Autism

Baroness Thornton Excerpts

Tuesday 7th December 2010 Lords Chamber

[Earl Howe]

My Lords, the statutory guidance that already exists—it has been revised in light of the response to the consultation—makes it explicitly clear that in addition to general autism awareness-raising training for staff, local areas should develop or provide specialist training for those in key roles who have a direct impact on access to services for adults with autism, such as GPs, community care assessors and commissioners and service planners.

[Baroness Thornton]

My Lords, I congratulate the Minister on continuing to make progress in this matter. As he will know, commissioning for autism services requires expert knowledge and, as my noble friend said, a recent National Audit Office survey found that 80 per cent of GPs said that they needed more training in autism awareness. Can the Minister outline whether any progress is being made to change that situation because, if it applies to GPs, it probably applies to other health workers? Is the Minister also supportive of the call from the National Autistic Society for NICE guidelines and for the inclusion of autism as one of the future quality standards currently under consideration by the National Quality Board?

[Earl Howe]

My Lords, we cannot mandate to NICE what quality standards are produced. However, the case for developing a quality standard for autism will be considered as part of work to commission a comprehensive library of such standards from NICE in line with our plans in the White Paper. NICE is already developing clinical guidelines on diagnostic pathways for autism, including one for children and young people with autism. That is scheduled to be published in September next year. On training, I cannot really add much to what I have already said to the noble Lord, Lord Low, but it is very high on the agenda.

Health: Passive Smoking

Baroness Thornton Excerpts

Tuesday 30th November 2010 Lords Chamber

[Earl Howe]

My Lords, we have no plans to legislate further for banning smoking in cars. As she will know, when a car is used as a workplace smoking is illegal, but when a car is being used privately that is a different matter. We do not intend to legislate.

On messages in schools, we know that youngsters are concerned about parental smoking. In fact, the younger the child, the more concerned the child tends to be. Schools are encouraged to include advice on smoking in the PSHE curriculum.

[Baroness Thornton]

My Lords, following the successful implementation of the smoking ban in all workplaces and public places in July 2007, which was opposed by many in the party opposite, will the Minister undertake—

[Baroness O'Cathain]

No.

[Baroness Thornton]

I except the noble Baroness, Lady O’Cathain, from that.

Will the Minister undertake to ensure that, under the proposals for GP commissioning, NHS smoking cessation services will continue to be effectively commissioned and funded and that nicotine products will continue to be prescribed?

[Earl Howe]

My Lords, the noble Baroness, Lady Thornton, is wrong. The Conservative Party did not oppose the second-hand smoke provisions. We did not oppose them in principle; we supported the Government. We opposed some of the detail, but that is a different thing.

On smoking cessation, there is no doubt that local stop-smoking services are effective and are available free of charge in communities across the country. Evidence shows that the most effective way of stopping smoking is with local stop-smoking services because smokers get behavioural support as well as effective medicines and treatments on the NHS.

Public Health

Baroness Thornton Excerpts

Tuesday 30th November 2010 Lords Chamber

[Baroness Thornton]

My Lords, I thank the Minister for repeating the Statement, which as we know was well trailed on the “Andrew Marr Show” on Sunday and on the “Today” programme this morning. There are some things that we would like to welcome and support in the Statement, and there are some that we think are a cause for concern. My overall impression is slight disappointment at the insubstantial nature of this Statement. Much of it is common sense and much of it picks up where the previous Government left off, but the Government have had quite some time to think about and to decide on the direction for public health. I believe that this White Paper is short on strategy. Therefore, I look forward to more substance as we move forward.

I think that we would agree that local authorities have an important role to play in the delivery of the public health agenda. Presumably, the new public health service will take on some of the responsibilities of the Health Protection Agency. I have to say to the noble Earl that I wonder why it was necessary to announce the abolition of the HPA, except to make a political point, which is disappointing, when a new agency is being created. The appointment of the new directors of public health will be very important in this programme of delivering a public health agenda. For them to be effective, they will need to be independent. How do the Government intend to ensure that directors of public health in local authorities have the necessary independence and power to deliver an agenda, which sometimes a local authority may not want to hear and may find expensive to deliver?

I am disappointed at the cheap gibes in the Statement, which I can only assume were the idea of the Minister’s bosses—that the nanny state ruled during the Labour years and that Mr Lansley’s “nudge-nudge” public health strategy will be more effective. We need to get past that sort of name calling. The evidence shows that by taking a lead, as Labour did, in the diagnosis of public health issues based on evidence and in taking some of the big decisions on, for example, smoking, exercise and diet—the noble Earl has not ruled out that this Government might need to do that too—we provided a good framework for people to take responsibility for their health and to start to change their habits. I hope that this Government will continue to support families where it is needed.

I do not think that nudging would have got us the ban on smoking in the workplace. “Nudge” will not replace the brilliantly successful schools sports programme. I am not sure that nudge will deliver the national screening programme mentioned in the Statement. I am certainly sure that nudge will not deliver healthy meals in schools or fruit for schoolchildren. So I am sceptical about the nudge part of this Statement.

However, we can all agree that factors such as unemployment, education, environment and equality are important determinants of health. The Statement is correct in saying:

“Unhealthy behaviours, like drinking too much, smoking … are … rooted in poor aspiration, adverse peer pressure and low self-esteem”.

As Marmot puts it, and as the noble Earl has said, they are the “causes of the causes”. That is absolutely correct.

