Care Bill [HL]

Baroness Wall of New Barnet Excerpts

Wednesday 3rd July 2013 Lords Chamber

I join my right honourable friend Andy Burnham in calling on the Government to demonstrate their commitment by utilising part of the £2 billion NHS underspend that the Chancellor siphoned off in his March Budget. Some £1.2 billion could be used in the next two years to help tackle the current crisis in social care and smooth the way to the new system, which we all welcome, by relieving the pressures it will face.

[Baroness Wall of New Barnet]

I know very little about local government other than that I work with it in the health sector, but I wonder whether, with the pressure that is on all of us with the cuts and the absolute need to reduce things, local authorities have looked at every opportunity. All I know is that since our income in an NHS trust has been looked at more carefully, we have had to have a look at the cost improvement programmes that we can deliver. We had never done that before, but we have delivered so many of those, improving costs by £17 million in the last year.

I am not making a criticism as I have no idea at all, and I know that we can all bemoan the fact that we have less money and all the rest of it, but until we know that we have done everything that we can, and got right down to questioning if we could do things differently, then we perhaps need to look at ourselves as well. Forgive me if you have already done that.

Perhaps I might respond to the question that the noble Lord is asking about what it means to integrate social care and local authority stuff. This is why I worry to death about this amendment. If this part of the legislation does not happen, the whole system will be in much worse straits than it is now. We have an issue about our local authority cutting back on some of the places in nursing homes, which means that we do not have the opportunity to put patients who no longer need to be in a hospital in the place where they ought to be to receive care.

At some stage or other, all of us have got to work together and say, “How do we do this?”. For lots of different reasons, not just the bed space, it is much cheaper for an individual to be in a care home bed than in a hospital bed. If we cannot resolve it between ourselves, and we cannot do it on our own as providers, local authorities cannot do it on their own, and neither can the care sector generally, then I wonder if we are ever going to get there. People perhaps need to start to look at how we might achieve this by being a bit tighter in other things.

[Lord Beecham]

My noble friend is right to draw attention, as many of your Lordships already have, to the need to integrate the provision and to avoid the sort of cost-shunting that can arise if organisations are kept separate. That is the point of the pooled budget: you look not just at the straightforward provision of care by one or other partner, or both partners, but at what will perhaps reduce the need for care in other ways. As I say, other local services such as leisure and adequate housing, in conjunction with the public health agenda, may very well reduce the demand for particularly expensive forms of care, as I am sure we all agree.

Of course, local government’s track record is not uniform, but it is right to say that local government has proved over the years to be the most efficient part of the public sector. There has been a huge improvement programme in local government, recognised by the shortly to be lamented Audit Commission, and others, over the years. The LGA in particular has sought, through a whole series of policies, including the very extensive and successful use of peer review, to engender new approaches and more cost-effective ways of dealing with a range of problems, including those in the social care arena.

I was about to conclude by drawing attention to another figure, which has just emerged today. It is a rather startling figure: £9.8 billion of uncollected VAT—10% of the total take—according to today’s Guardian. That dwarfs the amount that the Government are putting into the new arrangements. Just as local government needs, together with its partners, to engender the utmost efficiency in the mechanisms that it develops to provide services and make them cost-effective, as my noble friend suggests, so on the revenue-raising side central government has a massive obligation to ensure that it collects the taxes—instead of cutting the resources going into HMRC, which is responsible for collecting VAT, by a further 5% in the spending review.

We do not consider the cost of £3.8 billion and the welcome money that the Government are going to provide to be the last word in these matters. There will have to be a continuing process of establishing programmes that are effective and cost-effective. Looking at the totality, there is scope within the system to prioritise this area, providing that the Government take the right decisions—across the piece, not merely on the narrow front of health and social care but considering the implications for other services and functions of government—and collect the money that they are due anyway and which would relieve the huge pressure on these services and others.

I have a good deal of sympathy with the concerns expressed by the noble Lord, Lord Best, but I share the view of the noble Lord, Lord Sutherland, that it would not be right to hold things up. We must get on, but in doing so we must be realistic about the challenges that will be posed to those responsible for delivering these services. I look forward to hearing the Minister’s response to the various questions that have been raised in the debate.

