Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 10 months ago)
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Baroness Thornton
My Lords, I wonder if I might speak to both of the amendments that are down in the name of my noble friend, but also to take a step back from the very competent and skilled amendments and presentations by my noble friend Lord Warner and the noble Lord, Lord Patel. All these amendments also reveal what might be called a profound lack of agreement about what “integration” actually is. It seemed to me that at this point it might be useful to go and scope what people think integration means, and then perhaps ask the Minister to say which of these meanings he prefers, or which he would like to use. For example, the Royal College of Nursing is extremely worried that the combination of a maximum tariff and any qualified provider means that delivering integrated services will become increasingly difficult.
The NHS Confederation confirmed that the definitions of “integration” and “integrated care” to be used by Monitor,
“will allow different kinds of integration. For example: bringing together specialist services like trauma at one site, or integrating a person’s health and social care into one package, or offering a ‘package’ of care across a large population”.
However, it also goes on to say that:
“Though extending the tariff is the best way to ensure competition is on quality”,
in some circumstances,
“it must be recognised that getting the tariff right is a highly complicated task”.
How will this deliver integrated care?
The King's Fund states that:
“Organisational integration appears to be neither necessary nor sufficient to deliver the benefits of integrated care, notwithstanding the achievements of integrated systems such as the Veterans Health Administration”.
It goes on to talk about the Kaiser example mentioned by the noble Lord, Lord Patel. The fund also says that the Government’s reforms being centred on extending patient choice and provider competition includes encouragement to any willing provider to deliver care to patients and to complete separation of commissioning and provision with the NHS. However, the results could be a system in which there is commissioning from and choice between an “increasingly fragmented array” of competing public, private and voluntary sector providers. As a consequence, integration would be difficult to achieve.
The Nuffield Foundation says, on the tariff and incentive integrated care, that the payment by results tariff was designed primarily, as my noble friend said in his initial remarks, to support choice in competition and bring down waiting lists for elective treatment. It does not appear to be well suited to supporting integrated care for people with long-term and complex conditions.
I am sure that the noble Baroness, Lady Young, will talk to us about diabetes, but briefing to us said that people with diabetes already need at least 14 different sorts of NHS services for them to lead long and healthy lives. That seems to be a challenge.
Arthritis Care’s recent response to the Future Forum consultation on integrated services, published a couple of days ago, is very pertinent indeed. It says that:
“‘Integration’ should be broadly understood as providing patient-centred, joined-up care which meets the clinical and personal needs of the patient at every point of their pathway. Arthritis Care fully endorses and recommends National Voices’ Principles for Integrated Care as a key reference point for all discussions on this issue … There must, above all, be a firm focus on the patient. What ‘integration’ looks like is likely to vary geographically and by service, but the specific structures and arrangements matter less than whether services are successfully meeting patient needs and expectations. What it ultimately comes down to is better care for patients and smarter use of resources”.
I think that is absolutely right.
The amendments that my noble friend and I have tabled are Amendments 104A and 178A. Like others in the group, they seek to place a duty on both board and CCGs to take account of the interdependence of services and the impact that the arrangements might have on sustainability, both financial and clinical, of other services. We are concerned that the regime that has been outlined in the Bill places a risk on the coherence of those services. I ask the Minister whether that is on the risk register and what it has to say about the risks that that places on those services.
My noble friend Lord Patel of Bradford, who is unable to be here this evening—I am happy to make these remarks partly on his behalf—is concerned about the disadvantaged people in the care system who are detained under the Mental Health Act. By definition, this is a group of service users who have very little ability to exercise choice or control. In a way, I think that this is a group of people against whom the test of integration and the test of this system should be used. If it can work for this group of people, it may work for others. As they are in a highly vulnerable position, there is an absolute need for integration among health and social care providers that starts at the point of hospital admission and goes right through to the end of their aftercare in the community. The effective provision of such a care pathway requires multiple agencies to work closely together. We know that from many inquiries into suicides and homicides involving people with mental illnesses, and it is highly challenging. There is a very real concern shared by patients, carers, doctors and nurses that encouraging competition in this complex area, without checks and balances to ensure that integration is a primary driver, is very damaging indeed. I know that the noble Baroness, Lady Hollins, will refer to her amendment, and we would support that; I could not have put it better myself.
This is a very complicated and complex issue. It is the first time that we have talked about it in Committee. One thing that the Minister needs to do at this stage is to focus on what the Government mean by different forms of integration and where they will apply and how the Bill will deliver them.
Lord Clement-Jones
My Lords, the noble Baroness, Lady Thornton, has given us a very wide range of views on what integration consists of. In putting forward Amendment 135A, perhaps I can add another perspective from the point of view of specialised commissioning.
On 14 November, the Minister lifted the veil, to some extent, on how specialised commissioning would work under the Bill. The Bill brings the budget and responsibility for commissioning specialised services together under the NHS Commissioning Board. That has been welcomed by many, including the Specialised Healthcare Alliance, and it gives a real opportunity to deliver the recommendations of the Carter report of 2006. However, the expected benefits of this new system will be fully realised only if there is effective and real co-ordination between the various parties involved in the commissioning, provision and use of specialised services. However, that increases the challenge of integration under this clause, given the gap that would open up between the board at national level and providers at local level, if no steps were taken to bridge it.
There is a danger that the board’s work would become isolated from local commissioners, providers, clinicians and patients and that proper involvement, collaboration and dialogue with those key stakeholders may not occur. In particular, that could lead to pathways of care becoming disjointed, resulting in a poorer experience for patients, inefficient care and higher costs. In addition, it will be imperative to ensure that clinicians and patients are at the heart of all aspects of specialised services, including specialised commissioning. However, although the full subnational offices of the board which, as I understand it, are proposed would nominally give it a more local presence, they bear no real relationship to where the specialist providers are based and patient flows. The patient organisations within the Specialised Healthcare Alliance, therefore, see it as essential that there should be a more local presence; in their view, four clusters would be inadequate.
At col. 541 of Hansard on 14 November, the Minister was not able to be specific when he spoke about this, but as I understand it there will be around a dozen major hubs. An assurance on the parliamentary record would be very welcome. What form of substructure will there be for specialised commissioning if that is not to be the shape of it? Can he give further clarification today? Will this be delivered by the board or will it be delivered in other forms by way of senate, networks or in other forms?
Having heard from the NHS Alliance yesterday about the need for local variation, I am very attracted by Amendment 197E in the name of the noble Lord, Lord Patel, which to me seems to hit the spot in allowing that variation and giving the CCGs the final say in how they conduct themselves. That has been put to several of us by the NHS Alliance as being absolutely crucial in allowing the various innovations and initiatives to thrive at local level in the CCGs, which are already becoming an interesting and improved way of delivering healthcare.
Baroness Williams of Crosby
I would not disagree with the noble Baroness on that issue. I agree with her, but I am trying to make a different point, which is that I think we have been left with, by sheer good fortune, if you like, a much better starting point for serious integration than many other health systems. It relates also to Amendment 203A, which was tabled by the noble Baronesses, Lady Hollins and Lady Finlay, about the role of competition, about which I am rather less confident than some others.
I shall mention two other findings from the report because it is a remarkable and impressive story. On the doctor/patient relationship, there was a question about how far patients felt that they had close relations with their doctors and the ability to speak to them and to discuss their cases with them. Once again, quite remarkably, the United Kingdom comes out second to Switzerland in the 11. To take a final and very surprising finding in this study, on medical, medication or lab test errors in the past two years, the figure for the United States was 22 per cent, for the Netherlands it was 20 per cent and for the United Kingdom it was 8 per cent. It is extraordinary that we so rarely blow our own trumpet in this country, and very occasionally, we should.
Baroness Thornton
The noble Baroness, Lady Williams, is right. It is a great report, and I have read it. Would she care to join me in speculating about why the department has not made it its headline story?
Baroness Williams of Crosby
I think the answer to that had probably better come from the department rather than from me, but I am consistently surprised by the failure, not of this Government but of Governments of the United Kingdom for a long time, to say what the real achievements of the NHS have been and to recognise that outside this country it is widely regarded as perhaps one of the most outstanding health services in the world. It is worth saying that from time to time because we have 1.2 million people employed in the NHS and they deserve a great deal of the credit for having maintained a high standard in the face of very considerable financial pressures, even in the past. We have always had among the lowest expenditures per patient in the 11 highly industrialised countries, with only a couple of countries—Australia and New Zealand —spending less than we do.
There are two points to this argument. First, we are in a much better place to integrate care than we seem to think we are because we have already clearly established relations of trust between doctors and patients, and between hospitals and doctors, to an extent that other countries clearly regard as enviable. Secondly, one has to ask why we suppose that competition is a better way to deal with healthcare than are integration and collaboration. There is one area where competition is clearly crucial, and I accept that. It is in innovation and in trying out new ideas. None of us would in any way be opposed to that happening. However, I would like to put it on the record that if we are going to move in the direction of collaboration and integration, we have a very strong base on which to do it and we have the makings of something very impressive and important. The makings of that appear to be stronger in this country than in most others.
Earl Howe
My Lords, the subject of the tariff may, to an outsider, seem rather dry but I will begin by saying to the noble Lord, Lord Warner, that I agree with him that it is fundamental to having an effective and efficient health service and better care for patients. Indeed, as noble Lords have articulated so well, this group of amendments takes us to the heart of one of our running themes in Committee; namely, the integration of NHS services, both within the NHS and more widely with social care services. I agree that this is a subject of profound importance. The NHS Future Forum highlighted this while also identifying that some people had real concerns that competition in the provision of NHS services could act against the development of integrated provision.
First, what do we mean by integration? A number of noble Lords have asked that question. The duties to promote integration would cover both integration between service types—for example, between health and social care—and integration between different types of health services. Whatever the combination and however they are integrated, the practical effect should be that services are co-ordinated around the needs of the individual. This duty would apply right the way through the system. It would certainly apply to the board when exercising its functions, not just its commissioning functions.
I agree with the noble Baroness, Lady Wheeler, who made a very important point about vulnerable people in particular. For example, CCGs could comply with their duty of integration by choosing to commission services jointly with local authorities. We have always envisaged that happening. The joining-up of services could, as I say, be between different organisations or between workers within an organisation or even with advice that is given to patients about self-care and the treatment that is delivered by providing organisations. What matters is that the service is based around those patients, not the other way round.
It might be helpful if I said something about the Government’s approach to competition in the NHS. We are clear that in some circumstances competition is a force for good. Competition can create incentives for providers to innovate and improve effectiveness, as well as enabling greater choice for patients. My noble friend Lady Williams made that point very well. However, there is no single model of competition that will be right in all circumstances. Indeed, in some circumstances, competition will not be appropriate at all. Who should decide questions of this kind? Our view is that it should be for commissioners to decide whether—and if so, how—to use competition to further patients’ interests. In doing so, commissioners must act transparently and would need to consider the type of service and the needs and preferences of patients who would receive it, and be able to demonstrate the rationale for their decisions.
The noble Lord, Lord Warner, made a helpful intervention on this issue. The NHS Future Forum report stated:
“We have also heard many people saying that competition and integration are opposing forces. We believe this is a false dichotomy. Integrated care is vital, and competition can and should be used by commissioners as a powerful tool to drive this for patients”.