I disagree with this Statement where it puts forward a cross-government initiative; that is, joined-up government. The noble Earl needs to explain how throwing somewhere between 400,000 and 500,000 people on the dole will help their self-esteem and their family’s prospects. He would need to explain the joined-up bit of the Government that led his right honourable friend the Secretary of State for Education to get rid of the successful school sports scheme that got our nation’s children playing sport. Ditto housing benefit cuts, which may put some families’ homes at risk or move them away from where they can earn a living. That is not going to provide the right environment. Finally, we have the abolition of the education maintenance allowance, which has allowed thousands of children from low-income families to stay on at school after 16. If, as Marmot says, life chances and opportunities are an important part of people’s well-being and health, how can the Minister explain the contribution of this initiative to public health?

I want to turn to the regulation of tobacco. This House has debated this issue at length and over quite some time, and by several large majorities it supported the introduction of point-of-sale tobacco regulation and the banning of tobacco products in vending machines. Just this morning, on the “Today” programme, the Secretary of State confirmed that he accepted the evidence that the visibility of cigarettes is a factor that leads to the initiation of smoking. He also mentioned the issue of plain packaging and the Government’s intention to consult on this. We all know that such a consultation will take years and that any action to put tobacco into plain packaging, following on from such a consultation, will take years to come into force. This cannot and should not be seen as an alternative to the legislation to ban tobacco displays. The display legislation is on the statute book. It will protect this generation of children from brightly coloured displays in shops. I should like to ask the Minister this: will cigarettes no longer be on display in supermarkets from October next year? Further, if the Government intend to consult on plain packaging, how long will the consultation take, who will run it and how much will it cost?

I have two or three more questions for the Minister. I warmly welcome the Government’s intention to invest in Sure Start children’s centres and in more health visitors. I also support the development of health protection plans and screening programmes, but I have to ask the Minister: is this nudge or is this target? How are the Government going to decide whether enough people are being screened, because that aim needs a target rather than a nudge? The ring-fencing of public health budgets is going to be a challenge. How will the Government decide what is going to be included in those budgets and what will be excluded? Moreover, how are they going to stop hard-pressed local authorities from raiding them? That will indeed be a challenge. We support the Government in doing this, but we will need to address how it will be possible to deliver that ring-fencing.

Finally, I certainly welcome the greater use of voluntary and community organisations. We worked with many organisations in different health fields, and that is exactly right. However, the funding and support for these organisations needs to be maintained.

Health: Academic Health Partnerships

Baroness Thornton Excerpts

Monday 29th November 2010 Lords Chamber

[Baroness Thornton]

My Lords, I join other noble Lords in congratulating the noble Baroness, Lady Finlay, on drawing this important matter to the attention of the House. As has so often happened in the past, the noble Earl and I are usually, or probably, the least qualified people to answer this debate, given the quality of the contributions that have been made this evening. I particularly thank my noble friend Baroness Donaghy for her thoughtful contribution.

Evidence from around the world demonstrates the profound role played by world-class research and teaching in driving innovation in healthcare. Academic health science centres are designed to maximise clinical and academic synergies by ensuring that clinical research and teaching staff work in concert to unified plans that transcend the separate structures of their respective clinical and academic institutions. In 2007 a review of healthcare in London led my noble friend Lord Darzi in a framework for action to recommend the creation of a number of academic health partnerships. In October 2007 Imperial College Healthcare became the first to be established in the UK when Imperial College London’s faculty of medicine merged with the Hammersmith Hospital and St Mary’s Hospital NHS trusts. I know that several more—mentioned by other noble Lords—have subsequently been established, notably Cambridge University Health Partners, King’s Health Partners, Manchester Academic Health Science Centre, UCL Partners, Barts and The London NHS Trust.

We can be proud of the achievements of these innovative partnerships and the benefits that they have brought in their own areas to the cities that they are in and across the world. The engines of clinical innovation— for example, at Barts and The London—will be 70 new clinical academic units, clusters of closely related specialties or sub-specialities working to a single plan for clinical care research and teaching. For example, guests from all over the world flew to London the week before last for the opening of a new cardiovascular biomedical research unit at the Royal Brompton Hospital. The BRU is a joint initiative between the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London and puts the partnership at the forefront of international research into the most challenging heart conditions. It is funded by the National Institute for Health Research.

There appear to be three legs to the AHSC stool. For it to work properly it needs excellent education, excellent healthcare and excellent research. It also needs time. This is not a five-year project; this is a 15 to 20-year shift in the development of excellence and innovation in these areas. My understanding is that the funding of the academic health science centres is a mixture of MRC, DBIS and NIHR. Under the current structure, SHAs and PCTs have delegated responsibility to administer research funding. In addition to his powers to conduct or assist research, the Secretary of State has a duty under Section 258 of the 2006 Act to ensure that facilities are made available for universities with medical or dentist schools in connection with clinical teaching and the research connected with clinical medicine or clinical dentistry. This duty is delegated to the strategic health authorities and PCTs under the regulations.

Therefore, my first question to the Minister—echoed around the House—is unsurprisingly: how will this particular aspect be delivered and funding allocated under the new NHS structure? Who will undertake these duties with the demise of the strategic health authorities and PCTs? Linked to that, we need to ask about workforce planning. As many noble Lords have mentioned, clinical academics need to be fed through to these bodies. How will that happen?

The British Medical Association has recommended consideration of the roles of networks, health innovation and education clusters and the National Institute for Health Research and how these will fit into the Government’s overall plans. Can the noble Earl assure the House that the funding for the National Institute for Health Research is, indeed, safe?

On the necessity for ensuring excellence in education, we also need to look at the implications of the Browne review of university funding because we need to know how the leg that concerns teaching and universities will be affected. Presumably the cutbacks in the funding of higher education will have an impact on AHSCs in relationships with universities as they collaborate with them. There is the potential for a double whammy here, both in costs to individual students and, indeed, in the cutbacks that universities are to suffer as a result of the CSR settlement. Like other noble Lords, I welcome the fact that research has been protected under the CSR, but it seems to me that at least two legs of this stool are looking a bit dodgy. I invite the Minister to tell the House how the Government intend to support the future of these partnerships in the long term.