NHS: Mid-Staffordshire NHS Trust

Baroness Wall of New Barnet Excerpts

Monday 24th June 2013 Lords Chamber

[Earl Howe]

My noble and learned friend makes an important point. Of course, that will be the virtue of local Healthwatch, which will be the eyes and ears of the local community in a particular area. We have also strengthened the role of governors of foundation trusts, whose job it will be to have an equally up-to-the-minute view of their organisation’s performance.

[Baroness Wall of New Barnet]

My Lords, I want to reinforce the message put to the Minister this afternoon and tell him what it feels like at the sharp end of the health service. Both my noble friends who have spoken echoed the comments—misquoted or otherwise—made by the Secretary of State. Those comments have caused absolute fear and I am not exaggerating. We had the CQC at our trust on Friday. Our regional person for the CQC is fantastic, the CQC’s reporting is really good and, as noble Lords know, I am supportive of it. However, will the noble Earl please ensure that the messages stop? These people carry out a really important job and if we stop believing that what they do matters, then I do not know where we go. Can we please make sure that the reinforcement of the CQC, with new people involved, will make a difference?

[Earl Howe]

Ministers have been highly supportive of the current CQC leadership and in no way do we wish to undermine its work. Having said that, if concerns arise about how the CQC has done its job in the past, Ministers have to be candid about that.

Care Quality Commission: Morecambe Bay Hospitals

Baroness Wall of New Barnet Excerpts

Thursday 20th June 2013 Lords Chamber

[Earl Howe]

My Lords, I can give that assurance. In part, we have the answers in the Grant Thornton report commissioned by the CQC on the actions that the CQC took or did not take. As I said in answer to the question asked by the noble Lord, Lord Hunt, it is reassuring that the chief executive of the CQC has undertaken to produce for the department within the next two months a report to provide assurance that any cover-up has been fully exposed and that we will learn fully not only the facts but the lessons that we can draw from them.

[Baroness Wall of New Barnet]

I thank the noble Earl for repeating the Statement. It has caused quite a stir. My worry is two-fold. First, we had a big reaction to what happened at Mid Staffs, and now we have this. I would want us to be very careful not to become desensitised by some of these things—I do not mean in this House, but elsewhere.

I will pick up on the comments of the noble Baroness, Lady Emerton, and agree with her totally. As chairman of Barnet and Chase Farm Hospitals NHS Trust, I find it bewildering that, never mind any cover-up at the CQC, the board was not aware of those tragic deaths of mothers and babies. Certainly, in my trust that would absolutely be reported, both through the quality and safety committee that deals with what are called SUIs, or serious untoward incidents, and from the board itself. It would be helpful, as has been suggested, that the inquiry goes a bit further than just the CQC.

[Earl Howe]

I am grateful to the noble Baroness. In fact, the trust has taken significant action in response to the concerns raised by the CQC and Monitor. In addition to responding specifically to the three warning notices issued by the CQC, there have been significant leadership changes at the trust. Sir David Henshaw was appointed as interim chair and Eric Morton as interim chief executive. The trust appointed four new non-executive directors and a new chief operating officer and recruited a new obstetric consultant and additional midwives. There have been other appointments as well. It has established a programme management office, as requested by Monitor, to oversee the implementation of programmes of work to bring about lasting improvements across the trust—and it has recruited a number of posts to the programme office to take that work forward. So I am encouraged that it is taking the position as seriously as it should in the circumstances and that, again, there is a refreshed team at the top of that organisation.

NHS: Accident and Emergency Units

Baroness Wall of New Barnet Excerpts

Wednesday 19th June 2013 Lords Chamber

[Earl Howe]

My Lords, I have to emphasise to the noble Lord that, although I understand his concerns in relation to Wexham Park and other hospitals, there is no government policy about the closure of A&E departments. The whole thrust of government policy since we were elected to office has been that there should be no top-down direction of this type of decision. Rather, we are clear that any changes to healthcare services should be locally led, clinically driven and involve the local population in a consultation. All patients have the right to high-quality urgent care at whatever time they use the health service. The key for local commissioners and decision-makers is to ensure that that happens. I am aware that the situation at Wexham Park has improved and money is being invested to ensure that there are enough beds for the future.