The Government agree. That is why the Bill set out duties for both the board and CCGs on promoting integration when commissioning services. The board, CCGs and health and well-being boards, as well as the regulators, Monitor and the CQC, will have duties to encourage integration and work across health and social care.
These changes should make it easier to deliver higher quality service pathways of patient-centred care. To help support commissioners, health and well-being boards will provide a forum to bring together people from across the health and social care sectors. Furthermore, the Bill gives the boards a specific duty to encourage health and care commissioners to work together to advance the health and well-being of the people in their areas. I might just mention that we have also asked the NHS Future Forum to consider in more detail how we can ensure that our reforms lead to better integrated services, and its conclusions on that topic will be with us shortly.
It is perfectly possible to have responsive, joined-up services working in patients’ interests and competing for their choice. For example, commissioners could decide to run a tender for a whole pathway of integrated services to be delivered by a single provider. This could encourage providers to bring forward innovative, integrated care solutions that deliver greater patient benefits and greater efficiency. Only a few weeks ago, I visited in Oldham an example of exactly that: musculoskeletal services delivered in the community, specialists from a variety of disciplines situated in one building and accessible to patients directly, and with short lines of communication. It is very popular with the clinicians and patients involved, and is achieving great results.
Of course, as the noble Baroness, Lady Hollins, pointed out, the extent to which particular services will benefit from both integration and choice will vary. Diabetes networks provide high-quality services with a high degree of integration but limited choice for patients between providers. I am sorry not to have a contribution from the noble Baroness, Lady Young, on this point, but I am sure she would agree. Certain mental health services may be another example of this. For other services, more choice may deliver better outcomes. This is why the provision in the Bill enables services specified in a particular way in the national tariff to be unbundled and paid for separately. That should happen, however, only where this is demonstrably in patients’ best interests. The comments made by the noble Baroness, Lady Hollins, in support of her Amendment 203A were very helpful in that context.
Monitor would have duties to support commissioners by enabling integration through the exercise of its functions. This reflects the fact that, as I have indicated, the driver for integration within the reformed healthcare system must come from clinical commissioners rather than from the regulator. Having said that, we are clear that, consistent with its duty to enable integration, Monitor will have an important role here. For example, the Commissioning Board would specify services for the purpose of tariff-setting, which may include bundling services together or specifying care pathways. Monitor’s role would be to devise methodologies for pricing those services.
I would not want to go further than that and make it a statutory requirement that the tariff could specify services by reference to clinical pathways, as some amendments in this group imply. That would be overly prescriptive and unnecessary. While tariffs for whole pathways of care may be appropriate in some circumstances—and I have mentioned an example or two of this—that may not always be so. For example, it might be appropriate to give patients choice about which provider provided a particular element of their care along a pathway. If the tariff enabled only a single payment for a whole pathway of care, it could deny patients that choice. Hence, we need to retain flexibility within the tariff and remain focused on outcomes.
My noble friend Lord Clement-Jones spoke with great authority about specialised services. Sir David Nicholson, as chief executive designate of the Commissioning Board, published Developing the NHS Commissioning Board in July, which set out proposals for how the board will operate and how it will be organised. It is envisaged that the initial sub-national structure will reflect the arrangements that have been made for PCTs and SHA clusters. It is envisaged that the field force, as he describes it, will be responsible for commissioning specialised services, providing the flexibility for this to be organised at different levels according to what is most appropriate for that condition. My noble friend was absolutely right to draw attention to the need for integrated pathways of care in specialised services. We believe that we are setting up the structures to deliver just that.
The noble Lord, Lord Warner, helpfully indicated that the tariff should be based on four main principles: integrated care rather than episodes of care; best practice, not average costs; a full range of services; and particularly the need to avoid costs that did not need to be built in and windfall gains. Those factors form the basis for the new tariff structure provided for by the Bill. Provisions will allow currencies based on integrated services and pathways of care by specifying bundles.
Monitor will set the costs based on a fair level of pay for providers. The board will be required to work towards the standardisation of currencies, which will enable the extension of the tariff to a wider range of services. What the noble Baroness, Lady Finlay, said about tariffs reflecting clinical complexity was absolutely right. We tabled amendments in another place to prevent providers from benefiting from cherry-picking services, including providing for a fair level of pay and a requirement for transparency in patient eligibility and selection criteria.
My noble friend Lady Tyler spoke compellingly about addressing inequalities. The Bill does not lose sight of that. The board’s duty under new Section 13M, to be inserted into the NHS Act under Clause 20, and that of clinical commissioning groups under new Section 14Y to promote integration—
Baroness Thornton
I am thinking about Monitor, what it is doing and its role as an economic regulator. Why is it the best body to decide on the price, cost and value of things?
Earl Howe
It needs to be a body that is separate from the NHS Commissioning Board. Determining what represents an appropriate price in the system is a very specialised discipline. We think that it will be helpful to have a sector-specific regulator doing that work. I would be happy to write to the noble Baroness setting out our rationale on this, but I make no pretence that this is a complex job. We do not think that it can be done very readily at the local level, although it would not be impossible. We think that local commissioners will need to be supported in this task.
Baroness Thornton
Perhaps when the Minister writes to me, he could explain why it is better that economists and regulators dictate those decisions rather than clinicians.
Earl Howe
Yes, I will. To address the point that I began just now, the board’s duty to promote integration specifically requires it to exercise its functions to ensure that services are provided in an integrated way where it considers that this would reduce inequality in outcomes. Those words are very important. That is mirrored by Monitor’s duty to enable integration.
I completely understand the intentions behind the amendments in this group. We have had a very helpful debate. We believe that the duties in the Bill, coupled with the wider levers in the system to promote integration, address the points that have been made. In the light of what I have said, I hope that the noble Lord will withdraw his amendment, although I am sure that this is a theme to which we shall return.
Health Research Authority (Establishment and Constitution) Order 2011
Baroness Thornton Excerpts(12 years, 10 months ago)
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Baroness Thornton
My Lords, I thank my noble friend Lord Turnberg for introducing the debate on this order. As noble Lords know, this order establishes the Health Research Authority to facilitate and promote research related to the health service through the research ethics committee that will check that research proposals meet ethical standards and will establish and appoint members to those committees. I think everybody would agree that the provenance of this initiative is the Academy of Medical Sciences’s review, which was published in January, and that the urgency arises from the abolition of the National Patient Safety Agency.
I will first ask a couple of questions about the National Patient Safety Agency because I would like to get some issues on the record. We are all aware of the reason that this order has been brought forward. The Minister has been completely clear with the House about the process. It needs to be there to scoop up the National Research Ethics Service. What is happening to the National Reporting and Learning Service and the National Clinical Assessment Service? The National Patient Safety Agency had three functions, and those were they. What is going to happen to the other two very important functions?
In addition the National Patient Safety Agency was responsible for commissioning and monitoring the National Confidential Enquiry into Patient Outcomes and Death, the Confidential Enquiry into Maternal and Child Health, and the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. I would like to know what will to happen to them. Where are they going to live when the National Patient Safety Agency no longer exists? Indeed, what will happen to the special programmes that the agency has conducted over the years, such as the programme into maternal and newborn babes? This is very important work, with accumulated knowledge and skilled staff, and I am concerned about that.
I agree with the noble Lord, Lord Willis, about the momentum that there is to establish an independent health research body. That was underlined by the discussions we had on the Public Bodies Bill over the future of the Human Tissue Authority and the HFEA. It would also benefit the Committee if we could be brought up to date as to where things are with them, and their future. But the outstanding question is: why can we not start now and include the new agency in the Bill, and get on with it? We will have that debate on the Floor of the House.
I have just a few more questions. How will the independence of this special health authority be guaranteed, because it is not the arm’s-length body that will ultimately be created? What costs are involved with this? Are there any extra costs for which funding will have to be found to set up this ethics committee? How will that be progressed? Finally, what will happen to the current board members of the National Patient Safety Agency led by Sir Liam Donaldson?
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 10 months ago)
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Baroness Thornton
My Lords, I rise to intervene at this stage because I think this is the only place where I can ask the Minister about an important matter concerned with the ability of the House to conduct a comprehensive consideration of the Health and Social Care Bill.
On Friday last week my honourable friend John Healey MP made available the report that he had received from the Information Commissioner. What he asked for a year ago was the risk register which would have set out the key risks with information about them and an assessment—RAG, which is the traffic lights system—of their likelihood and impact on the implementation of the Bill through the transition period. His request was initially refused and has gone to appeal. Noble Lords will realise that this information is completely pertinent to the further consideration of the Health and Social Care Bill in Committee here. The issue I seek clarification on is the very damning judgment of the Information Commissioner. He says that the Department of Health must disclose this information within 35 days of receipt of his notice. Were the Secretary of State to wait until the last possible minute, this would take us near to the very end of our Committee stage on the Bill. In the spirit of open and transparent government, I ask the Minister to make the information available to the House as soon as possible, and certainly in time for consideration of the Bill on Wednesday morning at 11 am.
The risk register is available immediately because it is a regularly updated component of good governance of any major programme, and as such can be easily accessed. In other words, it is not a difficult document to duplicate or forward to anyone. The commissioner finds that there is a very strong public interest in the disclosure of this information given the significant change to the structure of the NHS proposed by the Government. I hope that the Minister will be able to assist the House by making this information available very quickly, because I am sure he will realise its relevancy. I hope very much that I will not find myself back here on Wednesday morning asking why the release of this documentation has not been possible. I regret that, under those circumstances, I may be asking what the implications for the future consideration of the Bill might be if the House does not have access to this potentially very important information.
Baroness Williams of Crosby: I hope that the Minister will give very careful consideration to this request. I believe it will enrich our debate substantially and of course enable us to deal with issues that may change as we learn more about the effect of these statements. I plead with him on behalf of these Benches to consider whether the department could release these documents as quickly as possible.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I am grateful to the noble Baroness for giving me prior notice of her question. I am grateful too to my noble friend Lady Williams for her remarks. As I stated in my letter to Mr John Healey some time ago, I am of course conscious that there will be public interest in the contents of the risk register. However, from a government perspective, we need to balance this with the public interest in preserving the ability of officials to engage in discussions about policy options and risks without apprehension that suggested courses of action may be held up to public and media scrutiny before they have been fully developed or evaluated. We also need to balance the need for my ministerial colleagues, our officials and me to have sufficient space in which to develop our thinking, explore policy options, and weigh all this against the risk that disclosure may deter candid discussion in the future, which may in turn impact on the quality of decision-making. Those are the issues.
We are therefore currently considering the decision notice from the Information Commissioner. We have to respond by 6 December and we intend to meet that deadline. Unfortunately, I cannot go beyond that commitment today. In the mean time, it is perhaps right for me to point out that we have already made public a very considerable amount of detail about our reforms, including information on key sensitivities and risks by policy area in the impact assessments that were published in January and September this year. I refer the noble Baroness to these documents. In addition, we continue actively to engage with stakeholders, building on the work of the NHS Future Forum and listening exercise.
Baroness Finlay of Llandaff
I hope that the noble Lord, Lord Mawhinney, will be tempted by this comment. If commissioning groups do not have a duty towards education and training, there is a real danger that they will commission services that are equal in quality but undertake no education and training and are therefore of a lower price as they do not incur the expenditure of having to have facilities, and so on, to provide education and training as well. In that case, we will deny the developing workforce expertise of quality placements in many parts of Britain as local commissioning will not take account of it.
