NHS: Mental Health Services

Baroness Tyler of Enfield Excerpts

Monday 8th October 2012 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, it is always daunting to follow someone as eminent as the noble Lord, Lord Layard, in a debate on mental health, but that is what I will seek to do.

Like many other noble Lords this evening, I very much welcomed the Government’s mental health strategy, No Health Without Mental Health, which gave clear priority to a long-neglected area of health policy. The implementation framework for that strategy, which was published earlier this year, was equally welcome in ensuring that the strategy did not simply gather dust. Like my noble friend Lord Alderdice, I greatly welcome the £400 million that the Government have invested in improving access to psychological therapies—IAPT—as a key plank of the strategy.

While I am pleased that the NHS Commissioning Board has endorsed the framework, it is also vital that the board makes the implementation of the strategy one of its key priorities. Like the noble Lord, Lord Layard, I think that means that it should feature prominently in the commissioning board’s mandate and the NHS outcomes framework. I ask the Minister to update, and I hope assure, the House on that point.

However, even that will not be enough to make a reality of improved mental health services for all. More is needed and I want to pick out three things. First, the forthcoming changes in the commissioning arrangements give the potential for a greater focus on early intervention. This means commissioners in CCGs and the national commissioning board having access to the right level of mental health expertise, both to assess mental health needs and to commission the right services to meet those needs.

Secondly, the Government have stated their intention to introduce payment by results for mental health services. The first step here is the long-awaited development of tariffs for mental health services. I know that those involved in the development of tariffs have expressed concerns about the lack of clear guidance from the Department of Health and in some cases poor data and inadequate IT systems at a local level. This does not augur well. I think that the sector as a whole recognises the challenges that payment by results represents for the whole mental health system, but can the Minister update the House on what additional support the department is making available in this complex area? Thirdly, with the expansion into mental health services of payment by results, we also need to ensure that the outcomes for which providers are paid fit with the objectives of the mental health strategy and are aligned with NICE’s work on quality standards. In other words, it must all join up.

We all know that mental ill health cannot be tackled by NHS mental health services alone. It is crucial that others—we have already heard about them this evening: local authorities, employment, housing, and criminal justice—play their part. The new health and well-being boards will be vital in helping local government, the NHS and others, including the voluntary sector, to tackle the causes of ill health at source. I look forward to seeing well-being services set up, which would include occupational health, housing, smoking cessation, fitness centres and mental health services working together for new attitudes towards public mental health.

Like others, I mentioned the importance of IAPT at the beginning of my speech, and I recognise that we have already heard some differing views on this tonight. While I am a great supporter of the concept of talking therapies, my view is that the current policy does not adequately or accurately reflect the importance of providing a range and choice of counselling and psychotherapy to meet a range of needs. I recognise and welcome the limited expansion of IAPT from purely CBT models to include other models such as couple therapy for treating anxiety and depression in cases where relationship problems are also a factor—either a cause or a consequence of the depression.

However, specialist providers, particularly those in the voluntary sector, have found it very difficult to navigate their way through an IAPT commissioning process that was clearly designed with the statutory sector in mind—a point that I thought was made very compellingly by the noble Lord, Lord Wills. I believe that counselling and psychotherapy play a vital role in promoting good mental health and well-being, and in the treatment of mental ill health. In my view, current government policy still does not sufficiently reflect the role that counselling and therapy can and do play. I would like to see more collaboration and joint working in this area.

Finally, I draw attention to the importance of improved mental health services for children and young people, for if mental health services have long been seen as the Cinderella of health services generally, surely children’s mental health services are the Cinderella of that Cinderella service. Yes, the role of the NHS is crucial here, but so too is the role of schools and the voluntary sector.

We all know of the parlous state of the NHS Child and Adolescent Mental Health Services, known as CAMHS. In a recent survey of providers and commissioners conducted by YoungMinds, over half of respondents said that they intended to reduce their spend this year. The biggest cuts were in local authorities, with some slashing up to 25% from their budgets. On a more positive note, some 20% said that they were planning to increase their funding for CAMHS. All this can only exacerbate the existing, very large variations in availability, quality and timely access to these vital services. On top of these, many voluntary sector services, as we have already heard, are having to cut back or close down.