[Baroness Wall of New Barnet]

My Lords, I declare an interest as the chair of Barnet and Chase Farm Hospitals NHS Trust. I was in my A&E department at Barnet Hospital this morning for two hours. In addition to the concerns that my noble friend has expressed, the real issue is that people are turning up at A&E who really should not be there, do not need to be there and ought to be able to get treatment elsewhere. Obviously, government policy is to ensure that we have more services outside, but can we make sure that that happens more quickly than is currently the case?

[Earl Howe]

My Lords, the noble Baroness is absolutely right. There is no doubt from Sir Bruce Keogh’s urgent and emergency care review, published this month, that attendance at an A&E department often reflects the lack of availability or the lack of awareness of alternative sources of help. Some patients may default to A&E departments when they are unsure about which service is most appropriate to their needs. That has to be addressed and is being addressed in Sir Bruce’s review. It will look at the entire system of emergency care and how we can make sure that it provides the right care, in the right place and at the right time.

Care Bill [HL]

Baroness Wall of New Barnet Excerpts

Wednesday 12th June 2013 Lords Chamber

[Lord Warner]

My Lords, I will speak to Amendments 65, 66 and 67 and to Clause 77 standing part. I share very much the concerns expressed by my noble friend Lord Hunt and I am not going to repeat what he said about the slightly strange situation that we are now in with the CQC having enforcement responsibilities in relation to some bodies that it registers but not in relation to others.

I want to concentrate on the missing part of this group of clauses, which is the Trust Development Authority, and go into a bit more detail on this area than my noble friend Lord Hunt had time to do. The purpose of these amendments is to try to pursue the question of whether there is parity of action required by the Trust Development Authority and Monitor, when the CQC issues a warning notice, irrespective of whether that notice applies to an NHS trust or an NHS foundation trust. There is something very curious about writing this quite complicated legislation, which, if I may say as a connoisseur of health and social security legislation, has the air of a rather rushed job. The builder was going to go off site quite quickly if we did not get the trimmings of the house finished—it has that feel to it.

The Bill is very focused on the enforcement action by Monitor, but is pretty much silent on what the TDA does. Like my noble friend Lord Hunt, this strikes me as extremely odd, because, as a general rule, the weaker trusts—I exempt my noble friend Lady Wall and her skilful chairmanship of her trust—are tucked away in the Trust Development Authority. You have to remember that they have all had the best part of 10 years to convince people that they could be given the autonomy of NHS foundation trust status.

I seem to recall that since its inception the TDA has not made a great deal of progress in getting over the hurdle trusts for which it has responsibility. My recollection, and the noble Earl will be able to correct me if I am wrong, is that there is only one trust in the past 18 months, Kingston, which has made it to FT status. There is hardly a queue of candidates in Monitor’s FT pipeline. Indeed, there is a real danger—if I may say so, slightly pessimistically—that the Trust Development Authority will struggle to live up to the middle word in its title.

What seems likely to happen, as we move forward into the next few years, is that as the money gets tighter we start to see increasing failure among some of the TDA trusts and a greater flow under this new legislation of warning notices from CQC. I have therefore become rather intrigued as to what should happen when the warning notices thud on to the desks of NHS trust boards and they fail to respond adequately.

Under this Bill, it is relatively clear, even with the reservations my noble friend Lord Hunt made, what happens with FT boards and Monitor. Far less clear, indeed totally unclear on the basis of the legislation, is what happens with TDA trusts, which after all account for about £30 billion a year of public sector expenditure, so there are quite a lot of patients going through their beds and doors.

In my search for further enlightenment, I have taken the trouble to read the document that the Trust Development Authority published last December with the rather upbeat title, Delivering High Quality Care for People, the accountability framework. This is a model of Department of Health speak—I am something of an expert on this, as is the Minister. It makes clear that trust boards will have to comply with some of the licence conditions set by Monitor, but it is rather uncertain which ones it will have to satisfy. It has set a lot of operational performance standards which look uncannily like the evil Labour targets imposed from time to time. It promises more details on the Trust Development Authority’s oversight model. I have yet to see very much of that further detail, but nowhere in this document is it clear what happens to these trusts that fail to live up to the expectations of that accountability document published about six months ago.