Medical Profession (Responsible Officers) Regulations 2010

Baroness Thornton Excerpts

Tuesday 23rd November 2010 Lords Chamber

Moved by

[Baroness Thornton]

As an amendment to the above Motion, at end to insert “but this House regrets that the draft regulations may imperfectly achieve the policy objective of the introduction of a revalidation scheme in light of the Government’s proposed changes to the NHS administrative structure which will affect the operation of the revalidation scheme in general, and these regulations in particular”.

[Baroness Thornton]

My Lords, as the Minister quite rightly suspects, it was a combination of the report of the Merits of Statutory Instruments Committee on 7 October and my concerns that some aspects of the statutory instrument as drafted need further explanation that caused me to put down this amendment to the Motion this evening. I think it is important to say from the outset that as one of the Ministers who guided the Health and Social Care Act 2008 through your Lordships' House with my noble friend Lord Darzi, I am very pleased that this Government are showing determination to push ahead with this agenda because at the heart of this legislation are patient safety and ensuring that all clinical professionals deliver high quality, effective and safe care to their patients.

I fully appreciate that responsible officers are integral to improving care, and the development of their role seeks to raise the already high standards of the overwhelming majority of professionals, but their job is to identify and swiftly deal with the small number of staff who are not able to meet those standards. The public, professionals and the NHS have a right to be assured that licensed doctors are fit to practice.

I have absolutely no desire to delay the important matter of implementing this legislation. However, I think that it is important that the secondary legislation does the job that the original legislation intended. The report by the Merits Committee raises some important questions in this regard, as do some of the important bodies whose membership will, as it were, be on the receiving end of the instruments.

I think that the regulations do a very good job of describing the duties of the responsible officer and, indeed, the connection between responsible officers and designated bodies and medical practitioners, and this leads me to my first set of questions. Part 1 of the schedule contains a list of designated bodies that includes at least two organisations that the Government intend to abolish: strategic health authorities and primary care trusts. I join the Merits Committee in its recommendation that the House seeks clarification on how the Government's proposed changes to the NHS structure will affect the revalidation scheme in general and these regulations in particular.

Since the 2008 Act, the UK Revalidation Programme Board—hosted by the GMC, which I thank for its briefing and comment on this matter—has been rolling out the reform in phased stages, including a number of pilot exercises which aim to produce a well informed and robust system. Can the Minister tell the House how the changes that have been proposed will affect the pilots and their results? For example, the published guidance says that the responsible officers themselves will be assessed by the responsible officer in the strategic health authority, so what will happen now? How will the Government overcome this problem? I anticipate that we can expect some further orders and, if so, when and will they too be piloted? If nothing exists in the structure of the newly reformed NHS between groups of commissioning doctors at local level and the NHS Board at national level who or what will perform this function?

At the time of the original legislation, we had considerable discussion about the GMC and its role in this matter and about not conflating its particular and important role as the independent regulator for doctors in the UK or, indeed, creating conflicts of interest. At the moment, it seems to me that the only body that would appear to have a structure between the very local GP consortia and the national board is the GMC. What is the Minister’s view of this? How will revalidation work under those circumstances?

I thank the Minister for forwarding to me the letter that his honourable colleague Anne Milton sent to members of the Delegated Legislation Committee in another place. In this letter, she addressed the changes of architecture to the NHS. However, I am afraid that I did not find her explanation very comforting. She says:

“The Government’s proposed changes to the structure of the NHS set out in the White Paper ‘Equity and Excellence: Liberating the NHS’, in particular the abolition of PCTs and SHAs, will not affect the majority of organisations designated under Regulations, including NHS and independent hospitals. These organisations need to start putting the systems in place that support doctors, and provide the information that demonstrates the quality of care they provide. Without this, there is a danger that doctors will be inadequately supported for the introduction of medical revalidation in 2012. I believe that the medical leadership and stability provided by having responsible officers in place will also be important during this period of change”.

Well, quite: the two bodies that can provide that leadership are being abolished.

I turn now to concerns that have been expressed by professional organisations, which particularly led the Merits Committee to say that,

“these regulations are drawn to the special attention of the House on the grounds that they imperfectly achieve the policy objective”.

When I was a Minister, I would have regarded that as the parliamentary equivalent of being put on the naughty step and given a detention at the same time. I think that the Minister needs to give some thought to this matter and to put his responses on the record.

The British Medical Association has said that the laying of the order is “premature”. Although I am not one for delaying these matters, the Minister needs to address its concerns. The Royal College of Surgeons has expressed disappointment that many of its concerns were not addressed in the regulation. It raised the issue of potential conflicts of interest to arise from the installation of responsible officers with simultaneous corporate board responsibilities—for example, medical directors.

The RCS seems to think that such officers might be torn between trust obligations and the professional role of the responsible officer. I am sure that the Minister will be familiar with the examples that these organisations have raised. How do the Government intend to avoid the revalidation recommendations becoming the tools of managers and trust management agendas, rather than matters relating to the compliance of GMC and Royal College standards? Will the Minister confirm that it is the responsible officer’s responsibility to examine the doctor’s clinical ability and professional conduct, not his contribution to the meeting of trust budgets or targets? On this matter the regulations appear to be silent. Perhaps the Minister will expand. The RCS has expressed particular concern about the failure to incorporate whole practice appraisal in these provisions. I think that the Minister needs to give the House an explanation and reassurance about the need for the comprehensive protection to which patients are entitled.

On indemnity, will the Minister confirm how the Government will approach the issue of the potential increase in contributions for medical directors who take on the role of the responsible officer?