Baroness Thornton
My Lords, at the risk of stating the obvious, the massive reorganisation of the NHS proposed in the Bill, combined with the need to make £20 billion of efficiency savings, without doubt, and with common agreement across many of the professions, threatens the quality and delivery of medical training, post-graduate training and workforce planning. That is why noble Lords have been exercised about this matter from the outset.
The concern is that responsibility for medical training will be given to healthcare providers who, as I understand it, have a history of allowing service and research to dominate the agenda at the expense of education. That brings with it risks of its own. Many trusts, as other noble Lords have said, have persistently failed to support education supervisors by recognising this activity in job plans and increasingly failed to support their staff in fulfilling important national roles related to standards setting and training. I think that most noble Lords who have spoken would agree that there is an insufficient mention of the safeguards that need to be put in place to protect the quality of medical training.
The noble Lord, Lord Kakkar, and my noble friend Lord Turnberg mentioned their concern about post-graduate deaneries. Indeed, that was a major stream of work for the Future Forum. I would like to say to the noble Lord, Lord Mawhinney, that as he made his remarks about the Future Forum I wrote in my notes that I do not understand why the Department of Health seems to have franchised that particular piece of policy-making out to the Future Forum. I think that the Future Forum was right in what it said about the dangers and risks involved in abolishing the strategic health authorities and its recommendation that it was mandatory and critical that alternative arrangements should be made.
We know that post-graduate deaneries are currently pivotal in quality-managing the delivery of medical training in trusts, but the planned replacements, being answerable to and funded by healthcare provider units, may lack the impartiality required to drive the quality agenda at a time when it is most needed because of the fiscal pressures and the associated threat to education quality. We all agree that effective management of the complexities of post-graduate medical training require professional leadership skills and experience, which take many years to develop. The noble Baroness, Lady Finlay, underlined that point in her remarks. My noble friend Lord Warner put his finger immediately on the crucial aspect—how will the money be safeguarded and how will we make sure that the funding that is necessary is in the right place, is accountable in the right place, and cannot be directed into places that we would not wish it to be? How will the Government make sure that that is what happens?
I was very struck by the briefing on this matter by the Royal College of Nursing. The noble Baroness, Lady Emerton, referred to this. The Royal College of Nursing expressed its concern that Medical Education England would dominate the new organisation, HEE. I think we would all agree with the RCN that:
“It is essential that nurse educators are treated as equals and the membership of HEE is representative and not led by the medical deaneries”.
The Royal College of Nursing also believes that there is an essential role for national planning in the delivery of these important functions. I think that there are great risks in the decentralisation of education and training in terms of quality, standards and safeguards. It is unclear how the skill networks or the LETBs will be held accountable for performance issues. It is not clear what authority Health Education England will have to enforce performance issues or how its overseeing of the skills network will take place.
There are some key questions for the Minister to address. The crucial one, which was mentioned by the noble Lord, Lord Owen, who used the expression “chasm in continuity”, is how long we will have to wait for legislation. We cannot be sure that the primary legislation that will be required in this area is going to come down the track in the next year. The Minister needs to recognise that it is too risky to leave this to chance and we have to put the appropriate duties and powers in the Bill to ensure the continuity that the noble Lord, Lord Owen, mentioned. On these Benches, we are very happy to discuss how to resolve that particular issue and how to ensure that medical education is safeguarded.
This is an important group of amendments. I am slightly worried by the statement of the noble Lord, Lord Ribeiro, that this is work in progress. The problem is that there is too much work in progress and there will be too much work in progress for the next few years. This is an area where we cannot take chances. We know from previous reorganisations, for which my Administration were responsible, that we have to be absolutely sure that we are safeguarding the education and training of future generations of workers in the National Health Service.
The most reverend Primate said that continuity and certainty are vital. I agree with him. Certainty in this area is vital. I look forward to hearing the Minister’s views, but I suspect that we have not heard the last of this subject.
Earl Howe
My Lords, the Government are clear that the education, training and continuing development of the healthcare workforce are fundamental in supporting the delivery of excellent healthcare services across the NHS. I am very pleased that so many noble Lords here today share that view. It is certainly the Government’s view. I very much welcome what have been excellent comments on this subject.
Amendment 47A, tabled by the noble Lord, Lord Kakkar, seeks to insert a new clause placing a duty on the Secretary of State to establish a body called Health Education England. Similarly, Amendment 47B, tabled by the noble Lord, Lord Warner, seeks to place a duty on the Secretary of State to “provide or secure” an education and training system and to establish Health Education England to take responsibility for these education and training functions. Amendment 47B also specifies that the budget for education and training should be calculated on the basis of total health service expenditure and,
“should be no less than the level of expenditure on education and training at the time of Royal Assent”.
The Government recognise the importance of having an effective education and training system for the healthcare workforce. The NHS invests approximately £4.9 billion centrally in the education and training of health professionals. It is vital that there is a robust system in place to manage this investment wisely, with clear lines of accountability to Parliament. I would point out to the most reverend Primate that that is exactly why we tabled Amendment 43 which, as the Committee will recall, we debated in our first session. The Committee has already approved that amendment, which is now in the Bill and which says that there is a duty on the Secretary of State to exercise his,
“functions … so as to secure … an effective”,
education and training system. It is perhaps worth my flagging up that that amendment has received a positive response from the British Medical Association, which, in the current circumstances, is a rather remarkable fact. I reiterate that it is designed to ensure that the healthcare workforce has the right skills, behaviours and training to deliver a world-class health service. But we want to put flesh on the bones here. We recognise the need to do that and I therefore undertake that we will publish detailed proposals for the education and training system ahead of the Bill’s Report stage where we will describe how this duty will be enacted in practice. However, there are parts of our plans that I can set out now.
It is vital that we ensure a carefully managed transition into the new system and protect staff and students currently undertaking training. We are taking a number of actions in developing the new system to achieve this that I would like to highlight. The Future Forum recommended that the establishment of Health Education England should be expedited to provide leadership and stability in the system. We agree and it is heartening to see that many noble Lords support this course of action. We have appointed a senior responsible officer to drive this forward and inject pace into the design and development of Health Education England.
To respond to the noble Lord, Lord Owen, while I do not share in any way his analysis of the future prospects of the next health Bill, he was right on one matter: we plan to establish Health Education England as a special health authority in 2012. This will enable it to take on some of its functions from October 2012 and be ready to be fully operational from April 2013. There is not and there will not be the chasm that the noble Lord referred to. Noble Lords will have a chance to scrutinise the establishment order and regulations to set up Health Education England as a special health authority when they are laid before Parliament in early summer 2012. Lest there is any doubt on the matter, I reassure the Committee that it is our intention that Health Education England should form excellent partnerships with a full range of bodies involved in the planning, commissioning, provision and quality assurance of education and training.
However, I can say in particular to the noble Lords, Lord Warner and Lord Kakkar, that Health Education England will provide national leadership for education and training, overseeing workforce planning and the commissioning and delivery of education and training across the system. We have been clear about its accountability to the Secretary of State to ensure that, at national level, there are sufficient health professionals with the right skills, education and training to meet future healthcare needs. Providers of NHS services will be expected to meet the obligations set out in the NHS constitution, including the right of recipients of NHS healthcare to be treated with a professional standard of care by appropriately qualified and experienced staff. Health Education England will hold responsibility for the management of the NHS multi-professional education and training budget, or MPET. To ensure that this budget is sufficient to support the development of the future NHS workforce, equipped with the right skills, our intention is to base the size of this budget on the needs of the service, supported by robust analysis of local workforce and education and training plans.
The question of postgraduate deaneries was raised in particular by the noble Lord, Lord Turnberg. The SHAs will continue to be accountable for postgraduate deaneries until 31 March 2013. Securing continuity for the work of the deaneries will be a key part of a safe transition. It is expected that deans and many of their staff will continue to take forward the work of deaneries with an emphasis on a new, multi-professional approach in the new system architecture.
To pick up one point made by the noble Lords, Lord Kakkar and Lord Turnberg, we also want to see stronger partnership working between postgraduate deaneries and universities. Further work is under way on the detail of these arrangements, with the right accountabilities for the quality of education and training lying with Health Education England and the professional regulators.
I was asked by the noble Lord, Lord Kakkar, about ring-fenced funding. As he knows, the MPET budget currently funds the education and training of the healthcare workforce and it is the responsibility of SHAs to invest the budget appropriately. We have proposed transparent systems to ensure that organisations receiving MPET funding under the future arrangements are held to account for using it for the education and training of the workforce.
The noble Lord also asked whether there will be a requirement to engage fully with academics. I partly covered that point but I emphasise that the new system presents a golden opportunity to build stronger links between the NHS and the academic health sector and to strengthen the educational foundation for research and innovation. Health Education England will ensure that research capability and capacity is maintained and it will forge strong partnerships with academia. Health Education England will work with the royal colleges, the Academy of Medical Sciences, regulators, universities and service providers to ensure that the needs of healthcare delivery are reflected in developing curricula in the context of the statutory responsibility of regulators.
The noble Lord, Lord Turnberg, asked me about standards. I reassure him that standard-setting will be the role of Health Education England at a national level, and this is in addition to the important role that the professional regulators play in this area.
However, despite the progress that we have made, a lot more work has to be done to get these important arrangements right. In my view, that is why it is important that we do not try to amend the Bill in a way that later turns out not to be appropriate. The Future Forum is now leading a second phase of engagement on education and training, focusing particularly on the need for greater flexibility in training, variation in standards and quality, and the need for stronger partnership working between education, academia and service providers. I take this opportunity to mention that tomorrow I am hosting a seminar with Professor Steve Field, chair of the forum, and I welcome your Lordships’ involvement.
I appreciate that the service is waiting for detailed plans for the education and training system to be finalised and published, and I have two promises that I can make on this. The first is the one to which I have already alluded. Once the Future Forum has concluded its work, and prior to Report, the Government will publish more detail on the changes to the workforce planning, education and training system. That, incidentally, will include more detail on postgraduate deaneries. Secondly, it is likely that primary legislation will be required to support the continuing development of the education and training system, including establishing Health Education England as a non-departmental public body, but we think it is important to spend time to make sure that these arrangements are correct rather than legislate at this stage. However, I can tell the Committee that we intend to publish draft clauses on education and training for pre-legislative scrutiny in the second Session in the same way as on research. This approach will enable us to ensure that the legislation is fit for purpose and that it allows additional opportunities for parliamentary scrutiny of the legislation. I hope that this undertaking will be welcome to noble Lords and will indicate the Government’s strong desire to provide maximum clarity on these matters at an early stage. Therefore, I hope that noble Lords will feel able not to press those particular amendments.
The noble Lord, Lord Kakkar, and the noble Baroness, Lady Finlay, have tabled remarkably similar amendments—Amendments 133 and 199A respectively—also on the subject of education and training. The noble Lord, Lord Kakkar, wishes to impose a duty on the NHS Commissioning Board to,
“promote education and training of the health care workforce”.