I welcome the new bond initiative funded by the Department for Education to increase the availability, quality and young-person focus of early intervention services that address mental health issues earlier. However, this is currently a limited pilot in five local authority areas. Equally, I welcome the new children’s IAPT pilot, again in a small number of areas. I ask the Minister what plans the Government have for rolling this out more widely.

Touching on a point made by the noble Baroness, Lady Meacher, while thousands of young people in Wales and Northern Ireland benefit from national programmes of school-based counselling, England lags behind as the only country without a commitment to these services. This leaves many young people in England without effective and accessible therapeutic support in schools, despite the fact that counselling is associated with significant reductions in psychological stress. The Welsh Government’s national school-based strategy, which has been externally validated, has been shown to be an overwhelming success, so much so that the Welsh Government are planning to make counselling in Welsh secondary schools a statutory service. With the clear benefits that it has demonstrated in improving attendance, behaviour and attainment in schools, surely providing access to school counselling could be one good use of the pupil premium in England.

Why have I made such a great play of children and young people’s services? Research has shown that huge costs to the economy are associated with mental health problems, which all too often begin in childhood and continue into adulthood. Perhaps I may give noble Lords a few facts. Half of all lifetime mental illness presents by the age of 14, contributing to the vast economic and social costs of mental health problems. One in 10 children under the age of 15 has a diagnosable mental health disorder. Rates of mental health problems among children increase as they reach adolescence. Between one in 12 and one in 15 children and young people deliberately self-harms. More than half of all adults with mental health problems were diagnosed in childhood, but—this is the crux of the matter—fewer than half were treated appropriately at the time. According to the then Department for Children, Schools and Families in 2009, 60% of children in care have some form of mental health disorder. This is an astonishing figure that calls for an urgent response.

In summary, mental health problems obstruct many key goals for children. I would welcome the Minister saying what more the Government are doing to join up policy effectively, particularly between the Department of Health and the Department for Education, in order to address the mental health problems of children and young people. It is a no brainer that we must do this. It makes sense socially, economically and morally.

NHS: Spending Formula

Baroness Tyler of Enfield Excerpts

Tuesday 3rd July 2012 Lords Chamber

[Earl Howe]

My Lords, we come back to the issue of age in this context. I say again that we believe, as did the previous Government, that age is the primary driver of an individual’s need for health services. The very young and the elderly, whose populations are not evenly distributed throughout the country, tend to make more use of health services than the rest of the population—the noble Baroness gave a very graphic and important example of where that applies. This principle is reflected in the most recent PCT-weighted capitation formula. As I said earlier, there are imbalances that, over time, we will seek to correct.

[Baroness Tyler of Enfield]

My Lords, accepting that —as the Minister said—we are where we are, could he explain what evidence base is being used to determine the allocation of resources to CCGs?

[Earl Howe]

My Lords, the funding formula is made up of a number of components, including capitation, deprivation, age, the number of young people not staying in education and the number of people over 60 claiming pension credit. I have a long list in front of me. However, ACRA, the independent body that I mentioned, is composed of a group of independent-minded people who are keen to take into account every relevant factor that bears on this question. If my noble friend wishes, I will write to her with a more detailed list of the factors that historically have been in the formula.

Care Homes

Baroness Tyler of Enfield Excerpts

Monday 28th May 2012 Lords Chamber

[Earl Howe]

My Lords, as I made clear earlier, there is already a test for those people who are in charge of a care home. The CQC has procedures to verify the acceptable status of such people. Furthermore, there are very strict rules under the Financial Services Authority regulations, which require company directors to pass a “fit and proper person” test. We are not sure what added value might be conveyed by a further test, as the tests are already there.

[Baroness Tyler of Enfield]

My Lords, given the very great anxieties experienced by care home residents and their families on this issue, what steps are the Government taking now to prevent another Southern Cross situation arising, in both intelligence gathering and strengthening the regulation and oversight of the sector?