Finally, the GMC has expressed concern about appeals and that there is a significant omission of local appeals systems. The GMC fitness to practise processes should not be both the first and the last resort for appeal. There should be a viable appeals structure that flows up to fitness to practise. The British Medical Association says that in some organisations progress has been slow in demonstrating the capability to pull together the necessary data to actualise the new system. It says that appraisal has been patchy and disjointed in many organisations, and that that is quite aside from getting around to supporting any appeals system that may arise. I have raised several issues and I suspect that other noble Lords will seek clarification on the various other issues. I look forward to the Minister’s response.

[Baroness Finlay of Llandaff]

My Lords, we all know the sad history of this, through Shipman, which has led us to where we are today. I do not want to block these reforms because they will improve medicine for patients and for clinicians. But there are some questions which need to be sorted out urgently. One question is the role of the responsible officer in relation to doctors in primary care, particularly with the reorganisation.

In his opening remarks, the Minister spoke about trusts, but I would suggest that hospital practice is very much the easy end of it. The difficulty is where will doctors in primary care sit? How will the responsible officer work in relation to them? Where will academics sit and who will be the responsible officer, because there is sometimes a conflict, as has been pointed out, between academic priorities and the clinical priorities of a trust where that doctor may have an honorary contract? Even more, what about locums? What about the doctors who are constantly moving around? How will they be captured in the system? How will they be adequately and appropriately revalidated? Even with what used to be called 360 degree appraisal—that is, getting opinions from a lot of people—with locums there is a real danger that they will only spot their friends to fill out the forms because they may have had lots of contacts. Those concerns may never be sufficiently in the system to be raised before such a doctor moves on.

There is also a difficulty for those who raise problems. It may be that the doctor who is seen as the sand in the shoe of the trust, the difficult person, is raising real concerns about the way in which management is conducted, which is impeding good patient care. We know that one of the biggest problems is attitude. Often, the biggest problem encountered is not about the ins and outs of technique, because you can retrain on that quite quickly, but is about someone’s attitude. Someone who is whistleblowing, someone who works in the same organisation—I hate to use the term “whistleblowing”, because it is a sad reflection of the NHS as it is today that that term is around—and raises concerns should not in any way potentially be penalised for doing so. We would just go backwards and not forwards if that is the case.

Given that the majority of doctors are doing a really good job and are very flexible and going through changes, the system that comes in must not be too onerous. It must not be just a tick-box exercise. It has to be subtle enough to pick up real issues around performance and attitude. It has to pick up qualitative feedback, so that a bad attitude is detected, including a bad attitude towards patients.

As regards the responsible officer, I am afraid to say that I am sufficiently old-fashioned to think that I would prefer the minimum time after qualification to be a bit longer. It is not until someone has been practising for about 15 years that they really have accrued enough wisdom to be able to take on what will be a very onerous and potentially important role in relation to their colleagues. We need them to have a degree of wisdom. The appeals system is absolutely crucial if this is to work well and fairly. I hope that the Minister will give us a full reply in his response.

We also must be clear that the system will not pick up another Shipman. This is a clinical system and not a criminal justice system, so no one should be fooled into thinking that it will. Dame Janet Smith pointed out two things. First, the most important information about patient safety is doctors watching other doctors. They have to be able to raise concerns easily. Secondly, a good clinical governance system is a system in which questions can be raised at an earlier stage and more readily. So it is the whole system of the NHS with good clinical governance that will make this work. I hope no one thinks that just having responsible officers putting in appraisals will do the job because that will be a wallpapering exercise.

However, my main concern relates to primary care and to financial conflicts. In a privately managed organisation there may well be a conflict between what is actually in the patient’s best interest and what is being put forward as the protocol in that managed care programme. It may well be that the doctor is working in the patient’s best interests, but not in those of the organisation. Again, there has to be a degree of neutrality among the responsible officers. I hope that the Minister will be able to give replies to all these concerns, and like other noble Lords, I look forward to his response.

--- Later in debate ---

[Earl Howe]

My Lords, the answer to the first question of the noble Baroness, about career breaks and so on, is yes, the regulations allow for that. In answer to her second question, we are not specifying that responsible officers have to be medical directors. As she knows, we are leaving it up to the organisations to decide that. Therefore, she can be reassured on her other questions.

[Baroness Thornton]

My Lords, I thank all noble Lords for contributing to this debate, particularly the noble Baroness, Lady Finlay, the noble Lord, Lord Colwyn, and my noble friend Lord Rea. I also thank the Minister for his comprehensive answer. Noble Lords will have heard me say from the outset that I did not intend to delay the implementation of the regulations. However, noble Lords should also acknowledge that if we ignored the reservations expressed by the Merits Committee and various medical organisations, and did not to pay heed to what they had to say about this, we would not be carrying out our duty of scrutiny. I thought that the most important thing was to get on record the answers to the very questions that we have raised.

I thank the Minister for his usual comprehensive and competent answer, which helpfully addressed many concerns. The abolition of PCTs and strategic health authorities is on the “wait and see” bit of this agenda. We can take it that the Department of Health has not yet worked out what it is going to do. I take some comfort from the fact that this, like much else, is in the melting pot of what is becoming the NHS at the moment; it is work in progress. With that and with thanks, again, to the Minister, I beg leave to withdraw the amendment to the Motion.

Amendment to the Motion withdrawn.

Health: Chronic Obstructive Pulmonary Disease

Baroness Thornton Excerpts

Wednesday 17th November 2010 Lords Chamber

Asked By

[Baroness Thornton]

To ask Her Majesty’s Government when they will implement the National Clinical Strategy for Chronic Obstructive Pulmonary Disease.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the reforms set out in Equity and excellence: Liberating the NHS will ensure that the NHS focuses on improving outcomes for patients. As a result, we are looking at the role and nature of clinical strategies within the reformed NHS to ensure that they reflect this focus.