The noble Baroness, Lady Finlay, wishes to introduce a similar duty on clinical commissioning groups. As I have indicated, the Government’s intention is to delegate responsibility for education and training to healthcare providers. They are at the front line of service delivery and are best placed to understand how the workforce needs to develop and respond to the needs of patients.
Responsibility for education and training is of great importance to employers and the various professional bodies that the noble Lord, Lord Kakkar, mentions in his amendment, but commissioners will also have a role. I agree entirely that education and training needs to be effectively linked with the wider system. I am aware of concerns voiced by the royal colleges and professional bodies on precisely that matter. I wish to reassure the Committee that I recognise the vital interrelationship between education and training, and commissioning decisions. That is exactly why national and local education and training plans will need to respond to the strategic commissioning intentions set out by the board and clinical commissioning groups.
Similarly, in commissioning decisions there will be a need to consider the implications for education and training—it works both ways. The NHS Commissioning Board has to work closely with Health Education England and it will be a mutually supportive relationship. Indeed, this will be a prime example of the co-operation duties that will apply to the board and to other NHS bodies. Commissioners must also promote and have regard to the NHS constitution, which of course contains the pledges that I have already referred to.
I do not intend to speak for very much longer but there are a couple of points that I ought to cover. A number of noble Lords pointed to the lack of medical school involvement in the set-up of local arrangements. I need to be clear about this: the new arrangements are underpinned by the desire to strengthen both the provider voice at the local level and the role of professionals and education providers. We envisage that one of the functions of local bodies will be to ensure strong partnerships with universities and medical schools. Providers of services will have to work in partnership; they cannot just sit alone and ignore everybody else. The form of the local provider-led arrangements is still being developed. More details will be available prior to Report, but I have stressed the links that we envisage with academic colleges at a local level.
I hope that I have indicated that, contrary to the statement from the noble Lord, Lord Warner, that within the modernisation agenda we somehow forgot about education and training, this is not at all the case. As I mentioned when we debated this before, this has been an active programme of work ever since the general election. It is a complex issue and we want to get it right. My noble friends Lord Ribeiro and Lord Mawhinney were spot on in their judgment on this. We are taking action now. We are not losing time over this.
To sum up, we have made provision for education and training in the Bill. We will publish our detailed proposals before Report and we will publish draft clauses on education and training for pre-legislative scrutiny in the second Session. With those assurances, I hope that the noble Lord will feel able to withdraw his amendment.
NHS: Hinchingbrooke Hospital
Baroness Thornton Excerpts(12 years, 10 months ago)
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Baroness Thornton
To ask Her Majesty’s Government what profit margin the contract between the Department of Health and Circle Health Ltd specifies for the running of Hinchingbrooke Hospital announced today.
Baroness Thornton
My Lords, I beg leave to ask a Question of which I have given private notice.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we do not know Circle's profit margin. I can, however, explain the basis on which Circle will be paid. Circle will effectively receive a success fee for bringing the trust into surplus and keeping it there. If Circle does not make the trust operate at a surplus, it will not receive any fee and it will lose money on the transaction. Circle will receive all surpluses up to the first £2 million of any year's surplus, and then a share of surpluses of more than £2 million to keep it incentivised to generate the further surpluses that the trust will retain.
Baroness Thornton
I thank the noble Earl for that comprehensive explanation of taxpayers’ money. The issues I want to address are ones of transparency in process and criteria. Will the Minister provide details—I do not expect them this morning—of the meetings and minutes of meetings between Ministers, civil servants and Circle Health Ltd, and meetings with Mark Simmonds, MP, who is a paid adviser to Circle and a former member of the Conservative Front Bench? How will the Department of Health know whether this is a good deal? I can see how we will know whether Circle has made a profit or not. What is the objective here? Will a clinical as well as a financial audit be built in, and will those results be made public? In other words, how will the taxpayer know whether this is a good deal?
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.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 10 months ago)
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Baroness Cumberlege
I am very grateful to the noble Baroness, Lady Williams, who has put the matter eloquently and correctly. I am very much in favour of my noble friend’s wish to try to get some negotiation. As the noble Baroness said, many of us feel that that is the way forward.
This is a difficult issue. It is trying to get the balance right between, on the one hand, the accountability and responsibilities of the Secretary of State, and, on the other, the freedom of those managing the service to do so without interference. Many of us are trying to achieve that balance.
I should like to refer to the letter that the noble Lord, Lord Warner, mentioned because I want to get it into Hansard. My noble friend urges us to consider three key factors in his letter and I quote the second one. He said that,
“we fulfil the policy intention that the Secretary of State should not be involved in the day to day operations of the NHS. Ministers should set the overall strategy, hold national arms-length bodies rigorously to account for their performance, and have the requisite power to intervene if the system is not operating effectively”.
Those are my views entirely.
I am now going to say something that I know is extremely unpopular in the Palace of Westminster: politicians are really neither loved nor trusted by the public to a great extent and I have to say also that they are seldom admired by those working in the NHS. There have been too many decisions that have been taken without any evidence to support them, resulting in very long delays in things such as reconfigurations. Those delays have jeopardised patient care. Reversals have been made at the last minute, ignoring well founded clinical advice from clinicians saying to us that the service is unsafe, yet the position of an inadequate, unsafe hospital or service continues because of political interference. That undermines the confidence of managers to manage.
I want to mention Kevin Barron, who is the Labour MP for Rother Valley—
Baroness Thornton
I do apologise to the noble Baroness, but I absolutely cannot resist asking her whether she thinks that the public love quangos more or less than politicians, since the intention is to put our National Health Service in the hands of an extremely large quango. So is it Andrew Lansley or David Nicholson?
Baroness Cumberlege
My Lords, I have not seen any evidence from MORI or any other polling organisation that has put that question to the public, so it is left in the air. I have seen the MORI poll that very recently showed that 88 per cent of people who were questioned said that doctors were the most trusted profession to tell the truth, whereas only 14 per cent thought that the truth was told by politicians. I think that is really sad—sad for democracy and sad when it comes to trying to build the confidence of people who are in charge of the National Health Service.
One real problem, which exists even if the same party is in power for a length of time, is a lack of a consistency of leadership. The Secretaries of State are here one minute and gone the next. Really successful organisations—I am thinking of schools, hospitals, companies—benefit from continuity in leadership. I read the other day that Sir Alex Ferguson has been in charge of Manchester United for 25 years. If we had had that inspiring leadership for a real length of time, I wonder what difference it might have made to the NHS. Since 1997 we have had seven Secretaries of State. Frank Dobson was in charge for 17 months. Alan Milburn, the longest serving Secretary of State, served for four and a half years and some might think that he was the most successful. At least he had time to draw up the NHS Plan, which made an impact on the service and he had time partially to implement it. John Reid—now the noble Lord, Lord Reid—Patricia Hewitt and Alan Johnson all served two years, and Andy Burnham less than a year.
Those of us who have served in government know, as Ministers, that you take up your post with enormous enthusiasm and unrealistic aspirations. You want to do things. Above all, you want to improve the NHS. You believe that you are in charge and that you can set policy. But, no, the first thing that happens is that you inherit the policies of your predecessor, which are not your policies that you know and love. They are not yours, but you do your very best to implement them. Then you have a chance to set your own policy but, before you have had time to implement it, you are off again. In the mean time, you are expected to make some very courageous, unpopular decisions about institutions that you may know very little about and about people whom you have rarely met. So how do you exercise judgment and build relationships when you are there for such a very short time, possibly just two years? That contributes to an NHS that gets confused and fed up and is mistrustful of its masters.
Baroness Thornton
I am sorry to interrupt the noble Baroness. I am listening carefully to her because she has great experience. Is she not talking about transferring the setting of targets, projects or whatever from the responsibility of Andrew Lansley as Secretary of State to Sir David Nicholson as head of the NHS Commissioning Board? If the problem, as she sees it, is the setting of too many targets and projects—although I do not know what that has to do with Clause 4— I am not sure what safeguards there are to stop that from happening anyway.
Baroness Murphy
Perhaps I may respond. It is a direct result of that chain of command that goes from the Secretary of State, to Ministers, to Sir David Nicholson and to everyone inside the Department of Health. It is a direct result of the impact on the management system.
Baroness Thornton
My point to the noble Baroness is that I do not believe that it will change.
Baroness Murphy
I am sorry but I think it is the direct result of Clause 4. I shall continue my theme, if I may.
It is vital that we do not get lost in the impact of what the setting of targets does to the management structure. If the Government set goals and we have key performance targets, at the moment hospitals, services and local commissioners have no responsibility for their strategic direction or goals. I talk as someone who has been a strategic health authority chairman and I know exactly what micromanagement of health authorities and trusts means. I will come on to foundation trusts and why it has not worked entirely with them.
The targets are passed down through commissioning organisations without any understanding of the capacity to deliver. No sooner has one directive been issued than another set of politically interesting goals arrives as an additional directive—without removing the first. All this has no connection to how healthcare is delivered at the front line to patients and it creates a sort of parallel universe of management that never really touches operational patient care.
In mental health services, the care programme approach was an absolutely classic example of something that was implemented without any thought being given to how the service was really delivered and it therefore took 10 years to put in place. In successful businesses, managers focus their time and attention on operational realities—on how to help staff solve problems and improve day-to-day operational performance. This is the front-line machine that implements management decisions. However, in the NHS, managers are not interested in the front line. At every level, they focus upwards to the next level and, as a health authority chairman, I was pretty horrified to find that at least 25 per cent to 30 per cent of my CEO’s time was taken up at meetings and other activities, to which we referred as “feeding the beast” of the Department of Health or of Ministers. I understand that in many trusts some 50 per cent of this time is taken up with managing the centre.
The preoccupation with satisfying the centre leaves front-line staff—unsupported and often demoralised—to cope with broken systems, unless they have a substitute in a charismatic clinician who leads them instead. That is why high-flying specialist units work exceptionally well and why everyday bog-standard services are often a disgrace. That is why meeting targets is often a game. Data are manipulated and money is diverted from one front line to another to achieve a target temporarily until the Minister’s attention is diverted to the next enthusiasm.
The four-hour waiting time target at A&E is a very good example. This was an admirable target—some would say it was not tough enough—but it was achieved only with horrendous diversion of funds from other front-line areas and a reordering of clinical priorities, but with no real change in hospital behaviours or any understanding by staff as to why they were doing it. Metrics for the purpose of compliance are almost always different from those that one would wish to collect to understand and improve patient care pathways. A&E services targets were achieved at the cost of diverting increasing numbers of patients into medical assessment units and we have ended up with an 11.8 per cent increase in emergency admissions and vast numbers of patents being admitted from A&E who would not previously have been admitted—all in the interests of reducing a particular target, but without any fundamental change in the way that hospitals are run.
That is what this autonomy clause is meant to assist—we seem to me to be forgetting that. We must have organisations within the health service which set their own objectives, manage them properly and start concentrating on the front line of patient care. There is ample accountability in the Bill to ensure this along with the proper regulatory system. I know that autonomy can lead to machismo behaviour and that it can go wrong. We do need tough regulation, but we need tough light-touch regulation, with a mandate that has been agreed beforehand. With that, we will see that this autonomy clause is utterly vital to the way that we should be developing the health service.
