve and I wanted to be the most junior Minister in the department. I cannot remember a single week in which I was not lobbied about a change. It was never written; it was all mentioned over cups of tea.

There is a challenge. On the one hand, the Secretary of State needs to be accountable—I could not agree more about that—but at the same time the Secretary of State must have regard to evidence, if independently proved by groups of professionals, to make change happen. There must be a clear red dividing line between what I call the politics of saving votes and the politics of saving lives. There is a fine line between the two. One deals with accountability to the public purse and expenditure; one deals with accountability for quality. I have seen Secretaries of State who have had the leadership and strength to balance those two. I do not believe that such balancing could be written into legislation. It requires political leadership and political strength to make some of those tough decisions.

Change is happening all around us. Scientific discoveries have meant that life expectancy has increased by about 10 years since the creation of the NHS. We should not contaminate that with our own local agendas. It is unfortunate that even up to now our consumers—our patients—have not been empowered with the knowledge that I and other noble Lords in this House have of what is good and what is not good. Transparency is extremely important. I see evidence of that being reinforced by the Bill that I had the privilege of taking through in the past. Transparency is one way of getting the balance right between the politics of saving lives and the politics of saving votes.

[Baroness Masham of Ilton]

My Lords, I want to say only a few words. I cannot agree with the noble Baroness, Lady Cumberlege, that members of the public do not trust their Members of Parliament. Unfortunately, there have been a few problems, but surely we have moved on from there. I have just been to a meeting with about 20 Members of Parliament of all parties, who are supporting their constituents over the children’s heart surgery unit in Leeds. They trust their Members of Parliament more than they trust the people doing the review.

[Baroness Finlay of Llandaff]

My Lords, I hesitate to join in this debate, because it has been fascinating and wide ranging, and I hesitate particularly to come in after the noble Lord, Lord Darzi of Denham. However, I would like to pull out two factors which are important here.

First of all, there are inherent tensions. Fears have already been expressed by the noble Lord, Lord Davies, in particular. One of the fears is whether we will have a National Health Service or a national health insurance, which will actually be an insurance programme. Those who belong to a GP and are part of a clinical commissioning group will then access those services which that clinical commissioning group determines to commission, irrespective of who the provider is, and there will actually no longer be a National Health Service.

That is linked to autonomy, because the worry in this clause—the second anxiety—is where the boundaries of that autonomy lie. This clause does not seem to stipulate any boundaries to the autonomy at all, nor indeed, whose autonomy overrules another’s. Will it be the Commissioning Board, or the clinical commissioning groups? Where is the hierarchy? Health services are actually a spectrum. You cannot divide the actions of one from another, because they have a knock-on effect. A clear and very simple example is that delayed diagnosis in primary care results in later presentation and more expenditure in secondary care, but more importantly, in poorer outcomes for the patient, who has effectively been withheld from accessing expertise for too long.

Behind all that is a worry, because general practice per se is not an NHS employed service. GPs are individual contractors whose general medical services contract is remarkably poorly defined. It may be that the autonomy of the Commissioning Board will allow it to define very clearly what is in general medical services and what is out. The whole concept of GMS suffered hugely when the 24-hour responsibility went and out-of-hours services came in. That fragmented, to a large extent, what GPs did.

It is completely mistaken to believe that liberating the NHS depends on these clauses in the Bill. I have my name to one of the amendments to delete one of the clauses, but I do not see, from the debate that we have had today, how deleting the clauses will stop the changes to liberate the NHS that everybody has been arguing for.

Unfortunately for patients—and the NHS service is there for patients—the NHS has indeed become risk averse in a culture where the managers have become frightened, for whatever reason, of speaking out, and of taking patient-oriented decisions, and have often put pressure on clinicians to not do what they have wanted to do. I fear that behind that, too, there has been peer pressure and a mistaken view that it is unprofessional to show that you care. There has been a view that, if you step out from the local culture to do what is right for the patient, even though it may not be right for the service or the system, that can result in severe disciplinary action against an individual. We see the extreme of that with people who whistleblow and speak out for services. However, I do not think that any of that will be affected whether the autonomy clauses are in or out of the Bill.