Continuing my search for enlightenment, I have moved on to read the May Department of Health document entitled, The Regulation and Oversight of NHS Trusts and NHS Foundation Trusts. It claims to throw light on the Bill’s quality of services clause. The first nine pages are pretty clear. We start to get into a bit of difficulty when we get to page 10, which is headed “Intervention”. That is when I became really puzzled. It says—I am not quoting, but this is pretty much what it says—that the TDA can request recovery plans, increase engagement with the trust, commission an independent and rather exciting thing called a deep dive, review the skills and competencies of the board and executives, and commission an interim report.

The noble Lord, Lord Hunt, and I are veterans of debating the regulations setting up the Trust Development Authority. Many of us thought it would be doing that anyway. We did not think this was some kind of new regime. This looks like a bit of a rehash of what it should have been doing in order to get the trusts for which it was responsible to pass the foundation trust tests set by Monitor. When it was set up, it was supposed to have that responsibility for quite a short period of time. It hardly looks like some new, sexy enforcement set of procedures which we would expect it to take when the CQC warning notices come to its attention. It looks as if the enforcement procedure for the trusts in the TDA remit is that they have to be given further chances. It is not explicit but—dare I suggest, as my noble friend Lord Hunt I think implied? —we could be heading back down the road of money being taken away from the successful trusts to buttress people in organisations who are not cutting the mustard in terms of the quality of services or the financial management that is required not only to be an effective foundation trust but to be an effective trust.

It is not at all clear to me how the Government are going to tackle the fact that the weaker brethren are within the responsibility of the Trust Development Authority but there is nothing in the Bill which actually says what the TDA will do. I am sure that the noble Earl will tell me about other bits of legislation, but it seems to me that if we want to convince the public that there is a new show in town for real enforcement when things continue to fail in a trust, whether it is an FT or an NHS trust, it would be sensible to put these provisions in the same Bill, particularly when we all know that the weaker trusts are under the TDA.

Paragraph 27 of the May document I mentioned is pretty elusive. Commissioners can have a go at reconfiguring if there is failure but that may not work. Eventually, the trust is unsustainable and becomes the responsibility of the TDA. Guess what the TDA can do? The TDA has absolute discretion as to whether it advises the Secretary of State. It can advise the Secretary of State to appoint a trust special administrator but is not required to. Under the current guidance, which only came out a month ago, the most the TDA is required to do is to consider doing that. If it chooses not to, it need not. We therefore have a situation in which the TDA seems to be operating under a different regime from Monitor. This is a really serious situation to be considered, and I suggest to the Minister that it will become a public confidence issue. I am not making a party political speech—this is all about getting legislation which is fit for purpose to restore public confidence after the Mid Staffordshire debacle.

Why does this Bill not provide for a much sharper set of actions from the TDA when the CQC issues a warning notice to a trust? The notice is a clear signal that the TDA’s efforts to rehabilitate the trust are simply not working. I suggest this with a bit of nervousness, but should the Government not consider withdrawing these clauses and provide a clear set of rules and requirements that protect patients effectively, whether or not they are in NHS trusts or FTs? I do not think that the Bill, as drafted, does the job of protecting patients. I do think that the TDA needs to be brought into this part of the Bill on a basis of parity and equivalence with the requirements that will be made of foundation trusts through the enforcement panels of Monitor.

[Baroness Wall of New Barnet]

My Lords, unlike my noble friend Lord Warner, I am not a connoisseur, other than about what happens in my trust. Maybe I can share our experiences in response to the questions on which my noble friend Lord Warner has been seeking clarification. I think it will answer some of them, although not all.

As many noble Lords will know, 18 months ago Barnet and Chase Farm Hospitals NHS Trust took the decision that it could not comply with Monitor’s requirements, primarily the financial aspects, and brought in Deloitte to do a complete survey of all our services. We met the benchmark for clinical services but, because of the historic debt, we did not meet the financial benchmarks. We went up to two for Monitor’s rating on finances, but it goes up to four, and so we were two—two and a bit—for one period. Although we sought support through the SHA at the time, from a body that offers trusts opportunities to apply for funding, we were unsuccessful. This is where I may not be able to assist my noble friend Lord Warner, because we decided ourselves, as a trust, that we would not be fit for purpose in that sense. There is a process, and people who have been involved in it much more than I have will know what that process is. We notified Monitor that we would not be able to do that.