Today is World COPD Day. I can assure the House that we are committed to improving outcomes for those who suffer from COPD and from asthma. We will make further announcements shortly.

[Baroness Thornton]

I join the Minister in welcoming World COPD Day, which draws attention to this incurable, degenerative lung condition. However, I am disappointed that he has not thought fit to use today to adopt the COPD strategy, which was left up and ready, as it were, when the previous Government left office. Apart from anything else, I wonder whether he is aware that the British Lung Foundation’s research shows that up to 80 per cent of GPs cannot tell the difference between asthma and COPD. That is a very serious issue for prescribing. The adoption of the COPD strategy would bring systematic training and awareness-raising of this condition.

[Earl Howe]

My Lords, as I indicated in my Answer, the reform programme that we have outlined is intended to ensure that all parts of the system work more effectively in improving health outcomes. That has to include COPD. We have to ensure that everything that we do fits into the proposed new architecture of the NHS. In the mean time, we will continue to work with key organisations and with clinical leads for COPD and asthma to make sure that change happens. I know that a great deal of activity is in hand across the NHS to improve outcomes for patients with COPD and asthma as a result of the good work undertaken so far.

Department of Health: Arm’s-length Bodies

Baroness Thornton Excerpts

Tuesday 16th November 2010 Lords Chamber

[Earl Howe]

My Lords, my noble friend makes a good point. We need to distinguish between posts that are administrative in nature, where we will see considerable reductions, as I have mentioned, and posts that relate to clinical activities. There is obviously a clear case for the latter posts to be advertised and filled where necessary.

[Baroness Thornton]

Will the Minister explain to the House why the Human Tissue Authority and the Human Fertilisation and Embryology Authority have been included in the Public Bodies Bill when some 28 other NDPBs—I apologise to the House for that—were listed on 14 October in the announcement made about quangos? Will the Minister also explain whether an impact assessment has been done on any or all of these bodies, and when we might see the results of that? How many people does he expect will be made redundant, and at what cost?

[Earl Howe]

My Lords, the impact assessment will be published as soon as we know the size and shape of the costs involved. As I mentioned in my original Answer, we do not know that at the moment because we do not know about natural wastage, the grades of the people who will have to leave, and so on. The main reason why those two bodies have been included in the Bill is that our proposals, when we finalise them, will be very simple. As I have outlined, they will involve reparcelling the current functions of the bodies in different directions. That is not a difficult thing to do: it can be done very easily by secondary legislation.

Health: Chronic Fatigue Syndrome

Baroness Thornton Excerpts

Monday 8th November 2010 Lords Chamber

[Earl Howe]

My Lords, I understand why the noble Baroness asked that question. I believe that platelets cannot be stored in refrigerated conditions and are therefore, in theory, open to more infection. I am advised that SaBTO, the expert committee, looked at this and advised that no action was currently necessary.

[Baroness Thornton]

My Lords, I took a look at the blood transfusion service’s excellent website over the weekend to see what it had to say about who should and who should not donate blood. Basically, it said that you should be in good health. People with CFS/ME often experience a range of symptoms that could be made worse by donating blood. Notwithstanding the problem of diagnosis and that the precautionary principle is exactly right, surely that is the point. There should be a common-sense approach that people with ME should not give blood because they are not well enough.

[Earl Howe]

My Lords, the noble Baroness has put her finger on it. On a precautionary basis, even though the risk is considered low to those with CFS/ME when they are without symptoms, it was considered appropriate to exclude them permanently from being blood donors in case it affected their own health.

Health: Diabetes

Baroness Thornton Excerpts

Thursday 4th November 2010 Lords Chamber

[Baroness Thornton]

My Lords, I congratulate my noble friend Lord Harrison on initiating this debate and on his tireless work on behalf of those with diabetes. I also congratulate the noble Baroness, Lady Young, on her new post. She is indeed a multi-purpose Baroness. When I first got to know her she was working on behalf of birds. Then she seemed to cover the whole environment, with a quick diversion into health regulation. I am sure that she will now hold the Minister’s feet to the fire on behalf of those with diabetes. We can indeed look forward to that.

By the time we get to the point where someone with diabetes has had a limb amputated or is in serious trouble with their feet, we have failed them at several levels. In two-thirds of the 2.5 million people with type 2 diabetes, the disease was preventable, which means that prevention still has a long way to go in terms of smoking, diet, alcohol consumption and lack of exercise. As the noble Baroness, Lady Hussein-Ece, said, prevention is vital. My noble friend Lord Graham of Edmonton was right to look to the future in terms of tackling obesity in children. It seems crucial that any new regime which the Government introduce should have at its heart prevention and the levers that will make prevention work.

Let us consider, for example, the issue of smoking. We know that things such as the smoking regulatory regime are often—pardon the pun—slow burning. However, over time smoking must become something that people simply will not and do not do. In this regard, can the Minister confirm that the tobacco regulations on vending machines and points of sale are still on track? I keep hearing rumours that the decision is being reopened by the Minister’s colleagues in BIS. Perhaps the Minister could take the opportunity to inform the House of the situation, because smoking is a major contributory factor in diabetes.

We know, and it has been said today, that foot problems are one of the many complications associated with diabetes and the most common cause of non-traumatic limb amputation in the UK. As many noble Lords have said, it is a shocking statistic that 100 people a week have limbs amputated as a result of these complications with their disease. I am also shocked—although I suppose I should have known this, having been a health Minister—that the tariff system pays for a limb to be amputated but not for it to be saved. I ask the Minister to explore that and what can be done about it.