[Earl Howe]

My Lords, the Government are working with the Association of Directors of Adult Social Services and the Care Quality Commission. We are gathering greater intelligence on the social care market and its major providers, which will be used to give early warning of impending problems. We will continue to meet regularly with the major care providers to discuss their trading performance, their financial situation generally and how they are addressing any issues which put pressure on their ability to continue trading.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Monday 19th March 2012 Lords Chamber

[Earl Howe]

My Lords, I will speak also to Amendments 9 and 10. The three amendments in this group share a common purpose in strengthening the duties on the NHS Commissioning Board and CCGs in relation to reducing inequalities. I am grateful to my noble friend Lady Tyler for highlighting on Report the need to ensure this, and I promised at the time to introduce the necessary amendments at Third Reading to achieve it.

New sections 13G and 14T place duties on the NHS Commissioning Board and CCGs to have regard to the need to reduce inequalities between patients with respect to their ability to access health services, and to the outcomes achieved for them by the provision of health services. As the Bill stands, the NHS Commissioning Board and CCGs must assess in their annual reports how they have discharged this duty. However, they are not explicitly required to plan for this and, in the case of CCGs, not specifically assessed on this in the board’s annual performance assessments. These amendments introduce explicit requirements on these points. They require the board to include in its business plan, and CCGs to include in their annual commissioning plans, an explanation of how they intend to discharge their inequalities duties. I remind noble Lords that CCGs will consult on their commissioning plans with those for whom they are responsible, and must involve each relevant health and well-being board in preparing and revising their plans.

The amendments also require the board to specifically assess in its annual performance assessment of CCGs how they have discharged their inequalities duty. So CCGs will have to set out in their plans how they will take account of the need to reduce health inequalities and report on how they have done this in their annual reports, which is of course already a provision in the Bill. Their performance on this will then be one of the factors taken into account by the board when it assesses their performance. Together, these amendments ensure that from the development of the plans to the reporting on their effects, having regard to the need to reduce inequalities will be given particular emphasis and importance by commissioners. I beg to move.

[Baroness Tyler of Enfield]

My Lords, I shall speak to government Amendments 7, 9 and 10, to which my name is attached, and in so doing I thank the Minister for tabling them. As he has explained, they all relate to health inequalities; I would like briefly to place them into a wider context. In doing so, given that this is Third Reading, I make one general point. My view from the outset has been that this Bill should be judged ultimately by the health outcomes it produces—essentially, whether and how it improves people’s lives, particularly the most vulnerable. Because so much of the debate over the past year has—necessarily, I guess—been about structures, I sometimes feel that we have rather lost sight of this fundamental point. One specific point that has not received enough airspace in our deliberations, perhaps until today, is about reducing health inequalities—or, put another way, doing something real about unequal life chances. At the very outset, I felt that the fact that this legislation contains a landmark legal duty for the Secretary of State to reduce health inequalities was really significant.

As the noble Earl has explained, as the Bill has progressed through its various stages this duty has been strengthened at various levels in the new structure, so that reducing health inequalities now runs through the whole fabric of the health system in a way that we have not seen before. I will not repeat precisely what these amendments do, because they have been very ably set out. Briefly, however, in relation to the requirement that each CCG’s performance is assessed each year by the board and includes the progress made in reducing health inequalities, we all know that what gets measured gets done. That is what makes this significant.

However, we should not look at these specific duties in isolation from other key aspects of the Bill on accessibility and integration. New duties to join up services between health, social care and other local services, such as housing and homeless support, will have a crucial role to play here. The role of health and well-being boards in promoting joint commissioning should enable more integrated services, particularly, for example, for older people and people with learning disabilities. Finally, the much stronger focus on public health—I greatly welcome its return to local authorities—will be key to tackling issues such as obesity, smoking, drug and alcohol abuse and sexual health, which make a real difference in reducing health inequalities. This all adds up to a much stronger package than we have had before. Of course, the proof of the pudding will always be in the eating, but this very welcome shining of the spotlight on health inequalities has the potential to be a game-changer for some of the most vulnerable.