Baroness Wall of New Barnet
My Lords, I had not intended to participate in the debate because I did not arrive until it had started, but I have been here a long time now and want to share with people how it feels on the ground. What the noble Baroness, Lady Cumberlege, said is absolutely true. I do not envy the noble Earl because I think that the analysis that the noble Lord, Lord Darzi, gave is exactly how it feels. There is that dilemma. The noble Baroness congratulated us on now having a decision from the Secretary of State. We do, but the decision is bound up in another clause, which brings about another kind of action that we must take. It has not removed anything; it has just given us another dilemma and delay in what we must do.
I say to the noble Lord, Lord Mawhinney, that I only wish that everybody in his position did what he did. Though I have five years of experience, I am not medically qualified; I am just somebody who cares about the people that I have responsibility for as the chair. My experience from those years was often of political interference. I ask noble Lords to forgive me for being emotive about this, but it is absolutely true. We had consultation for many years, authorised by the independent review body. The Secretary of State at the time, Alan Johnson, said, “Whatever the review body says, we will go with it”. That was perfect. Then we had a hold-up and a change of government. The new Secretary of State, Andrew Lansley, then came to our trust and said, “This isn’t going to happen. We want people on the ground to be able to say, ‘Yes, if I want this service, I can have it here, and, yes, if I want my baby here, I can have the baby here’”. Both those services were questionable in terms of their clinical reliability. They were not unsafe, because we would not be doing it otherwise, but certainly questionable. And so we started all over again.
A year later, we have gone through not a consultation but the four tests, where the clinical members of the local authority team went through the same process as was involved in the previous consultation—is it clinically safe or is it not? It took a year or so for the Secretary of State to come back with another response to that. That was another stall until, just a matter of weeks ago, we received a letter from the Secretary of State addressed to the local authority—because it had put the case to him—which said, “Yes, I think that the BEH strategy should go ahead, but, actually, I think that you should consider other things as well”. Those things cut right through the BEH strategy.
Local MPs are very open about the fact that they have interceded and expressed their views. They are very proud to say, “I’ve spoken to Andrew about this and I’m not going to have that”. This goes on all the time—I am not sure that this is inappropriate language to use in this House I ask your Lordships to forgive me if I am saying things that I should not; I am just trying to tell noble Lords what it feels like as somebody who is working in the health service on behalf of patients. That is how it feels. I do not know whether political interference by the Secretary of State, as I see it, can be removed by having the national Commissioning Board make the decisions, because my view would be that MPs will always go to whoever can make an intervention in Parliament. That goes for MPs from all parties; it is not about the present Government.
I do not envy the noble Earl in the decisions that he has to make about this, but the view of the noble Lord, Lord Darzi, is very much attuned to what I see in reality. There is a dilemma; there is that interference. But, on the other hand, there are major decisions that have to be made that can be made only by the Secretary of State in the sense of his or her national perspective. I have no words of wisdom, but I have a lot of feelings. Please can we get this right?
Baroness Thornton
My Lords, I have added my name to those opposing Clause 4. We have had a very good debate, to which my noble friends Lord Darzi and Lady Wall have brought an element of reality. However, their remarks do not take us from the point of wondering whether this is the right clause in terms of autonomy. They have both succeeded in pointing to the problem that exists, and I am not sure that the Bill solves it.
Autonomy, from the ancient Greek, means,
“one who gives oneself their own law … In medicine, respect for the autonomy of patients is an important goal … though it can conflict with a competing ethical principle, namely beneficence”.
It might be thought that a health and social care Bill would reflect the second part of the above definition—culled, I have to say, from Wikipedia—given the concern for the interests and dignity of patients. However, such is not the case. Clause 4 seeks to insert a new section into the National Health Service Act 2006 under the rubric: “The Secretary of State’s duty as to promoting autonomy”. The clause requires the Secretary of State when exercising functions in relation to the health service, so far they are consistent with the interests of the health service—not, it may be noted, in the interests of patients—to act with a view to securing certain things that the clause then goes on to list.
I had a discussion about this clause with the noble Baroness, Lady Murphy, yesterday or the day before. I say to her that the fact that we both seem to have completely different views of what this clause seeks to do actually tells us something about it and its drafting. We totally disagree about what we think this clause seeks to achieve. That alone should make us think that perhaps we need to go back to look at this clause.
Clause 4 places upon the Secretary of State a duty to promote autonomy, as we have said. We feel that this clause is part of the general shift of the Bill to denude the responsibilities of the Secretary of State, because—viewed alongside of the removal of the Secretary of State’s current powers under Section 8 of the 2006 Act to give directions to PCTs and SHAs—it significantly dilutes the Secretary of State’s powers to influence the provision of health services. Independent legal advice from Stephen Cragg QC, for example, commented on the consequences of Clause 4:
“If the Secretary of State attempts to use his or her powers to impose requirements on commissioning consortia, for example, then there could well be a judicial review challenge from a consortium which opposed the requirements on the basis that they infringed the principle of autonomy in the new Section 1C and could not be justified as necessary or essential. This approach replaces the, more or less, unfettered power that the Secretary of State has to make directions currently to be found in Section 8 of the NHS Act 2006 with a duty not to interfere unless essential to do so”.
The emphasis on autonomy links to the change in the role of the Secretary of State, as was explained wonderfully and adequately by the noble Lord, Lord Marks.
Since the founding of the NHS, the Secretary of State has always had powers of direction and intervention over NHS bodies, which enabled him or her to control the system. While some providers such as foundation trusts could be given earned autonomy—as was referred to by other noble Lords—the Secretary of State retained control through commissioning and the nature of contracts with foundation trusts.
This is a very important clause, and nothing that has been said in this debate makes me think that I was wrong to put my name on behalf of these Benches to the Question relating to clause standing part of the Bill. I appreciate that we will be having a broad discussion of these matters along with Clauses 10 and 1 but, unless the Minister has something very significant to say about how he sees this clause evolving, I absolutely have to agree with the noble Lord, Lord Marks, that this can come out of the Bill because of all the other powers that remain in it, which we will look at in due course.
Finally, I thank the Minister for his letter to me, which was circulated around the House. I thank him and his staff and the noble Baroness, Lady Williams, and her colleagues for the fact that we are finding a way forward to having a discussion which I hope and trust will bear fruit.
Lord Walton of Detchant
My Lords, I am glad that the noble Lord, Lord Willis, has raised this extremely important matter. Research misconduct is rare, but it happens. Several years ago, there were a number of quite cogent reports produced by Dr Frank Wells of the British Medical Association, Dr Stephen Lock, who was the editor of the British Medical Journal and his successor, Dr Richard Smith, which actually demonstrated that in a number of rare cases research results had been fabricated. This issue has been highlighted by a number of similar events in the United States and elsewhere. The universities, the research councils and a number of other bodies have looked at this matter and made a number of recommendations. I am not at all certain that this is the right place in this Bill for this issue to be raised, but the question needs further consideration by the Government—for instance, to decide whether this important issue should be in any way part of the remit of the proposed new medical research agency.
Baroness Thornton
The noble Lord raised a very interesting and important point, but I do not intend to delay the House by expanding on it.
Earl Howe
My Lords, Amendment 41A, tabled by my noble friend Lord Willis, will require the Secretary of State to set up a system to ensure that research is conducted properly and ethically and that there are sanctions in place in cases of misconduct. Let me say straight away that I am in agreement with the intention of my noble friend in tabling this amendment; the proper conduct of research is very important, just as proper conduct is critical in clinical practice. All my noble friend’s comments on that theme were extremely pertinent.
Looking at the amendment as it is worded, I can assure my noble friend that there are already systems in place to ensure that research is conducted ethically. Research, as he knows, cannot proceed without ethics committee approval. I realise that this is a probing amendment, but equally, as it is worded, it overlooks an important element in the current system of accountability, because it would risk undermining the clear responsibility in research, as in clinical practice, that employers have for the conduct of their employees and that professional councils have in regulating their members. Both can impose sanctions on researchers if their conduct is found to be inappropriate. I do not see that it is the responsibility of the Secretary of State to impose sanctions on clinical professionals, and it should not be his responsibility to do so for researchers. In the future, the Health Research Authority will continue the good work of the National Research Ethics Service, working with others to prevent misconduct by ensuring that the ethics of research have independently reviewed by research ethics committees.
This evening, I am able to give a new commitment to my noble friend. I am happy to tell him that we intend to publish the draft clauses on research for pre-legislative scrutiny in the second Session of this Parliament. That scrutiny will enable my noble friend and other noble Lords to comment on the detail of our proposals for the Health Research Authority and, in turn, enable us to ensure that future legislation is fit for purpose. I hope my noble friend will welcome that pledge.
If I may, I will cover the question my noble friend asked me about the concordat in a letter to him following this debate. I hope I have reassured him that there are systems in place to ensure good conduct in research. Nevertheless, his points are well made and I shall reflect fully upon them. I can only say at the moment that the Health Research Authority intends to build on these systems. In the light of what I said, I hope my noble friend will feel able to withdraw his amendment.
Baroness Wheeler
“The Secretary of State’s duty as to national workforce structures
After section 1D of the National Health Service Act 2006, insert—“1E Secretary of State’s duty as to national workforce structures
The Secretary of State has a duty to maintain a national pay and bargaining system for healthcare staff, to cover those staff providing NHS services and services for the improvement of public health.””
Hospitals and Care Homes: Hydration
Baroness Thornton Excerpts(12 years, 10 months ago)
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Earl Howe
My Lords, since the publication of the CQC summary inspection report, my right honourable friend the Secretary of State has requested a further 500 inspections of dignity and nutrition in care homes and 50 further visits to hospitals, which will start in the new year.
Baroness Thornton
My Lords, I was disturbed by the Minister’s first response to this Question because it sounded as if the Government are washing their hands of a hydration policy. Can the Minister say whether that is indeed the case? It seems to me vital that the Government should be providing leadership in ensuring that, at every level of health and social care, they are following through on the policies that are in existence and that have been disseminated over many years, and that they should not say that this is a matter for the policy of individual hospitals.
Earl Howe
No, my Lords, the Government are very far from washing their hands of this extremely important issue. As the noble Baroness will know, the new registration system under the Health and Social Care Act 2008 covers all providers of health and adult social care regulated activities. There is an outcome in that set of regulations which requires providers to adhere to the highest standards of nutrition and hydration. It is because of that that my right honourable friend has been so concerned to instigate these unannounced inspections by the CQC.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 10 months ago)
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The Countess of Mar
My Lords, I support this amendment. If ever there was a case against inequality of treatment, it is for people with ME. I am saying ME rather than ME-CFS because that is too long. The postcode lottery for people with ME has been highlighted in two inquiries by the All-Party Parliamentary Group for ME over the last five years. People are constantly writing to Ministers complaining; the noble Earl himself knows, because I keep complaining about it. In 2002, the Chief Medical Officer announced an award of £8.5 million to set up specialist centres for ME. These have just fizzled out. Once the £8.5 million ring-fence money had been spent, the first thing that was cut was services for people with ME. The trouble is, they are blighted with the distinction of being yuppie flu sufferers—people who swing the lead. They are not: this is more and more often now being proven to be a physical disease with mental side effects, as cancer and MS and a whole lot of other chronic diseases are. It is time the inequality of treatment for people with ME-CFS was obliterated.