Care Bill [HL]

Baroness Wall of New Barnet Excerpts

Tuesday 4th June 2013 Lords Chamber

[Lord Rix]

My Lords, I support Amendment 10, but I should like to clarify one or two points in the wording. It is possible for a person with a learning disability to have a physical health problem. It is also possible for a person with a learning disability to have a mental health problem. But that is not the main cause or even sometimes the basic cause for their particular condition, which is learning disability. I would therefore have preferred the wording of paragraph (a) of Amendment 10 to have been “learning disability”. The same situation arises in paragraph (b) of Amendment 10. People with a learning disability have a learning difficulty. That is natural. However, there are plenty of people who are not learning disabled who also have a learning difficulty. I would like to have seen Amendment 10 include learning difficulties and learning disabilities, but I actually support the general thrust of the amendment. I hope that if it is accepted the wording of a learning disability can be made quite clear.

[Baroness Wall of New Barnet]

My Lords, I support Amendment 12 in particular. It will be no surprise to the Minister that my interest, even my passion, lies in the status of healthcare workers, which is hugely important. We are recognising that even more by the way in which the continuing change in the health service is coming about.

I wish to pick up on the way the Bill reads in the context of the amendment. The clause refers to, obviously, education and training for healthcare workers. It then refers to,

“the provision of information and advice on careers in the health service”,

but to know where your career is going you have to have a start point. The Minister knows that many of us have been asking for, in the first instance, a recognition of the skills that healthcare workers bring to the job. Across any organisation that has opportunities for development, there is always a start point. A healthcare worker would need to know, for instance, what skills they have and what skills they need to go on to the next stage of whatever career they choose. The ambiguity, at best—actually, it is probably even worse than ambiguity—under which healthcare workers currently operate does not help that process. It will be difficult for the Bill to achieve its objectives if we do not start from the point where healthcare workers have that recognition of their skills in a formal way.

[Lord Warner]

My Lords, I support this group of amendments, particularly Amendments 8 and 12.

We had a good run over the issue of the equivalence between physical and mental health in the Health and Social Care Act. We need to move on from this rather semantic debate about whether healthcare involves both physical and mental health. Out there in the real world, there is a real sense and feeling that mental health does not receive its fair share of the attention that it needs. The political and public agenda in this area is beginning to change, which is a good thing, but we should not lose any opportunity, when legislation presents itself, to reinforce the message about equivalence, even if it occasionally upsets the draftsmen and officials of legislation. We cannot use opportunities too often to get across the message about equivalence.

One of my jobs as a Minister in Richmond House was, at one point, to try to reduce the amount of money and effort that was being spent in the NHS on the use of agency staff. It came as a considerable surprise to me, although it should not have done, that when I started to look into this area, particularly in the area of medical locums, psychiatry was represented as one of the specialities where there was a high use of locums because people simply could not get or make permanent appointments. We need to send a message to HEE that there is a longstanding, deep-rooted problem in this area. At the end of the day, if we do not train enough people to fill the established jobs available and we have to rely on locums and agency staff to do so, we will not achieve equivalence.

When the Minister goes back to Richmond House, I ask him to look at some of the data around whether the vacancy rates and the use of locums in psychiatry and psychiatric services is greater than those in other areas. He may find that there are some real issues around that which need to be tackled by HEE.

On Amendment 12, I wish to speak briefly as a former jobbing public sector manager in this area. When times are hard you do two things very quickly: you freeze vacancies and cut in-service training. That is what you do as a jobbing public sector manager. We always have to guard against cutting the kind of programmes, such as continuing professional development, that will help us to get out of some of the jams that we are often in. It is important to send messages about continuing professional development in the Bill. I strongly support the proposals in Amendment 12.