However, in case noble Lords think that I am being too uncritical, I finish on a point of concern. Local authorities are well placed to tackle inequalities, due to their responsibilities for education, housing and other factors which impact on health. The current proposition for holding councils to account for this is through what the Government call a health premium, to give extra money to those areas that reduce health inequalities. We need to be careful that this does not simply reward those areas where it is easiest to tackle inequalities and divert money away from areas where more fundamental problems may slow down progress.

In thanking the noble Earl most sincerely for tabling these amendments and paying tribute to his strong personal commitment on these issues, I respectfully ask him whether he will keep the health premium under review as it is rolled out.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Thursday 8th March 2012 Lords Chamber

Moved by

[Baroness Tyler of Enfield]

234ZA: Clause 182, page 180, line 28, after “Commission);“ insert—
“(ga) making recommendations to that committee to publish reports under section 45B(3) of the Health and Social Care Act 2008 about particular matters;“

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Wednesday 29th February 2012 Lords Chamber

[The Earl of Listowel]

My Lords, I support the amendment of my noble friend Lady Finlay of Llandaff. I noted what my noble friend Lady Murphy said. The Minister is aware that I have a long-standing concern about less-than-mainstream services for children and families, particularly in the mental health area. It became apparent several years ago when considering legislation around safeguarding children that there was a great shortage of appropriate interventions for children who sexually harmed other children. The approach was very piecemeal across the country. I became aware of a service working in London with these children. A team with a psychiatrist, a couple of clinical psychologists and a couple of social workers helped children who sexually harmed other children. Its interventions prevented those children going on to become adults who sexually harmed children. A large proportion of children who are sexually harmed are harmed by other children.

This is a very important service, and what I have heard again and again over the years was how the service had struggled to find funding. It appealed to its primary care trust, which simply did not recognise the importance and value of what it did. My concern is that, in a climate where there is such a shortage of resources, the national Commissioning Board may be too far away from these very small services in local areas. Therefore, it is important to do all that can be done to ensure that clinical commissioning groups have the expertise to recognise the value of these niche services and do what they can to support them. I look forward to the Minister's response and hope that he will comfort me.

[Baroness Tyler of Enfield]

My Lords, I rise briefly to support Amendments 75 and 94, tabled and spoken to so clearly by my noble friend Lady Williams of Crosby, which are very important. The nub of the amendments is that they are designed to address the problem that we know still exists of a limited number of people who are not on GPs’ lists and who, as has been said, fall through the cracks and often—inappropriately—turn up in accident and emergency units. I can verify this because on a recent weekend I spent 12 hours in accident and emergency with two of my relatives. During that time, time after time people came in with needs that were real but which it was not for A&E to meet. Problems with access lead to some of the inequalities in health outcomes about which we on all sides of the House are very concerned.

When considering the Bill recently, the Minister agreed to new duties to ensure that CCGs and the national Commissioning Board include in their annual report details of how they have met their health inequalities duties. I very much welcome these changes to the Bill, but I am not convinced that this reporting after the event is going to be sufficient to tackle some of these very deep-seated inequalities, which often lead directly from difficulties in access to NHS provision.

Will my noble friend the Minister consider giving some very real teeth to the absolute imperative, as I see it, of universal provision—an absolute founding principle of the NHS, which I know is supported across the House—and see whether these duties could be extended in some way so that CCGs and the board also need to include health inequalities and issues of access in their commissioning plans and in the board’s performance assessment of CCGs? I would be very grateful if the Minister could reflect on this in his concluding remarks.

[Baroness Masham of Ilton]

My Lords, I have added my name to Amendment 96. These patients can have very complex and varied needs. Will the Minister give an assurance that they will not fall through the net between the Commissioning Board and the CCGs? There will be a great need to have excellent communication between the Commissioning Board and the CCGs. There is concern, as has been shown here today—and if there is concern here, my goodness, what will be the problem outside when funds have to be found for these patients? I implore the Minister to sort this out.