Perhaps the worst inequality is in services for children. There are virtually no ME services for children in the UK, particularly children who are bed-bound and housebound, and this is a disgrace on our society. These children—very often high-achieving children—are suddenly struck down; they can no longer have social relationships because they are too ill or too tired to cope; they cannot continue with their education and yet there is no medical attention for them. I am sorry—I am suffering myself at the moment, so I am not being very comprehensive in what I am saying—but it does need to be said that these people need to be looked after. I support the amendment in the name of the noble Lord, Lord Warner.
Baroness Thornton
Eight noble Lords have amendments down in this group about inequalities. Many of them seek to do the same kinds of thing. I intend to speak to Amendments 22, 25A, 27A—I mention in passing that my noble friend Lord Beecham has his name against Amendment 29—31, 32, 68A, 68B, 69B and 120A.
I will quickly run through these amendments. Amendments 21, 22, 23 and 25 strengthen the duty on the Secretary of State to reduce inequalities in the health service. The Bill currently requires the Secretary of State simply to “have regard to” this need. Amendment 21 says “is required”—the strongest of these amendments—followed by Amendment 22 with “seek”, and Amendment 23 with “act with a view”. Amendment 25A says it is the Secretary of State’s duty to reduce inequalities between people and “between communities” in England. I will return to that in a moment. In Amendment 27A, we on this side are seeking to add detail to the inequalities that the Secretary of State has a duty to reduce. We argue that,
“inequalities in health status, outcomes and experience, … the outcomes achieved … by … those services”,
and,
“ability to access such services”,
must be taken into consideration. My noble friend Lord Beecham has added his name to the amendment in the name of the noble Lord, Lord Rooker. It adds a qualifier to the duty to reduce inequalities:
“to ensure that greater patient choice is not accorded a higher priority than tackling health inequalities”.
Amendment 31 says that, in an instance of a conflict of duties on commissioners or regulators, the duty to reduce inequalities is paramount. Amendment 32 says that, as part of this duty, the Secretary of State must publish comprehensive, publicly available data on the extent to which inequalities have been reduced across the NHS. Amendment 68A says that the duties of the NHS Commissioning Board as to the improvement of public health should be extended to cover the duty to reduce health inequalities. Amendment 68B concerns each local authority having to take steps to reduce health inequalities between people and between communities. Amendment 69B again relates to public health: the Secretary of State must also seek to reduce health inequalities between people and communities. Finally, Amendments 120A, 190A and 190B are about the national health Commissioning Board having a duty to reduce inequalities in health status. Noble Lords will get the theme that is running through here.
Clause 3 places a duty on the Secretary of State to have regard to health inequalities, and that is an aim and aspiration that we would, of course, support. However, the problem with this clause is that that duty is not capable of effective fulfilment. For example, public health analysis and needs assessment require comprehensive area-based population data. This is the basis of the current health system mechanisms for resource allocation and for the commissioning of public health measures designed to prevent or ameliorate systematic inequalities both between groups of residents in an area and across and among areas, with respect to the access of resources, services, and their use and outcomes. Census estimates, adjusted for factors such as age and deprivation, are used as the denominator for the population in such analyses. Our problem with this Bill is—and I would be grateful if the Minister would address this issue—that public health analysis will not be able to be carried out in this way in future because of the proposed shift from area-based PCTs to GP-listed clinical commissioning group structures. Therefore, denominators which allow GP registrations to promote reductions in inequalities might be inherently problematic because of continuous enrolment and disenrolment, which affect accuracy, as does patient selection. The denominator will not be representative of all the people in a geographically bounded area. Without a geographic population focus, it will not be possible to monitor inequalities. I realise that part of these issues is also addressed in amendments needed to Clauses 7 and 10, but they are points which we would like to have addressed here.
Amendments 120A and 190A address the argument that local authorities and clinical commissioning groups should have a duty to reduce inequalities not only in their areas, but also in England. We think this makes sense because, for example, somewhere like Lambeth or Bradford—where I come from—could make huge improvements within area inequalities but still lag miles behind the rest of the country. Amendment 25A calls on the Secretary of State to act to reduce inequalities between people and communities. The word “communities” is important in this context because it speaks to local authorities. Given that public health inequalities are going to be in their jurisdiction, it seems that this is an important matter. Therefore, we would like the Bill to address within-area geographical inequality because it refers to inequalities between groups and communities of groups, not just an individual’s access and receipt of services. We believe that the Government should set out how they intend to use non-legislative levers and incentives to translate the duties in the Bill into practical action and how the NHS will be accountable for progress in reducing health inequalities. Our Amendments 31 and 32 tie in with this. We think we need to understand where those levers will exist, how they will be used and how the Government will measure inequalities.
As noble Lords will realise, Amendments 120B and 190B also arise directly out of the Equality Act and concern individuals and discrimination in the receipt of services. I know the noble Baroness, Lady Greengross, will address Amendment 33, which is tabled in her name. We believe that Amendment 120B addresses the general duties of the national Commissioning Board, which are vital parts of the picture. If the duties to deliver and secure provision of the health service are split between the Secretary of State, the board and CCGs, corresponding duties to reduce inequalities must also be exercised by all three, and these amendments seek to put that in the Bill.
Lord Turnberg
My Lords, I had not intended to speak to these amendments, but it is clear that we have had problems associated with inequalities for a very long time, and they persist. Many years ago, we had the Black report on inequalities in health, which was a major landmark, and since then we have had Sir Michael Marmot and his marvellous book The Status Syndrome pushing away at the inequalities in health, and my noble friend Lord Layard and his book on happiness and the inequalities in life in general. There is no doubt that the effects of inequalities are very severe. We see quite marked differences in health and life expectancies in communities adjacent to those where life expectancy is very high. We have some communities where several years of life are lost. The effects are very severe indeed. The reasons why there are such inequalities are multiple. They are certainly way beyond the ambit of a health Bill. Clearly there are factors outside health services that make the difference. Nevertheless, it is important that we have within a health Bill recognition of that fact and of the need for those within a health service to take account of inequalities and make recommendations as a result of them, so I am very much in favour of these amendments. We should have them in the Bill.
Baroness Thornton
My Lords, perhaps I may respond very briefly from these Benches. I took the Committee through our amendments at a gallop, so perhaps I may make two points very quickly. This debate has illustrated the problem that these amendments seek to address, and indeed it was illustrated by criticism from the King’s Fund and the Commons Health Select Committee, referred to by the noble Lord, Lord Patel. The duties, although welcome, are too narrowly drawn and, crucially, do not extend to local authorities. I might say that the noble Earl’s party does have form in this matter. We know how a previous Conservative Government treated the Black report, ready in 1980 just after the Conservatives came to power. It was not to Mrs Thatcher’s liking and was never printed. Only 260 photocopies were distributed in a half-hearted fashion on bank holiday Monday—my noble friend says that he has two of them. I know that the coalition Government would not allow that to happen and I welcome the change of heart that is shown in this part of the Bill.
However, my understanding is that the weighting given to health inequalities in the formula of allocating NHS funding has been reduced from 15 per cent to 10 per cent. Can the Minister confirm that that is indeed the case? What signal does it send about the Government’s priorities and their commitment to dealing with health inequalities? It seems to me that the commitment to dealing with health inequalities could be remedied. There is a need for a widened definition of health inequalities to include reducing inequalities in the health role, and of access for the Secretary of State, the NCB and clinical commissioning groups. There is a need to specify and define inequalities, particularly inequalities between groups and communities rather than individuals, and there needs to be a strong duty on local authorities as public health duties are transferred to them.
Finally, the message here is that the Minister needs to look carefully at these amendments and that the Committee is very interested in engaging with the Government to strengthen this part of the Bill. I look forward to the noble Earl’s remarks.
Earl Howe
My Lords, the Government are committed to reducing health inequalities, to ensuring equity and fairness across the health service, and to improving the health of the most vulnerable in our society. On top of the pre-existing general public sector equality duty, for the first time the Secretary of State will have a specific responsibility to,
“have regard to the need to reduce health inequalities”,
whatever their cause. This duty will be backed by similar duties on the NHS Commissioning Board and clinical commissioning groups. Taken together, these duties will ensure a focus on the reduction of health inequalities throughout the system, with special consideration paid to outcomes achieved both in relation to NHS services and to public health.
While many noble Lords seek to amend these new duties, we believe that they are right as they stand. The duty will not be an add-on or an afterthought. The Secretary of State, the Commissioning Board and clinical commissioning groups will be required always when carrying out any and all of their functions to have regard to the need to reduce inequalities. I should also point out here that the duty is purposefully non-specific. Amendments 21, 22, 23, 25, 27 and 27A all aim in different ways to strengthen the wording of the Secretary of State’s duty. While I fully accept that the reduction of health inequalities must be a priority for the Secretary of State, it must also be recognised that the causes of health inequalities and the remedies to them are complex and multidimensional and require a multisector approach. Factors such as poverty, education, employment and culture require solutions which extend far beyond the Secretary of State’s or the Department of Health’s remit or capabilities. The duty on the Secretary of State must recognise the nature of the challenge we face in reducing health inequalities, and it must be deliverable. We should hold the Secretary of State to account only for the things that he is responsible for. The duty in the Bill is drafted with these factors in mind.
For the same reasons, I am afraid that I cannot accept attempts to amend the wording of the duty to “act with a view to” or “seek to reduce”. While I understand the noble Lord’s attempts to make the duty as strong as possible, “have regard to” captures the intention of the legislation; that is, that the Secretary of State must consider the need to reduce inequalities in every decision that he takes about the NHS and public health. The approach that the unamended clause sets out is the right way to achieve this. As it stands, the Secretary of State would have to have regard to the need to reduce inequalities in any decision that he made. Contrary to what some have thought, having regard is a strong duty which shows the Government’s commitment to the reduction in health inequalities. The duty to “have regard to” has established meaning and has been used in other important legislation, such as the duty to have regard to the NHS constitution in the Health Act 2009. The courts can and do strike down administrative actions in cases where decision-makers have not had regard to something in contravention of a statutory duty to do so. For example, they have struck down decisions of public authorities for failure to have due regard to their equality duties. The courts have said in relation to public sector equality duties that the duty to have due regard must be exercised with rigour and an open mind—it is not a question of ticking boxes. The duty has to be integrated within the discharge of the public functions of the authority. It involves a conscious and deliberate approach to policy-making and needs to be thorough enough to show that due regard has been paid before any decision is made.
Perhaps I could clarify for the benefit of the noble Lord, Lord Patel, and the noble Baroness, Lady Murphy, that the duty in Clause 3 already applies to public health functions. The expression,
“functions in relation to the health service”,
covers both NHS functions and the Secretary of State’s public health functions. “The health service”, as that term is used in the 2006 Act, is not limited to the NHS.
Amendment 27, tabled by my noble friend Lady Williams, would have the effect of making the Secretary of State and the Department of Health responsible for reducing inequalities generally, beyond those relating to health. We cannot accept the amendment because there are many areas, such as wealth inequality, which are rightly not within the department's responsibility, and therefore to place a duty on the Secretary of State for Health to reduce these would not be practical.