In the past, I have argued with the noble Baroness, Lady Cumberlege, that the NHS should not be a political football and that there should be some distance between political interference and the way that the service is delivered on the ground. However, I must admit that I had never imagined that we might be discussing what could potentially be complete fragmentation of the service.

I should like to run through some of the boundaries that I think are very important in discussing this matter, and I know that we will be debating this further in relation to the role of the Secretary of State. Like others in the Committee, I commend the Minister for the way in which he handled the debate on Clause 1 and for his very positive approach to the discussions that we all need to have on these clauses at the beginning of the Bill.

Do the people with the autonomy have the skills and capabilities to exercise that autonomy, and how will those skills and capabilities be measured? How will autonomy interact, when you are trying to drive forward collaboration and integration and trying to drive performance management, with a decent level of services and consistency to improve quality if one part of the system decides, for whatever reason, that it does not want to provide a particular service or part of it? Will there be a requirement on these autonomous bodies to publish the evidence of their performance, or would such a request be deemed to be burdensome and to be impeding their autonomy?

I was particularly struck by a line in the impact assessment, which states that the reforms will create,

“a statutory basis for the NHS Commissioning Board and consortia, to protect them from interference in commissioning decisions at both a local and national level. To ensure their autonomy, both board and consortia remain solely responsible for their commissioning decisions, and neither are obligated to gain approval from local councils or health and wellbeing boards”.

In other words, the K factor would not be able to function.

In the past, I have understood the concept of earned autonomy, where the power and ability to take decisions at a more local level come when there is proof that quality has been driven up. However, I fear that these clauses will not do that, and they may just give unfettered autonomy to organisations which may be ill equipped to cope with the range of responsibilities that will suddenly be thrust upon them.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Monday 7th November 2011 Lords Chamber

Moved by

[Baroness Masham of Ilton]

20: After Clause 2, insert the following new Clause—
“The Secretary of State’s duty to ensure transparency
After section 1A of the National Health Service Act 2006 insert—“1B Duty to ensure transparency
The Secretary of State must act with a view to securing—(a) that any persons providing health services should provide, within as short a period as possible, full information to patients, their carers or representative about any incident or omission in or affecting their care which may have caused harm, or may in the future cause harm,(b) that regulations are introduced to enable the Care Quality Commission to take action against a registered person or body who fail to disclose details of such incidents as set out in those regulations.””

[Baroness Masham of Ilton]

My Lords, Amendment 20 would establish a duty of candour so that any provider of National Health Service services would have to inform a patient, or their family or next of kin if they died or lacked capacity, when something went wrong with their care or treatment that had led to harm or could cause harm.

The principle of “no decision about me without me” has been stressed. If the patient is to be central to the legislation, the amendment should be taken very seriously. I hope that your Lordships agree with me that there are always risks in the treatment of patients, but that there should be openness and transparency, with no cover-ups, when things go wrong.

There is currently no statutory requirement on providers of National Health Service services to tell a patient, or their carer or representative, when something has gone wrong during their care and treatment, while a host of compulsory standards are set out in statutory regulations. The issue is left to guidance and a non-binding requirement in the National Health Service’s constitution to have regard to the principle of openness. This has allowed cases to occur where NHS organisations have withheld such information from patients, delayed its release or, worse, actively covered it up.

Organisations concerned with patient safety have campaigned for a statutory duty of candour to rectify this situation. The Government have agreed that a duty of candour is required, but their preferred route is a contractual duty built into the standard contracts between commissioners and some providers of NHS services. Patients’ organisations do not believe that that is adequate. It would not include all NHS providers, only those with standard contracts, and would not create access to the sanctions that the CQC has at its disposal.