--- Later in debate ---

[Lord Willis of Knaresborough]

I speak to Amendments 15 and 36 in my name and those of the noble Baroness, Lady Emerton, and the noble Lord, Lord Patel. On Amendment 15, one of the most daunting tasks for Sir Keith Pearson and his staff at Health Education England is the challenge of workforce planning. I do not believe that anybody has done that right in the health service since its creation. The noble Lord, Lord Turnberg, rightly pointed out that it takes a good five years to get a junior doctor. It takes 10 years to get a consultant. For senior consultants, we are probably talking about 12 to 15 years. For anyone to sit down in Richmond House or elsewhere and start to plan what is going to happen in 10 to 15 years is an incredibly difficult task, and no one has managed it yet.

Secondly, looking ahead, if 10 or 15 years ago you were planning a workforce, you would have automatically said that we need a supply of certain groups of professionals and that, provided we can get that supply, we will be reasonably okay. We can bring in a few from abroad, usually the Commonwealth, and often denude the poorest countries in Africa of their health staff and get the nurses from the Philippines. That enabled us to get by.

What we are doing now—I think that the Minister is acutely aware of this— is planning for a health and care service the like of which we have never seen. There will be research developments, especially in areas such as genomics and regenerative medicine, which will create cures for major debilitating diseases and, at the same time, give us innovative ways of dealing with people’s long-term chronic illness in their homes by self-management. Therefore, the professionals and the care support workers for those professionals working within the NHS have to be of a calibre and to have a flexibility the like of which we have never seen.

We have tabled Amendment 15 because HEE needs all the support that it can get in obtaining representation to support it to look ahead. By that, I am talking about the research base. We have to consider what medicine will look like, what cures will look like and what the demographic requirements will be in 10 or 15 years’ time—or even in five years—to plan the workforce. I hope that in reply, the Minister can reassure the House that there is that sort of long-term planning for a workforce not like today’s. We are not planning the workforce of yesterday with different numbers, we are looking at a totally different workforce for the future.

Amendment 36 is a probing amendment to gain assurances from the Minister that HEE will receive representations from organisations other than the medical royal colleges. The Explanatory Notes to the Bill specify only medical royal colleges in paragraph 515. We therefore ask that that be updated to reflect all royal colleges.

In the Francis report, one of the criticisms of the Royal College of Nursing—I refer to it specifically—was that there was a conflict between its role as a trade union and its role as a royal college. The Government and Health Education England have an opportunity to challenge it on that role and to make sure that it steps up to the mark as a royal college. Only by doing that will it actually serve the nursing workforce to its true extent. We have seen that with the medical royal colleges, and, by including royal colleges in this particular amendment, which would include the Royal College of Nursing, we are sending out a challenge to the RCN that it, too, must be part of this game rather than a bystander.

[Baroness Wall of New Barnet]

My Lords, I, too, support Amendment 36. I just want to pick out something that the noble Earl mentioned a little while ago in response to another question from me. He mentioned the work being done by Skills for Health and Skills for Care. Certainly in the context of this amendment—which, I agree, is a probing amendment—alongside the royal colleges and the other professional bodies, the work that Skills for Health and Skills for Care are doing is hugely important. Can the noble Earl enlighten me on what relationship Health Education England will have with those bodies? For instance, the noble Lord just referred to what the future looks like and what Skills for Health in particular is doing alongside Skills for Care. It is looking at what provisions there are for apprenticeships inside the health service, which is hugely important and allows people to develop from smaller roles to bigger roles over time. I wonder how, in the scheme of things, that relationship exists, how close it is and what influence Skills for Health and Skills for Care have, so that they are not working in opposition but are working integrally with what HEE is doing.

[Lord Hunt of Kings Heath]

My Lords, I have a few amendments in this group. It is an important group because it concerns not just the functions of Health Education England and its duties to co-operate but also, of course, the membership of LETBs, the local committees of HEE.

It is very important that HEE works with NHS bodies that have expertise in education, training and regulation, so I am very happy to support my noble friend’s Amendments 9, 18 and 34, and Amendments 15 and 36 in the name of the noble Lord, Lord Willis. I would add two organisations from which HEE must seek representations: the CQC and Monitor. I imagine the noble Earl will say that they are implicit in the generic list of bodies in Clause 89(2). However, it would be good to hear a little bit about how the noble Earl expects HEE to work with the two core regulators for the health service, the CQC and Monitor. In a sense, the CQC will, on a very regular basis, be picking up issues to do with staffing and staffing levels. Equally, Monitor will be concerned with financial issues. Of course, the two sometimes do not run easily together, so it is very important that HEE has very close contact with those two bodies.