Amendment 27A, tabled by the noble Baroness, Lady Thornton, would specify that the Secretary of State’s duty in reducing inequalities should be in relation to health status, outcomes achieved, experience and the ability to access services. The amendment is modelled partly on the wording of the Commissioning Board’s and CCGs’ inequality duties. While I agree with the intention behind the noble Baroness’s amendment, I can reassure her that the reference to “benefits” in the unamended clause already covers these aspects and so the amendment is unnecessary. The reason that the Secretary of State’s duty talks of benefits that people can obtain from the health service is that it includes public health as well as the NHS. The Secretary of State's duty is deliberately broader than the duty of the board and CCGs.
Amendment 29, tabled by the noble Lord, Lord Warner, aims to ensure that promoting patient choice is not given a greater priority than reducing health inequalities. I understand that some people have concerns that greater choice and competition could exacerbate inequalities, and I am aware that there are particular concerns that choice could benefit the better-off at the expense of others. However, our proposals on choice are intended to ensure that all patients are given opportunities to choose. We do not believe that the assertion that the better-off will benefit more from choice is borne out by the evidence. Indeed, recent evidence suggests that choice has the potential to improve equity. For example, some noble Lords may have seen the study published recently by the Centre for Health Economics at the University of York, which found that,
“increased competition from 2006 did not undermine socio-economic equity in health care and, if anything, may have slightly increased use of elective inpatient services in poorer neighbourhoods”.
So I do not believe that there are any grounds for thinking that improving choice and tackling health inequalities are incompatible. They should be mutually reinforcing.
Amendment 31, tabled by the noble Baroness, Lady Thornton, would introduce wording to ensure that if the duties placed on commissioners or regulators came into conflict with any other duty, the duty to reduce inequalities would prevail. I fully share the intention of making sure that these organisations do not ignore the goal of reducing inequalities. However, the inequality duty must already be complied with when bodies are exercising all their other functions. Therefore, I cannot agree that other duties placed on commissioners or regulators would conflict with their general duty to have regard to the need to reduce inequalities.
Amendment 32, also tabled by the noble Baroness, Lady Thornton, seeks to place on the Secretary of State a duty to publish evidence about the extent to which inequalities have been reduced annually. I fully agree that the NHS and the Secretary of State should be accountable for their efforts to reduce inequality. Clause 50 already places a duty on the Secretary of State to report annually on the NHS. Since tackling inequality will be such an important legal duty throughout the NHS, we have every expectation that inequalities will be a key reporting theme in the Secretary of State’s annual report.
Amendment 33, tabled by the noble Baroness, Lady Greengross, would place a duty on the Secretary of State to give particular regard to certain factors and characteristics when having regard to inequalities. Amendments 120B and 190B, tabled by the noble Baroness, Lady Thornton, would amend the Commissioning Board’s and clinical commissioning groups’ inequality duties, in new Sections 13G and 14S of the 2006 Act, to include the same list of characteristics and factors. I hope that I can persuade the noble Baronesses that there is no need for these amendments. First, it is unnecessary to prescribe the characteristics and factors to be covered by the Secretary of State, the Commissioning Board and the clinical commissioning group duties. The current, unamended duties would already cover health inequalities arising from any characteristic or factor. On top of this, as we have already discussed, the Secretary of State and the NHS are already bound by the general Equality Act 2010. Section 149 of that Act lists the characteristics covered in paragraphs (a) to (i) of the amendments. Therefore, the Secretary of State and NHS bodies will already have to give specific consideration to these characteristics. In not being specific in the duty on the Secretary of State, the Commissioning Board or CCGs, we are keeping the duty with regard to health inequalities as broad as possible, so that no characteristics which drive health inequalities are inadvertently omitted.
As the noble Baroness made clear, there are two new factors not listed in the Equality Act but proposed by the amendments. These are geographical variation and socioeconomic variation. However, it is unnecessary to specify these factors either. They are already wellestablished dimensions of health inequalities and will be taken into account under the duties on the Secretary of State, the NHS Commissioning Board, and CCGs. They are also already specified in the NHS outcomes framework, subject to data considerations.
Apart from being unnecessary, the amendments are also in a real sense undesirable. While I am sure that this is not the intention, their effect would be to give pre-eminence or priority to certain characteristics or factors. We are dealing here with the perennial problem of “the list”; by implication, anything not on the list is less important. Instead, the Government are committed to ensuring that all dimensions of health inequalities are encompassed by the proposed duties, a principle that I am sure all noble Lords can agree with. All factors leading to health inequalities should be considered, with the weight given to them depending on particular circumstances.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 10 months ago)
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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.
Earl Howe
My Lords, the amendment tabled by the noble Baroness, Lady Gibson, and all the amendments in this group, highlight the importance of ensuring that neither rural nor urban areas are affected by health inequalities. I quite understand the noble Baroness’s concerns—especially given that rural areas have unique circumstances that affect their health needs, such as a diffuse population and long travelling times for patients.
I therefore acknowledge that some significant issues face rural and urban areas, as was highlighted by the Marmot review. In particular, there are concentrations of shorter life expectancy and greater illness, and these tend to occur in some of the poorest areas of England, most of which are urban areas of deprivation. There are particular challenges with the provision of services in rural areas due to the higher cost of delivering services in more locations and the greater sparsity of rural communities.
However, although I am very sympathetic to the noble Baroness’s intentions, I do not feel that the amendments are the most effective way to achieve her aims. Existing reference to “England” or “its area” in the Bill already includes every type of population, including rural and urban populations. The responsibilities for commissioning are absolute across all the communities and individuals for whom they have responsibility. There is no discrimination between different areas. That principle runs throughout the legislation. Moreover, the fundamental and unique change we are making to commissioning is to give local GPs responsibility for securing services for their patients. That vital principle, above all others, will make a decisive break from the past by ensuring that the needs of much smaller groups of patients can be taken into account by the commissioners.
A CCG will be exercising its statutory functions appropriately only if it is meeting the reasonable needs of all the people for whom it is responsible, not just those in particular demographic areas. The guidance on commissioning which the board must issue under the power in new Section 14Z6 could, of course, cover issues relating to commissioning in rural and urban areas.
Although the noble Baroness’s amendments are unnecessary, they could also be damaging. That is because there is the potential under some of the amendments, however inadvertently, to limit the scope of the responsibilities which the Bill places on CCGs. Amendments 188 and 114 could limit the effect of the scope of the duty on reducing inequalities to a duty only in relation to reducing inequalities and access between rural and urban areas. That would not include the duty to tackle the variety of factors which can affect a person's ability to access the care that they need, such as socioeconomic background and ethnicity. The changes proposed to the Secretary of State's duty in new Subsection 1B are particularly problematic in their impact. The Secretary of State may no longer have regard to the need to reduce inequalities between the people of England but only between people in urban and rural areas. Similarly, Amendment 190 could limit the duties regarding reducing inequalities in outcomes to inequalities in outcomes between patients in rural and urban areas only. So I have concerns about the limitations that the amendments may impose.
Despite all that, I hope that I can reassure the noble Baroness that the Bill adequately provides for her worthy intentions—due, in particular, to its coverage of the whole of England. With that in mind, she may consider withdrawing the amendment.
EU: Economy
Baroness Thornton Excerpts(12 years, 11 months ago)
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Baroness Thornton
My Lords, perhaps I may press the Minister, following on from the question of the noble Baroness, Lady Jolly. I looked at the NHS brand guidelines website and it is most specific about the colours, size, margins, borders and even communication principles. It is silent, however, about who cannot use the NHS logo. It has a list of organisations which can use it but is silent about who cannot. Given that we may be heading towards a world with a multiplicity of providers, will the Minister undertake to look at the NHS brand guidelines with a view to making it clear under what circumstances the brand may or may not be used?
Earl Howe
I will, of course, look at that point. However, the NHS logo is considered to be the cornerstone of the NHS brand identity. The letters NHS and the logo type are trademarks managed by the branding team at the Department of Health on behalf of the Secretary of State for Health, who technically holds the trademark. They are extremely well recognised and trusted, and use of them is very carefully controlled indeed.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 11 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, before we move further forward with our debate, I hope that noble Lords will find it helpful if I make a very brief intervention. I am aware that a number of noble Lords wish to speak and I have no wish to prevent that. The Committee must, of course, proceed as it sees fit. However, I felt it might be useful to those intending to speak if I indicated now rather than later what the Government’s preferred course is in relation to this group of amendments. Some noble Lords will be aware that the Government regard the amendment tabled in the name of my noble and learned friend Lord Mackay and the noble Lord, Lord Kakkar, as having particular merit in the context of this debate. Notwithstanding that, and having spoken to a number of noble Lords during the past few days, including my noble and learned friend, it is my view that the best course for this Committee would be for none of the amendments in this group to be moved today, and instead for us to use the time between now and Report to reflect further on these matters in a spirit of co-operation. I shall, of course, say more when I wind up the debate but it may assist the Committee to know that that is the position that I shall be taking.
Baroness Thornton
In the spirit of co-operation across the House it might be useful if I outline the position of these Benches, too. During the past few days I have said to anybody who would listen to me that this is the position in which I thought we probably ought to end up. Those who have been sitting with me on the Long Table can bear testament to that. The reason I added my name to the amendment of the noble Baroness, Lady Williams, is because I feel strongly that that is the right way forward. I am very pleased to hear that the noble Baroness has not resiled from her position on that. I have talked to several lawyers and consider that the amendment in the name of the noble and learned Lord, Lord Mackay, may address political issues but does not fully address the legal issues concerning the responsibility of the Secretary of State.
I have what I can assure noble Lords is a sparkling 10-minute speech, but I do not intend to make it now. However, I may save it for a later occasion. I think this is a good solution if other noble Lords agree with it. I look for an assurance from the Minister about how the discussions on this matter should proceed. We have a record on this Bill of cross-House discussions involving all the people with an interest and expertise in matters relating to it. In that spirit, I wish these amendments to be withdrawn so that not only our lawyers but our medical experts, and, indeed, the Constitution Committee, can be persuaded to have another go at this issue. Towards Christmas we may find a solution that suits us all. If not, I may instead have to make my 12-minute sparkling speech on Report. I hope that the House will feel that this is a good way forward.
Lord Laming
My Lords, it is clear that around the whole House it is felt that the constitutional position of the Secretary of State is of immense importance. The House must give careful thought to that issue in order that we get it right, because the National Health Service is important to every citizen, as we heard earlier during our consideration of a Question. What the health service stands for, how it carries out its responsibilities and where responsibility and accountability rests are of great importance.
The House is indebted to all those Members who have put their names to the amendments. They are thoughtful amendments that represent the best interests and work of this House. It is a great credit to those who have put their names to the amendments that they are happy to consider withdrawing them today, because it is important that the House should not take precipitous action, that we accept the thoughtful response from the Minister and that we give plenty of time and opportunity to try to resolve this. There is actually a shared commitment around the House, and I therefore have every confidence that the House will reach agreement. I very much hope that noble Lords who have tabled these amendments will accept this opportunity to meet with the noble Earl and resolve this matter before the next stage of the Bill.
Lord Greaves
My Lords, I am not going to reveal all my researches and enlighten the Committee on the meaning of “ultimate”, except to say—
Baroness Thornton
The reason I did not make my 12-minute speech was that we are now going to go into a period of consideration. I respectfully say to the Minister that we could start the whole debate all over again if he continues telling us what the Government do or do not believe on this because that is presupposing, and possibly pre-empting, the discussions that we are about to have. The noble Lord may find it useful, but we have had a lot of this discussion. We have now, I thought, agreed to move into discussions outside the Chamber.