It is not just patients and patients’ groups who advocate a statutory duty of candour. Action Against Medical Accidents presents an impressive list of organisations and leading clinicians who support it. Just recently, at the Mid Staffordshire Hospital NHS Foundation Trust public inquiry, Sir Liam Donaldson, the former Chief Medical Officer for England and internationally renowned champion of patient safety, reiterated his long-held belief in a statutory duty of candour. When asked directly, he said that he had always personally agreed that there should be a statutory duty of candour. He explained that he favoured it because he was of the view that professionals should be encouraged to take responsibility when they have done something wrong rather than withhold instances of harm. I believe that failure to commit to a more meaningful measure in this Bill will not only fail to have the desired effect, but is a snub and an insult to patients, patients’ groups and other experts.

There is little if anything in the Bill that is genuinely drawn directly from the priorities and wishes of patients. A commitment to a statutory duty of candour certainly would be. This is an opportunity to show that patients really are being listened to. If the Government agree that the requirement to be open really is fundamental and essential, why on earth would a different approach be taken to this essential requirement, with it being left to the commissioning process? Commissioners are simply not equipped to regulate issues of this kind. If one accepts the argument that this is the appropriate way to proceed, then all of the core standards currently in the CQC regulations could simply be dealt with in the standard contract for providers.

Another key weakness in the Government's proposal is that providers’ contracts relate only to NHS contracts with trusts, PCTs and private voluntary providers of NHS services. That would not include primary care practitioners such as GPs. The Government admit in their consultation document that GPs are subject to different arrangements and that the duty could be brought in only in negotiation with their representing organisations. Very significantly, the BMA General Practitioners Committee has already stated that it would not sign up to a duty of candour, but it should not be negotiable. A duty is a duty.

The Government’s proposed contractual duty of candour would be weak even where it did apply. It simply would not cover the area where so much NHS care is undertaken—in primary care.

--- Later in debate ---

[Earl Howe]

I shall have to get back to my noble friend on whether it is specifically mentioned in the consultation. I can say that it is absolutely pertinent to the subject matter on which we are consulting. It would be extremely helpful if some of the response to the consultation covered issues such as mediation. We need to factor that in and perhaps my noble friend, with her experience, will feel able to send us her views on the subject.

[Baroness Masham of Ilton]

I thank all noble Lords who have supported, or not supported, the amendment. I say to the noble Lord, Lord Winston, that the last thing one wants is to make a difficult situation more dangerous. One wants to achieve accident prevention. It is vital that patients have trust in the doctors, nurses and other professionals who are treating them. Something has to happen now about the culture. We have to look at what happened at the Mid Staffordshire General Hospital. I sincerely hope that something will be learnt from that. I know that the Government want to improve things. I think that all doctors in the House are trusted by their patients, but there are doctors who have lost their patients’ trust. That is why I feel very strongly that whatever the Government try to do will have to be done by statute. Many doctors just follow the book and do not do what they should do.

I feel very strongly that your Lordships’ House, with all its expertise, as displayed tonight, must find a way. I sincerely hope that that will happen with the blessing of the Minister and the Government. I hope that we can work together and, before Report, get something that is acceptable to everyone, especially to patients. One must remember the patients who have suffered so badly and who are suffering today. Every time I open a newspaper, I see something about the culture of nursing, and something has to be done. It is the Government’s responsibility. We should go for a statutory obligation to protect patients. With that, I beg leave to withdraw the amendment.

Amendment 20 withdrawn.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Armstrong of Hill Top]

My Lords, it is particularly apt that I follow the speech of my noble friend because, in supporting these amendments, I wanted to relate a little of my experience as the Social Exclusion Minister who came in and tried to learn from all the other things that we had done in government—and what we had missed and needed to come back to. One of the issues that we came back to that is particularly apposite to the amendments related to people who do not fit into any category, who are the most vulnerable and who turn up at different places to try to get a service. No service treats them as an individual who has several problems.