As with many chronic conditions, there are several co-morbidities that often accompany diabetes. If people who have diabetes and those associated with them do not have access to accurate information about the management of the condition, support in managing it and knowledge about what to look out for, the NHS will have failed them in both the provision of information and the management of their condition from the outset. It is very important that the Minister gives us an idea of how the proposed information initiatives involved in the reorganisation of the NHS will deliver this important aspect of diabetes care.

We should emphasise the importance of the need to invest in prevention and the earlier stages of diabetes management in order to prevent a deterioration of health that leads to devastating complications such as ulcers, limb amputation and blindness. If it is the case that 10 per cent of NHS funding is spent on diabetes care and that this is set to rise because of ever-increasing numbers of people with diabetes in our ageing population, it seems absolutely self-evident—as many noble Lords have said—that preventing people developing diabetes and providing quality care and support for those with diabetes are essential to reducing the far-reaching emotional and physical consequences of foot disease, amputation and other issues.

I was also startled to learn about the cost of the specialist shoes—to be absolutely honest, I wondered whether you could not buy a pair of Jimmy Choo’s for that. I have never bought a pair myself, but it seems to me that that sort of comparison illustrates the absurd world in which we live.

We also know that the presence of specialist nurses and tailored care for diabetics is very cost effective. I agree with the comments of the noble Viscount, Lord Falkland, on the cost-benefit analysis of this. There is anxiety regarding the proposed reorganisation of the NHS vis-à-vis the community of specialists and the expertise that goes with them. Therefore, like other noble Lords, I seek comfort that, as with many other long-term conditions, we will not lose the growing expertise in this field. We do not want to have to reinvent that expertise when the dust settles around the new arrangements in the NHS.

We have to ask whether people who find themselves in danger of losing a limb or part of one will inevitably do so. Indeed, Professor Cliff Shearman, president of the Vascular Society of Great Britain and Ireland, said:

“Amputation is a devastating occurrence. It is estimated that in some groups of patients, 85% of amputations can be avoided. Early recognition of the patient together with early involvement of a multidisciplinary team can reduce amputation”.

Those comments make the fact that 100 people a week are losing a limb very shocking.

The issue is not a lack of available treatment, as my noble friend Lord Harrison said, because the appropriate technologies are available now. These technologies are used in the NHS but patients would benefit from having access to a multidisciplinary team to make timely decisions on the best course of action to prevent amputation, or minimise the extent of amputation if it is necessary. We fail if those multidisciplinary teams are not activated and available.

Therefore, I conclude by asking the Minister how the Government can ensure that both the teams and the technology are available and funded. It must surely be more cost effective to deliver prevention in order to minimise the number of people who present with diabetes, to deliver information so that they can manage their condition, to provide properly resourced clinical management of their condition and to make a serious effort to avoid the final and horrible fate of the loss of a limb.

Healthcare

Baroness Thornton Excerpts

Thursday 28th October 2010 Lords Chamber

[Baroness Thornton]

My Lords, the Government in their White Paper propose to establish the independent NHS commissioning board, establish new local authority health and well-being boards, develop Monitor as an economic regulator, and expect to have the new commissioning system in place by April 2013, by which time SHAs and PCTs will have been abolished. The noble Lord, Lord Hunt, is perfectly right to say that this is big.

It is a shame, therefore, that we did not have double the amount of time for this debate to enable noble Lords to develop their arguments. We still need to have those discussions about the Government’s proposed reforms. These are reforms that will turn the NHS on its head if they are carried through, and bring with them considerable risks to patient care throughout the system—in transition, and possibly in the outcomes. As Philip Stephens said in the Financial Times on Tuesday:

“NHS reform, an accident waiting to happen”.

I agree.

The Minister will forgive me if I repeat the question that I have put to him on at least two other occasions: where is the evidence base for this revolution? The noble Earl has quoted to me international league tables, arguing that the NHS is not succeeding as well as the health services of other countries; but we can both play at that game. Indeed, I can quote a table which shows how well the NHS is doing and is at the top. I will make it my business to make it available to the noble Baroness, Lady Knight. Certainly, not one of the league tables suggests that the NHS is the kind of basket case of underachievement that the noble Lord, Lord Alderdice, suggested.

The question that the Minister fails to address is: where is the evidence that requires the wholesale disruption of the UK health services to deliver what may well be legitimate improvements that the noble Earl and his Government seek to make? The noble Earl’s failure to provide the evidence leads to only one conclusion: that the evidence to justify the wholesale disruption of the NHS does not exist, and that the Government have set their face against pilots which might provide us with the proof or otherwise that this proposal will work. Legislation could then follow the evaluation of those pilots. You may then add to this that the reorganisation was not proposed in either the Conservative or Liberal Democrat manifesto. The coalition agreement said exactly the opposite—that there would be no top-down disruption. We can only assume that this is driven from within the Conservative Party by an ideological commitment, presumably led by the Prime Minister—despite whatever he may have said during the general election.

I have increasingly felt over the past month that Andrew Lansley and I are reading different submissions about the White Paper. I am reading them all, and I expect that he is, too. He seems to think that they are wholly positive. Everyone agrees that the Government’s overall objectives of patient choice and clinical leadership are right—and most of the submissions state that. At that point, I can only think that Andrew Lansley stops paying attention, or stops reading. The reason I say that is because, with few exceptions, most of the submissions—from the most positive of the BMA, given that doctors have a great deal to gain from this not simply in terms of responsibility, to the most worried, including those of the Stroke Association or the British Thoracic Association—are all saying, “Whoa, slow down. Such a large upheaval and change needs to be properly piloted and evaluated”; or they are asking the type of questions that can lead you only to that conclusion. I am afraid that so far the Government have signally failed to provide answers to some very legitimate concerns.