--- Later in debate ---

[Lord Adebowale]

My Lords, I support the amendment moved by the noble Lord, Lord Patel. I am grateful to the noble Earl for the time that he generously gave to me and the noble Lord to meet him and the civil servants. However, I was disappointed by the letter that we received following the meeting. I thought that we had driven home the point and had some sympathy from the noble Earl. I understand the need to tidy up legislation, which is an important thing to do, but I find it faintly disgusting that we are going to mess up people's lives. The legislation might be neater but lives will be made much messier.

I have just come from Manchester—from Turning Point’s offices there; and I declare my interest as the chief executive of an organisation that will be directly affected by the Bill—where we have a case of an elderly lady who has been with us for 14 months, at a cost of well over £100,000. We cannot get the NHS to pay it because it claims that it is the responsibility of the local authority, whereas the local authority claims that it is the responsibility of the NHS. That is the reality under the current legislation, even with, as the noble Lord pointed out, the provisions of Section 117.

We are told that, in tidying up, the proposed provisions will allow people who are discharged from mental health institutions to seek a judicial review if they are refused aftercare arrangements in co-operation with health and social services. I was astonished to read that in the letter. I do not know what planet the writer of the letter is on but I would welcome them to join my planet and actually visit and speak to people who are discharged from these institutions, and to talk to their families and friends, and then to come back and tell me whether they are in a fit state to seek judicial reviews against local authorities and the NHS. We must be real when discussing legislation that will affect the lives of real people who may not sit in this Chamber but who will cost us a fortune if we do not get this right.

It is with a very heavy heart that I support the noble Lord, Lord Patel, in his amendment. I hope that, at this late stage, the Government will see the obvious logic. Even in their responses to previous amendments they said that they wished to support the joined-up provision of health and social care. What better example is there of such provision than Section 117 of the Mental Health Act? It is as obvious as gravity. So we must insist—not to make a political point or reference to the Bill, but on behalf of people not in this Chamber who will cost the country dearly if we do not get it right—that the Government accept the logic of the amendment and just say yes.

[Baroness Tyler of Enfield]

My Lords, I support this important amendment. The whole basis of the Health and Social Care Bill is to place great emphasis on delivering integrated care as part of the needed reforms, and I am sure that we all support that. As the noble Lord, Lord Adebowale, has just said, though, Clause 36 in its current form will remove one of the few examples of genuinely joined-up service provision between local health and social services. A joint duty on aftercare services for these people, some of the most vulnerable in society, is crucial if they are not to have further lapses and become more and more marginalised. We talked earlier about people falling between the cracks, and that is the danger that we are in.

[Baroness Northover]

My Lords, I realise that noble Lords want to move on to other debates, so it might be opportune if I intervene now. We have always expressed sympathy for what the noble Lord intended in his original amendment. We listened carefully to the points put by the noble Lords when they came to see us, even if it seemed that we were not very responsive to what they were saying. We note the considerable emphasis that they place on retaining the duty of co-operation with the voluntary sector that is set out in Section 117. We realise that the clause removes the duty that is currently there, and that is clearly causing concern.

We do not feel that there is anything in the clauses that will bring in charging for any NHS or social care services that are currently provided free under Section 117, and the Government have no plans to bring in measures that would change the position on charging for Section 117 services. However, sometimes tidying up causes concerns. We are all used to dealing with the section as it currently stands and could continue to do so. We are nothing if not a listening team. The Government have therefore decided, and I hope that the noble Lord, Lord Patel, will be pleased, that we will not oppose his amendment. In the light of this, if your Lordships’ House agrees and wishes to accept his amendment, the Government will need to bring forward a few technical amendments at Third Reading to make a few consequential changes to the Bill to ensure that the amendment works properly in the amended 1983 Act. I hope that the noble Lord will be pleased that indeed we heard what he and his noble friend were saying.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Faulks]