Most of these people have mental and physical health problems and probably have an addiction. They are probably difficult to deal with and are likely to get aggressive because they know that they are not getting the response they need to help them move forward. We set up some pilot projects which I now work with as chair of the Cyrenians in the north-east—a charity which took up one of those pilots and extended it. The pilot is paid for now by Newcastle City Council and the PCT, which is much bigger than the subsequent clinical commissioning groups will be. I was not sure whether I should raise this matter in the previous group of amendments or in this one, but I do not want to keep having to rise to speak because there are issues here that the Government need to address. I chose these amendments because they relate to the Secretary of State, the national Commissioning Board, and the clinical commissioning groups.

Some things will have to cross those boundaries and be paid attention to by more than just a clinical commissioning group on its own, because the people we are talking about do not remain in one place. Sometimes there are insufficient of them in one place for a clinical commissioning group to take account of what they are going to need. We have people who go round and find the most disadvantaged and the most dispossessed—the ones who are not fitting in anywhere. We use ex-clients to go and find them. Most of the money comes from the local authority.

We persuaded the PCT to appoint a community matron with whom we work and to whom we send those people. She is then able to assess their physical and mental health needs. This has substantially reduced in-patient care, and because we have a different system we can show that fewer people end up in A&E and are then admitted to hospital. Such an arrangement can save money but is also able to provide interventions at an earlier stage—and that was what attracted me about the amendments, because they relate to prevention, diagnosis and treatment.

However, we do not work just with the homeless; we also have three projects for addicts. One of them is a 12-step, 12-week day-centre programme. The programme is fairly tough and the addicts have to be abstinent. We pay for that with money from three PCTs which were so enthusiastic about the work and what it was producing that they are now funding another centre for addiction, where we take in on a residential basis mothers and their children to seek to prevent the children going into care—because that was what was happening. We still have a small problem with the acute providers because sometimes when a family was going to come to us the providers had increased the methadone rather than helped the mothers to come off the methadone. We use the recovery method rather than methadone.

I hope that the Committee can see that these are complex cases, with complex interventions that are aimed at preventing more difficult interventions later.

I cannot see one clinical commissioning group commissioning any of this work, because it will be too expensive and there will not be a sufficient body of people to justify the work and money that it would need to put in. That is why, in the new architecture, the Government need to think how they will respond to those more complex problems, where the voluntary sector is coming up with more innovative solutions, but they need also to deal properly with what is often called dual diagnosis—I think it is often triple and quadruple diagnosis—where people have more than one problem. We need to bring the different groupings together to make sure that the needs of that individual or that family are addressed in a holistic way. It is important to recognise that more than a physical illness is brought to the table, as it were, in those cases. At least the amendment acknowledges that both physical and mental illness must be addressed.

We will get a complex architecture under the Bill, and it will be all too easy for people to fall back through the cracks within that architecture and for there not to be a holistic approach. The next set of amendments, which talk about integration, are also important, and I will come back to them, but the Government need to think again about how to address those complex issues in a way that allows the whole person in that patient to be addressed in a more effective way than we are often able to do at the moment.

[Baroness Masham of Ilton]

My Lords, I first want to ask a quick question to my noble friend Lady Hollins or the Minister. Would the words physical and mental include those people who have a drug and/or an alcohol problem? Would addiction come under “mental”? I do not want those people to fall through the net, as was said by the previous speaker.

[Lord Mackay of Clashfern]

I just wanted to say a word or two about the drafting involved in this. The noble Lord, Lord Williamson, pointed out that the opening clause, which is the foundation of the health service, states:

“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement … in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of illness”.

That is precisely the phrase that is the subject of the amendment, but it comes earlier in the Bill. I cannot believe that when the people who put the health service together in 1946 used that phrase, they did not have in mind that physical and mental health involved the idea that if there was illness, it could be either physical or mental. If we are to change an exactly similar phrase later in the Bill, consideration needs to be given as to whether we should do it at the beginning which is, after all, in many ways the most important place.