Certainly, there has been an outpouring of consultation papers from the department, and were Andrew Lansley not in such a dangerous hurry, that would be good. There would be a reasoned and sensible debate across the piece, but the breakneck timetable of Andrew Lansley means that there has to be a question mark over how seriously the Government are taking the concerns and reservations of an increasingly loud chorus.

This puts huge responsibility on us in Parliament in both places to ensure that these voices are heard and their questions answered and that we do not allow such wholesale disruption of the UK's health services at the ideological whim of this Conservative Government. Can the Minister tell the House what is the timetable for the proposed legislation and whether there will be an opportunity for prelegislative scrutiny? That would go some way to making this process more accountable and more considered, which something of this magnitude deserves.

If only one in four doctors believe that the proposed reforms will improve the quality of the patient care and only 22 per cent of doctors believe that the NHS will be able to maintain its focus on increasing efficiency while implementing the proposed reforms—which is what the King’s Fund says—will the Government please heed the chorus which says slow down? This is £80 billion pounds of taxpayers’ money. This is too big without more thought and explanation. This needs to be properly tested and piloted. This is people's lives and well-being. Surely we all deserve time and consideration for something so big.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, this has been an extremely wide-ranging and well informed debate, and I thank my noble friend Lord Hunt of Wirral for raising these important issues and all noble Lords who have spoken very eloquently. I share the wish that we had more time to debate these matters.

Just three months ago, my right honourable friend the Secretary of State for Health published the White Paper, Equity and Excellence: Liberating the NHS. It is an ambitious plan for reform. It is focused around three key purposes, which are the three themes of today’s debate: first, to put patients first and for patients genuinely to feel that no decision is made about them without them; secondly, to concentrate not on inputs and processes but on outcomes and to build a culture of evidence and evaluation and for innovation and evidence to drive quality care; and thirdly, in aiming to deliver the best care, we must empower the people whose responsibility it is to deliver that care. We will give general practice the power to commission services on behalf of patients, combining clinical decision-making with control of resources.

The Government are determined to improve the quality of the NHS and the outcomes for patients. Our ambition is clear: it is for the health outcomes in this country to be among the best in the world. Today, the NHS has some of the best people and the best facilities in the world, and I do not in the least belittle the improvements made to the NHS by the previous Administration, but the fact of the matter is that when it comes to what is really important—to outcomes—we lag behind. I hope that all noble Lords agree that patients deserve better. The NHS can be better, and with the reforms we have set out in the White Paper, it will be better. I know that there is a wide range of opinion about the White Paper. There always is when you try to do something substantial and challenging, but the Government have been encouraged by the widespread acceptance of the vision that we have set out and the principles of our reforms.

To deliver the best care, we must empower the NHS staff whose responsibility it is to give that care. In essence, GP-led consortia, led by GPs in close partnership with other healthcare professionals, will establish the range of services and contracts needed to give their local population the high-quality services they need and the choices they want.

The success of GP commissioning decisions will be determined by the relationships that they develop with others. Local specialist community nurses will be there to help GPs design the best community services, just as hospital consultants will be essential for designing specialist pathways before, during and after a period in hospital. Local authorities will be crucial for helping to integrate health with other local public services to optimise outcomes.

GP commissioning will not turn GPs into managers but it will enhance their role as leaders. When it comes to day-to-day managerial and administrative tasks, consortia will have a separate budget with which to buy in the support that they need, be that from a local authority, a charity, an NHS provider, an independent contractor or elsewhere. I say to the noble Baroness, Lady Thornton, that, in effect, there are going to be pilots. We plan to roll out pathfinder consortia over the next few months that will indeed pave the way and learn lessons that others can follow. GP commissioning also opens up the potential for working closely with local authorities.

[Baroness Thornton]

My Lords, the pilots will be running at the same time as the legislation is going through Parliament. I fail to see how that will influence the legislation.

[Earl Howe]

My Lords, under current powers introduced by the noble Baroness’s own Government, GP commissioning can take place within certain limitations, but it is possible for GPs to engage now in the kind of joint working that we envisage and indeed that her Government put in place. I see no inconsistency there, and I think that that will helpfully inform our debates on the Bill.

GP commissioning, as I said, opens up the potential for working closely with local authorities to jointly commission services, even for the pooling of budgets to tackle local priorities. For example, by working closely with the local authority and social care providers, far more can be done to help older people or those with a disability to live independently, reducing their reliance on the NHS by avoiding things such as hospital admissions.

GPs will lead but they will not be alone. The NHS commissioning board will be there to support and advise GP commissioners and to share and spread their experiences. There will be no need to reinvent the wheel hundreds of times. One thing that the commissioning board will do as little as possible, though, is tell health professionals how to do their job.

We will also give far more power to patients. Research clearly demonstrates that treatment is better and often cheaper when the patient is an active participant in their care, not simply a passive recipient. In the coming years, we will give patients real control over when, where and by whom they are treated. They will be central to all decisions about their aftercare, often—where appropriate—spending their own budget in a way that suits their needs rather than the needs of the system.

Personal choice will not be the only way that people will be able to shape their care; they will also have a say in how local services develop. Strong local democratic accountability will be an essential part of the new system. Patients will have a strong voice in local decision-making through local authorities and HealthWatch, a new patient champion. For the first time, local people will have real powers of scrutiny over local health services.

We are very good at treating ill health in this country but we are less good at preventing it. We have the highest rates of obesity in Europe, rising levels of drug and alcohol use and, despite recent falls, stubbornly high rates of smoking. As a result, nearly one-quarter of all deaths in England stem at least in part from an unhealthy lifestyle. We have to do far more to stop people from needing treatment in the first place—to keep people healthy. We need a new emphasis on public health. Later this year we will publish a second White Paper on public health. Its aim will be to transform our approach to public health, protecting the public from health emergencies such as swine flu and improving the nation’s overall health and well-being.