My Lords, I remember well the degree of consensus in your Lordships' House when we debated the statutory duty of candour—namely, that everything should be done to embed in the NHS the culture of openness and to be against any form of cover-ups. However, as I said on that occasion, the world has moved on a little since the days of Lord Cohen—with great respect to the noble Lord, Lord Walton. A number of initiatives have resulted in greater openness by clinicians and a sense of responsibility, which one can find right across the health service. All is not perfect, of course. The duty of candour has been much discussed in academic circles, and the noble Baroness referred to the experience in America where some states—not many—have a duty of candour. But there are very serious arguments that run to the effect that imposing a duty of candour can have adverse effects in that many are thereby encouraged to sue in circumstances where they might not otherwise have sued.

The form of this amendment is certainly good in the sense that it focuses on the serious rather than the trivial. None the less, it does contain the word “incidents”, which is extremely difficult to define. In what circumstances does a clinician, or those employing a clinician, have to go through the processes that the amendment involves? From what the noble Earl said on the last occasion, the Government clearly take the matter of candour extremely seriously. There is a consultation about it and, in due course, there will be reflections of that duty in the contract. Although I am entirely sympathetic to what lies behind this amendment, I am a little concerned that imposing terms, with the inevitable imprecision that this form of amendment carries with it, is not at the moment the answer.

[Baroness Tyler of Enfield]

My Lords, I, too, spoke briefly in the debate last time about the statutory duty of candour. At the end of that debate the Minister gave a number of important reassurances. One was to review the contractual duty in a specified period to see how effectively it was working. The second was to do with further work to explore how this whole issue could be taken forward in the area of primary care—an area which I, and certainly colleagues on these Benches, still feel is extremely important. I would be grateful if the noble Lord, in summing up, could say anything further about how a contractual duty of candour would apply to those in primary care. Also, could he give any further reassurances at this stage about the reasons why he feels that a contractual duty of candour in the way which is set out in this particular amendment would be effective?

[Lord Campbell of Alloway]

I very briefly take the point made about an apology for the mistake. I do this because when I was an advocate I appeared before the BMA for quite a lot of medical professionals. If your client says, “I am terribly sorry for my mistake”, it puts one in a very difficult position; the advocate must show that the mistake had nothing to do with the result. I will not take up time, but say merely, as an erstwhile advocate, watch it.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Monday 27th February 2012 Lords Chamber

To tackle this we need more than grants to build capability in the social enterprise sector; we need fundamental change in the procurement culture of the NHS. It is about more than just creating guidelines. It is much more fundamental than that. These two amendments offer the Government a few further pieces of the jigsaw and seek to help Ministers create more social value from public service procurement. I beg to move.

[Baroness Tyler of Enfield]

My Lords, the hour is late but I wish briefly to explain why I have added my name to this amendment moved so compellingly by the noble Lord, Lord Mawson, whose credentials in this field are second to none.

In Committee it was argued that the Bill, as currently framed, could have serious unintended consequences both for social enterprises and for the wider voluntary and community sector. In my remarks, I want to focus on the wider voluntary and community sector. The basic concern expressed was that staff working on the NHS Commissioning Board, and indeed more widely, would interpret the Bill to mean that capacity building and other measures to support the development both of social enterprises and of voluntary and community organisations would be outlawed. A consequence of this would be to make it harder for charities and community groups, which are often very small with tiny management capacity, to provide the services and support that many people, particularly the most vulnerable and the hard-to-reach, rely on.

I know that many charities and community groups are particularly effective in reaching out to the people whom the statutory sector finds hard to reach and they then can advocate on their behalf and indeed can help provide an authentic user voice in the system. In Committee the Minister gave assurances that essentially these concerns were unfounded and that the Government will,

“ensure that procurement practices do not unfairly restrict the opportunities for charities, voluntary organisations and social enterprises to offer health and care services”.—[Official Report, 28/11/11; col. 108.]

When I followed this up afterwards with very helpful officials at the Department of Health, they said that the NHS Commissioning Board would be publishing guidance on this issue for commissioners. That guidance I am sure will be helpful but is it enough? There is always a danger that guidance will not be adhered to, will be misinterpreted or indeed will not be seen.