I have every sympathy with all that has been said, and I am sure that it is right that we take serious account of it. We must remember the point made by the noble Baroness, Lady Murphy, about the need for integration of treatment for mental illness along with physical illness. Anything that separates them might not be conducive to progress. I have every sympathy with the proposal.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Barker]

My Lords, the noble Baroness, Lady Pitkeathley, mentioned that she wrote a book 40 years ago. I wish I had written a book about the experiences of older people in various parts of the healthcare system. Many noble Lords talked about integration at different levels. My view is that integration just within acute hospitals will be ever more complex in future because they will be treating many people with dementia. The treatment of people with dementia in different parts of acute hospitals is a growing scandal. It poses a challenge to health professionals of all kinds, many of whom have never bothered to think about the issue of dementia. They will have to think about it for their own specialisms in future.

I have taken part in this sort of debate many times and come to the conclusion that the debate rests on a single factor: information. It is the sharing and availability of information and data about outcomes. Everything else is secondary. The previous time we had a serious discussion about this was when we discussed the proposals of the noble Lord, Lord Darzi. Some of what he achieved, in particular in improving stroke care in London, rested on the willingness and ability of people just in different parts of the NHS—let us not be too ambitious—to share information. I ask the Minister what the department has learned since the passage of the legislation of the noble Lord, Lord Darzi, about the crucial issue of sharing information about patients and their treatments, and other data on outcomes. Until we address that issue, and until health professionals feel able to maintain client confidentiality while sharing information just with other professionals, everything else will be redundant: we will never crack any of this until we get that right. Therefore, I ask the Minister how the department’s thinking was influenced in the preparation of the Bill by what the noble Lord, Lord Darzi, achieved.

[Baroness Masham of Ilton]

My Lords, integration has been said to be important and I agree. I agree also how important specialised nurses are to those with long-term conditions such as diabetes, stroke, epilepsy, Parkinson's, tuberculosis, spinal injuries, many neurological conditions, rheumatoid arthritis and many more conditions. Specialist nurses should not be cut. They are the vital link between primary and secondary care. Pain control should be included in integration. Nothing so far has been said about it. Last night, I was at a presentation about rheumatoid arthritis, and it was stressed that pain control is important.

Integration means much more with long-term conditions. Occupational therapists are employed by local authorities to adapt houses. What is going to happen in the new regime to the wheelchair service? Who is going to look after that? What about housing for those with serious disabilities? What happens now? If there is no suitable housing, patients stay in hospital far too long. Professionals should all be working together.

Health: Diabetes

Baroness Masham of Ilton Excerpts

Tuesday 1st November 2011 Lords Chamber

[Baroness Masham of Ilton]

My Lords, does the Minister agree that if people cut down on sugar and alcohol it would help? Would he agree that this is a worldwide problem?

[Earl Howe]

I agree fully with the noble Baroness that sugar and the sugars contained in alcohol are a major feature in the obesity problem and in the incidence of type 2 diabetes.

Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Tuesday 25th October 2011 Lords Chamber

I think I have spoken long enough. This has been an excellent debate and, to pick up a point made by my noble friend Lady Jolly, I am sure that members of the NHS Future Forum will consider it with great interest. My door is open to noble Lords for a continuing dialogue on these issues, not least to the noble Lord, Lord Walton, as I have already said. I hope that he and other noble Lords will feel able not to press their amendments for now on the basis of the Government’s amendment on which I am happy to provide further clarification if it is needed.

[Baroness Masham of Ilton]

My Lords, could I ask the Minister about something that I do not understand? Why in my noble friend’s amendment does it not include the training of healthcare assistants?

[Earl Howe]

I have already made clear, my Lords, that the amendment could include healthcare assistants. We have been careful to make it all-embracing so that it includes not only all health professionals, but health support workers who are not health professionals.

[Baroness Masham of Ilton]

That is the Government’s amendment. The Minister said that my noble friend’s amendment did not include them.

[Earl Howe]

As I read it, it is the noble Lord’s amendment and it is for him to speak to it, but it refers to the education and training of “the health care workforce”. That will include a lot of people, but not those who are not healthcare workers.