I turn to some of the questions that have been asked. As I said earlier, the debate has ranged far and wide, and there have been a great many questions. We are short of time and I apologise to those noble Lords to whom I shall have to write, but I shall endeavour to cover as many topics as I can.

The speech of the noble Lord, Lord Winston, was uncharacteristic of him. I am sorry that he does not buy into the vision that we have set out. I am sorry that he does not think that we published the White Paper in good faith. The noble Lord gave the House to believe that the considerable efficiencies which we have signalled to the NHS it needs to achieve over the next four years were initiated by this Government. He will, I am sure, recall that they were in fact instigated by the previous Government. They are necessary and have nothing whatever to do with the Government’s White Paper. We need to treat more patients for approximately the same money without diminishing quality. That is the challenge.

I could hardly believe what the noble Lord said about the research budget. The announcements that we have made about research, arising out of the spending review, have been widely welcomed by the research community. We were clear that we wanted to protect science and we have done so. In the current economic climate, that is exceedingly good news.

The noble Lord, Lord Turnberg, in particular, should be reassured of our commitment to the promotion and conduct of research as a core NHS role. The White Paper makes that commitment clear. It also commits the department to a culture of evaluation. The reasons are straightforward. Research provides the NHS with the new knowledge needed to improve health outcomes. Research enables the department to know whether our policies are effective, cost effective and acceptable. The Government are committed to maintaining a ring-fence on research funding and will cut the bureaucracy involved in medical research. Work is in hand to achieve that.

The noble Lord, Lord Winston, also expressed scepticism about the whole idea of measuring health outcomes. Again, I was astonished that he, of all people, should pour cold water on our wish to do so. Just because it can sometimes be difficult to measure certain outcomes in a meaningful way does not mean that you should just give up. Great care must, of course, be taken when interpreting outcome indicators. You cannot simply make black-and-white judgments. However, if we focus only on processes, we risk creating a whole system of accountability that has lost sight of the overall purpose: improving the health of patients.

The noble Baroness, Lady Wall, asked me to underline the importance of local decision-making in the NHS. I readily do so. Those in a position to know what services are required to meet the needs of their patients are those closest to those patients—not politicians in Whitehall, but local doctors in general practice, local doctors and managers in hospitals and patient groups with local knowledge. All of this is part of our vision, which we intend to give substance. I was grateful to the noble Lord, Lord Mawson, for all that he said on this.

I welcome the remarks of the noble Lord, Lord Beecham, about health and well-being boards. It is not only they that will be scrutinising their own activities. As part of the public health service, health and well-being boards will be subject to quality and outcome standards set by the Secretary of State, and will be supported in their efforts by the public health service centrally.

The noble Baroness, Lady Masham, spoke in her characteristically impassioned way about patient safety. I agree with her that patient safety is absolutely vital. It is a key domain of our proposed outcomes framework; a key part of the quality agenda. My noble friend Lady Knight will, I am sure, agree that the most important thing that we need to do is bring about an open and transparent safety culture within all NHS organisations, a culture that is open about when mistakes are made and in which the number of serious incidents falls. Most importantly, it must be an NHS that learns from its mistakes.

The noble Baroness, Lady Masham, referred to the case of the tetraplegic man in Wiltshire whose life-support machine was cut off. This is a tragic and deeply distressing case, currently being investigated by the Nursing and Midwifery Council. Under the new registration framework, introduced in April 2010 for NHS trusts, all providers of regulated activities must register with the Care Quality Commission and meet a set of 16 requirements of essential safety and quality. These include a requirement to ensure that all staff have the necessary qualifications, skills and experience, which are necessary for the work to be performed. All agency staff must meet the same professional standards as permanent staff, as set out by the independent regulator, the CQC and each local safeguarding board. The Department of Health expects all NHS trusts to ensure that they employ appropriately qualified and supervised locums and agency staff.

My noble friend Lady Miller set out her view on which outcomes patients want. Her remarks were very helpful. I am pleased that there appears to be much commonality between what she set out and what was included in our proposals for the NHS outcomes framework. At the highest level, the outcomes that we felt mattered were preventing people dying prematurely; enhancing the quality of life of patients with long-term conditions; supporting people to recover from acute episodes of ill health and following injury; ensuring people have a positive experience of care; and, finally, treating people in a safe environment and protecting them from avoidable harm. Those domains get very close to what most of us would regard as a synoptic view of what good outcomes mean.

The noble Lord, Lord Turnberg, spoke about the need to achieve integrated care across primary and secondary sectors. I agree with him. The purchaser and provider split that the White Paper refers to must not be seen as a reason or excuse for GP consortia not to seek the advice, support and collaboration of clinical expertise on the provider side to ensure that the best possible services are commissioned for patients.

The noble Lord, Lord Mawson, asked how we can ensure that GPs will work across the community and public sector generally. Health and well-being boards have a critical role to play in co-ordinating a strategic patient-centred approach at a local level. GPs, local community representatives and democratically elected councillors will be tasked with making sure that they act on behalf of their patients and communities to deliver integrated services. A board will have a formal duty to involve and consult local people.

The noble Lord, Lord Beecham, asked in particular how GP consortia will work with local authorities. We have proposed that local government should have an enhanced responsibility for promoting partnership working and integrated delivery of services across the NHS, social care, public health and other services. It will be important for GP consortia to work in partnership with local authorities—for example, contributing to joint assessments of the health and care needs of local people and neighbourhoods, and ensuring that their commissioning plans reflect these needs.