I want to refer very briefly to my own experience in this field. Until a month ago I was chief executive of the charity Relate. Our local centres which are very small with very limited management capacity found themselves in a commissioning exercise in relation to the talking therapies part of the NHS services. It was not an encouraging experience, to be frank. These local centres often found that potential NHS commissioners would wrongly assume or argue that the local Relate centres would be quite unable to mesh with the NHS’s systems, data, outcomes measurement or requirements. Often this simply was not the case but it reflected a lack of understanding on the part of the commissioners. I know that this has been the experience of a number of other charities both big and small.

In conclusion, this modest amendment would be more effective than simply guidance in preventing these unintended consequences. I very much look forward to hearing the Minister’s concluding remarks.

[Lord Newby]

My Lords, it is with very considerable diffidence that I rise to speak at this hour and for the first time on this Bill. Tomorrow we have, I hope, the Third Reading of the Public Services (Social Value) Bill which I introduced at Second Reading in your Lordships’ House. That Bill will require all public bodies, including health service bodies, to consider the broader social value of tenders when deciding whom to place the tenders with. At one level, therefore, it could be argued that these amendments might not be necessary. What concerns me is what happens after, as I hope will be the case, this Bill passes tomorrow. What change will take place in the health service and elsewhere? One of the absolutely key changes that has to take place is the one set out in Amendment 64B; namely, that weightings must be attached to social value at the point at which companies, social enterprises, charities and so on are submitting their tenders. Unless the procurement regulations are changed to provide for such weightings it will be very difficult to have the kind of change in culture and practice which the Public Services (Social Value) Bill seeks to achieve.

I wonder whether the noble Earl, who has already very helpfully in a debate on a previous amendment committed the Government to giving guidance in respect of one matter, will be prepared to commit the Government now to the extent that the Department of Health would require NHS bodies commissioning services covered by the Public Services (Social Value) Bill to include within the tender document a weighting in respect of social value.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Harris of Haringey]

I am grateful to my noble friend for that reinforcement. I regret that, within some NHS trusts and some provider organisations, there is not the same approach. There is a concern that it is better to keep a patient, or the family of a patient, in ignorance and hope that the whole matter goes away. The purpose of the amendment is not to penalise the individual clinician—we all recognise that accidents happen—but to foster the culture of openness that the department wants to see; it wants to ensure that that duty is reflected, not only as far as the individual professionals are concerned, but also as far as the organisations are concerned. Otherwise, too often the lawyers and managers will say, “In the interests of the trust, let us try to keep this quiet”. I am glad to hear that it does not happen in every instance, as I am sure it does not, but the purpose of the amendment is to provide a statutory framework that will make it quite clear to all those who might otherwise be tempted to cover up these incidents that they must say, “This is important and we have to be open”.

[Baroness Tyler of Enfield]

My Lords, I have a few remarks to make in support of the amendment, to which my name is attached. I shall be as brief as possible, because much of what I wanted to say has already been said. I pay tribute to the noble Baroness, Lady Masham, for arguing so eloquently for a statutorily enforceable duty of candour.

Having listened to the debate, I remain of the view that a provision in the Bill requiring provider contracts to include a duty of candour clause would be the best way forward and would send the clearest possible signal to the whole healthcare system about the need for openness. We have already heard that, as presently constructed, not all parts of the healthcare system would be covered by the contractual route. It would certainly send a much stronger message than merely relying on the contractual route. I do not see the two being mutually exclusive nor do I think that the principle of contractual freedom would be compromised by having a statutory duty of this sort. I believe that the duty of candour issue is of a different order from much of what else will appear in provisions in provider contracts. I also believe that it resonates very well with the public and would make a reality of what I think should be the most important underlying philosophy of the Bill, putting the patient first and the whole “No decision about me, without me” mantra.