Lord Beecham
My Lords, I rise to move this amendment in my name and those of my noble friends Lady Thornton and Lord Hunt of Kings Heath. As we make steady progress through this Bill, your Lordships will encounter many amendments more elegantly drafted than this one, I have to admit. Given the evident affection in which lawyers are held in your Lordships’ House, I trust that this member of the junior branch of the profession will be forgiven for the drafting of this amendment, especially as I was not responsible for it—
Lord Beecham
But I did subscribe to it. There is a sort of collective responsibility on these Benches, too.
This is a probing amendment—it could hardly be anything else in the circumstances—that tries to deal with what actually constitutes the health service. Of course, this phrase runs through the Bill but there is not within the Bill a definition of what constitutes the health service, let alone “a comprehensive health service”—the words used in Clause 1, which we will be returning to on Report. The amendment seeks to add to Clause 1(3) and the intention is to reflect Section 3 of the 2006 Health Act, which laid out clearly, to a reasonable extent at any rate, the scope of the Secretary of State’s duties. The Secretary of State was obliged to,
“provide throughout England, to such extent as he considers necessary to meet all reasonable requirements”
broadly six categories of service, amplified in Schedule 1 to the Act by more detailed requirements around medical inspection for pupils at schools and issues of that kind.
It clearly is impossible to lay down in legislation everything that might be brought within the purview of the Secretary of State or indeed any other body for the purposes of defining precisely what a national health service should be and what would constitute a comprehensive health service. Clause 10 in any event transfers some of those responsibilities to commissioning groups, as the noble Lord, Lord Marks, has pointed out, but it is not entirely clear from the clause, to put it mildly, what functions will be included in their responsibilities.
Baroness Thornton
Baroness Thornton
My Lords, I will also speak to Amendments 10 and 14. The purpose of these amendments is to strengthen the responsibilities of the Secretary of State for improving quality by changing the requirement to act with a view to reducing inequalities to providing services or making arrangements for others to provide services that ensure an improvement in quality. Furthermore, in the light of Clause 1 removing the Secretary of State’s role in providing services—although we still have that matter to resolve—it probes the extent to which the Secretary of State might be able to effect an improvement in the quality of services.
In general, we would welcome and support an explicit duty being placed on the Secretary of State to improve quality—of course we would. The grouping of these amendments has two components. First, it makes the point that quality and inequality affect communities as well as individuals, so planning must be on a geographically defined basis. Secondly, there are amendments designed to make the Secretary of State more directly rather than indirectly accountable—that goes back to the Clause 1 argument again. Amendments 9 and 10 tighten up the Secretary of State’s duties. As amended, the provision would state that the Secretary of State must exercise the functions of the Secretary of State in relation to the health service by providing services or making arrangements for others to provide services to secure continuous improvement in the quality of services provided. This mirrors the changes that we have argued for in relation to Clause 1, to make the Secretary of State more directly responsible rather having responsibility at one stage removed.
As I am sure the noble Baroness, Lady Finlay, will explain to the House, the amendments in her name are also important. This is the first time—but certainly not the last—that the idea is introduced of responsibility for an area-based population. The amendments acknowledge that quality and inequality affect communities as well as individuals. We support this idea of area-based responsibility and will later seek clarification on how basing some commissioning on GPs can be reconciled with the need to plan for geographical populations. Indeed, Amendment 14 is on the same theme, making the Secretary of State directly responsible and going back to that formulation of provision as opposed to being one step removed. As amended, the provision would say that in discharging the duty under subsection (1) of the proposed new Section 1A of the 2006 Act, the Secretary of State must either provide services that ensure, or make arrangements to ensure continuous improvement in the outcomes that are achieved. Actually, the amendment is defective because the word “must” has to be left in.
Lord Mawhinney
I am extremely grateful to the noble Baroness, but she skated over what an area-based population is. Presumably, if the Secretary of State has responsibility for individuals he has responsibility for a lot of individuals who happen to live cheek by jowl to each other. I am sure that it would be helpful to the Committee—and it would certainly be helpful to me—if she told us what an area-based population is or might be.
Baroness Thornton
The amendments that open the debate are in the name of the noble Baroness, Lady Finlay, so I suspect that she will also take the opportunity to explain that to the Committee. However, I think that we will have several debates as we move through the Bill that are about the concerns that some of us have if the commissioning of services is based on GP lists and not on a population in an area. What this probing amendment seeks to do is to help to open up that discussion about how you make sure that there are not people in an area who may not be on a GP list and who fall through the cracks in terms of health provision in that area.
This series of amendments seeks to do two things. One is to raise the point about equality and inequality as it affects communities as well as individuals. For example, the provision of family planning services in an area affects an area as well as the individuals who make use of the services, and you would indeed plan those services. That may not be a good example because of course that is public health, but I think that the Minister will see that you have to look at how you plan services in terms of not only the individuals but the needs of an area.
Lord Newton of Braintree
I am sorry to interrupt, and this may be another question for the noble Baroness, Lady Finlay, but what is a primary care trust if it is not concerned with the population of the area as that primary care trust is defined? This all seems to me like gobbledegook.
Baroness Thornton
My Lords, it is about the people in the area—but of course primary care trusts are going to be abolished by this Bill.
Lord Newton of Braintree
The noble Baroness said that this was the first time that we had had area-based planning, but a primary care trust is an area-based entity, planning for the population of an area.
Baroness Thornton
I think that the noble Lord misheard me. I said that it was the first time that we had discussed this in the process of this Bill. I beg to move.
Baroness Finlay of Llandaff
My Lords, I shall speak especially to Amendments 10A, 10B and 11A, and address my remarks principally to Amendment 10A, whose aim is to avoid fragmentation and inequity through a loss of contiguous, coterminous and comprehensive area-based structures for healthcare resource allocation planning, commissioning and service co-ordination. The amendment would ensure that the sensible changes that were just agreed today over GP contracts for this year are carried forward into GP consortia arrangements. The Secretary of State, Andrew Lansley, himself discussed issues around area-based practice at the congress for the Royal College of General Practitioners last month, and had a fairly extensive and open discussion with the GPs there on this topic.
I move to the Bill as it stands. I hope that with some of the background discussions that have been happening, my amendment will not just be dismissed and will be quite seriously considered, because it might solve a problem.
In the Bill, the new commissioning consortia’s duty—
Baroness Thornton
My Lords, this has been a very worthwhile discussion. As I said at the outset, there are two issues here. I am grateful to the noble Earl for reassuring us about the issues to do with quality, which he has done very satisfactorily indeed. I should give the noble Baroness, Lady Finlay, a vote of thanks. I knew that she would explain the issues about area-based clinical commissioning groups much more clearly than I. Moreover, the noble Lord, Lord Newton, put his finger on it when he asked whether the clinical commissioning groups will be structured on the basis of clearly defined geographical areas contiguous with each other and inclusive of the entire population. I think the noble Earl said “yes” to that question.
I am less happy about something that I think we will return to, which is how people who already fall through the gaps in care and access to primary care will be treated and whether their situation will be worse. That is because right from the outset I said that what we had to do was apply what is in this Bill to patients and conditions to see how it works for them. In Kingston at the moment, for example, a GP practice has been able to deregister 48 people with mental illnesses who live in a home. They have been scattered among GPs throughout the area. I think that that is very unsatisfactory and there does not seem to be any way of challenging the decision. It worries me that if we are establishing clinical commissioning groups that will have even more independence to take those kinds of decisions, things will get worse for those who need primary care rather than better.
I will not press any of the amendments tabled in my name, but we will return to this issue. I beg leave to withdraw the amendment.
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.
Baroness Thornton
My Lords, I congratulate the noble Baroness, Lady Hollins, on bringing forward the amendments and all those who have spoken in what I think has been an extremely useful debate. All those months ago, we had all-Peers meetings about this and many other issues. I am sure that the quality and comprehensive nature of the amendments owes something not only to talent and expertise but also to the fact that the experts in the House have been working with many organisations over a long period. I congratulate everyone on the quality of the debate and the amendments.
The amendments approach the Bill holistically—I do not really like that word. They concern the Secretary of State's responsibilities, the duties of the Commissioning Board and the duties of the clinical commissioning group—the triggers, the levers that may make this a reality. Because of that, I am very attracted to them. It is also important that they express the expectation of parity of esteem between mental and physical health services. As has been said, my Government and this Government have certainly made progress on this issue. I look forward to hearing the Minister’s comments, and I hope that he will find some way to recognise the support for the amendments across the House.
Earl Howe
My Lords, I agree with the noble Baroness, Lady Thornton, that this has been a debate of very high quality, covering a topic of huge importance. All the amendments deal with the same matter. Each seeks to amend the duty of quality to include an explicit reference to the prevention, diagnosis or treatment of physical and mental illness. Amendment 11 does so for the Secretary of State; Amendment 105 applies to the NHS Commissioning Board; and Amendment 180 applies to clinical commissioning groups.
I completely share the noble Baroness’s concern that we should never forget mental health in the drive for improving quality—quite the contrary. The noble Lord, Lord Patel of Bradford, and many others, mentioned parity of esteem between mental and physical health and the need to end the dualism in thinking that has in the past hindered an holistic approach to care. Noble Lords have expressed the concern that the Bill is wrongly silent in not referring explicitly to mental illness. I hope that I can successfully plead not guilty to that charge. First, I reassure all noble Lords on the central point of drafting, which is that all references to illness already include both mental and physical illness. The term illness is defined in Section 275 of the National Health Service Act 2006 as including mental disorder within the meaning of the Mental Health Act 1983. As a result, references to the prevention, diagnosis and treatment of illness would already apply to both physical and mental illnesses without the need for those additional words. The definition is already there. Therefore, the signal mentioned by the noble Lord, Lord Rooker, is already there.
The new duties placed on the Secretary of State for Health, the NHS Commissioning Board and clinical commissioning groups continuously to improve quality as defined by the noble Lord, Lord Darzi, already apply to the provision of both physical and mental health services. That is not to say—and I would not seek to suggest—that such services need no improvement. The noble Lord, Lord Patel, was quite right to draw attention to variations in mental healthcare around the country, despite the significant additional resources that have been directed to mental health services in recent years.
I fully agree that the National Health Service must look holistically at both the physical and mental needs of the patients whom it is there to serve. That is why the NHS outcomes framework, which we published last year, seeks to drive better health outcomes for those with mental illness. That is where the difference will lie in future. For example, Domain 1 of that framework, which focuses on preventing people from dying prematurely, includes a specific indicator on premature mortality in people with serious mental illness. Domain 2 of the framework focuses on enhancing the quality of life for people with long-term conditions, regardless of whether these are physical or mental health-related. However, to guard against the risk that there might be an overriding focus on physical health, there is also a specific indicator looking at the employment of people with mental illness. Clinical experts, including the Royal College of Psychiatrists, agree that this is an important outcome for people with mental illness and one that the NHS can make a significant contribution to improving. Finally, Domain 4 of the framework focuses on:
“Ensuring that people have a positive experience of care”,
including a specific indicator to capture the experience of healthcare for people with mental illness.