Many noble Lords on these Benches feel very strongly on this issue. The key principle at stake is the right of patients, their families and their carers to know what has gone wrong with their care and treatment when, unfortunately, mistakes, including negligence, have been made. The statutory route would help to ensure consistency. We have already heard an interesting debate about the current lack of consistency. I very much agree with the noble Lord, Lord Harris, about the extent to which it would help to change the culture under which, currently, we know cover-ups have occurred, and make them much less likely to happen in the future. I recognise that a statutory duty alone will not achieve this; it will be a necessary but not a sufficient condition. The culture change that we have heard about will need role models among both clinicians and managers walking the walk, as well as training and support for staff, so that mistakes are acknowledged and, critically, lessons are learnt from the mistakes.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Wednesday 8th February 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I strongly support the amendment. Yesterday, I went to a meeting on prostate cancer, a disease that 10,000 people a year die from unnecessarily because of late diagnosis. I should like to tell noble Lords a small story about a friend of mine. He went three times to his local surgery in north Yorkshire and was sent away. His son was worried because there were symptoms, so he took him down here to London. He was diagnosed with prostate cancer straight away in a private clinic, but it had gone through to his bones because of late diagnosis. The treatment is much more expensive, so if only there was a standard throughout the country. Therefore, this is a very important amendment.

[Baroness Tyler of Enfield]

My Lords, I also support the amendment on prostate cancer, which is a very important area. However, I wish to support the government amendments in this group—Amendments 68, 112 and 144, to which my name is also attached. These amendments all relate to reducing health inequalities and, in a nutshell, create a new duty on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups to report annually on their progress in tackling health inequalities.

As this is Report stage I will not rehearse the stark statistics on life expectancy that we heard during earlier stages of the Bill. We also heard compelling accounts of what needs to happen to improve health outcomes for those particularly vulnerable and disadvantaged groups whose patterns of usage of the health service often take a different form from those of other sections of the population. These groups include the homeless, those with mental health problems and others whom we heard about earlier.

As I recognised in Committee, the explicit duties on health inequalities which the original version of the Bill placed for the first time on the Secretary of State, Commissioning Board and CCGs were landmark duties. They certainly represented a major shift from the current position. However, as a number of noble Lords, me included, argued in Committee, those duties did not go far enough, and we called for their strengthening, particularly so that CCGs and other parts of the structure would be required not simply to “have regard” to the need to reduce health inequalities but to act to secure real improvements in terms of access to health services as well as outcomes. It is also critical that those bodies should account publicly for their progress in so doing.

I thank very much my noble friend the Minister for listening and acting. The nub of these amendments is that they shine a clear spotlight on health inequalities by introducing real transparency and accountability at national and local levels. I very much hope that the amendments will be instrumental in changing the culture so that things such as sharing good practice in tackling health inequalities become a key part of workforce training and very much part of the currency of everyday language in the NHS.

These amendments have the potential to make a reality of the words in the public health White Paper that spoke of,

“improving the health of the poorest, fastest”.

It is for those reasons that I support these amendments, and I thank the Minister for tabling them.

[Lord Harris of Haringey]

My Lords, I support the amendments in this group because I believe that it is important that we look at the mechanisms that will be embedded in the Bill, assuming that it eventually receives Royal Assent in some form, and that will in practice drive change in the direction that we all want. That includes improving the quality of the care offered, and it means addressing the issues of health inequality to which the noble Baroness, Lady Tyler, referred.

One of the omissions from the Bill is that, apart from placing some general duties on the various bits of the NHS, there is very little about demonstrating how those duties will then be exercised or creating a mechanism for assessing that. The amendment, which talks about reporting annually to Parliament on the progress made, seems an essential first step in making sure that that happens.

The reports on inequalities will be increasingly important in this area. However, Amendment 112, dealing with CCGs’ annual reports on how they have discharged their duty to reduce inequalities, raises another question, and this comes back to the issue of what will be the catchment areas of individual CCGs. Unless there is far more central direction than I have understood—and perhaps the Minister can reassure us on that—it seems likely that there will be, to use an unpleasant term, ghettoisation in some CCGs.