As regards Clause 91 and LETBs, which are essentially committees of HEE charged with ensuring sufficient skilled healthcare workers in the area of the LETB, the Bill makes clear that in carrying out its main functions, the LETB must represent the interests of all persons,

“who provide health services in the area for which the LETB is appointed”.

I have already referred to my interest as chair of a foundation trust, and I very much welcome the architecture in which it is clear that, at the local level, the people in the driving seat should be the people who provide services. In the past, people running hospitals and other services have been divorced from decisions about training commissions. That is one of the reasons why I believe there has been such a problem with the ability of people coming out of universities and other education institutions to practise when they get into the field. Having the people who provide services round the table is a very important development.

Of course, it is also important that other people are involved in those discussions. In the architecture of the Bill, there are two categories of membership provisions. In Clause 91(3)(a) and (3)(b), it is clear that LETBs must include,

“persons who provide health services in the area”,

and,

“persons who have clinical expertise”.

It is consistent with the provisions in relation to Health Education England. Then in Clause 91(5), people involved in education may be appointed to a LETB—but, by implication, if they may be they do not have to be. My Amendments 40 and 42 to 46 really seek to ensure that LETBs have a broad-based membership. Surely, it should be mandatory to have the involvement of education providers and health workers who are not professionally registered. My noble friend Lady Wall made that point very well indeed.

Also, where are the representatives of patients and carers? After all, they understand the output of the workforce. Surely, they ought to have a place around the table as well when it comes to these decisions about training commissions: where they are placed, what the demands are and what the monitoring is. Again, I would replicate the argument about nurses that we had on the membership of HEE. In some sense, we could have grouped those amendments together because it is the same argument: that around the table of the LETB, you must have some senior nurses when so many of the discussions of the LETB will be about the quality of nurse training.

What about the health and well-being board? We have heard earlier debates. In fact, in the House of Commons Select Committee this morning, when witnesses were giving presentations about what has happened in emergency care, the representative of the LGA made a very strong point about the potential role of health and well-being boards, which are concerned not just with public health but with how well the whole system is integrated. I very much agree with that, so I would have thought that a LETB would be well advised to have the chairmen of relevant health and well-being boards around the table to discuss issues of staffing. I hope that the noble Earl will give me some reassurance that in establishing LETBs as provider organisations, something with which I certainly agree, there will be room for these other interests to be represented as well.

--- Later in debate ---

[Earl Howe]

Certainly, I do. I am happy to take that idea away, and if I can give him any further information during the course of our debates I will. Equally, the LETBs have strongly established connections with professional regulators and professional bodies. For example, the postgraduate medical and dental deans, who are now an integral part of the LETBs, work very closely with the GMC and medical royal colleges in the management and quality assurance of training for junior doctors. I hope that those remarks will reassure noble Lords sufficiently for them not to press the relevant amendments.

In reply to my noble friend Lord Willis, who expressed concern about the way the Explanatory Notes were framed, it is important to look at the entire context of the passage he quoted. The words “such as” appear in that passage before “the medical Royal Colleges”, so it is not meant to denote an exclusive reference to the medical royal colleges; it is very much trying to say that the professional bodies in general will be relevant here.

Amendment 35, tabled by the noble Lord, Lord Hunt, and the noble Baroness, Lady Wheeler, seeks to amend Clause 89 to require HEE to seek advice from the Care Quality Commission and Monitor. It is very important that Health Education England works closely with those two bodies. The Care Quality Commission plays an important role in assessing the quality of healthcare services, and in so doing it assesses their ability to deliver services safely and effectively. In doing so, it will consider whether healthcare providers have suitably skilled staff and in the right numbers. It will need to work closely with Health Education England to share findings and evidence to support improvements in education and training. Health Education England will also be able to share information on the effectiveness of providers in supporting clinical placements and training programmes to support the Care Quality Commission in its role.

HEE and Monitor will work closely together to ensure the financial stability of the health system. This will include working together on the reform of education and training funding and the development of education and training tariffs. To reflect the importance of these relationships, the Bill places a clear and reciprocal duty on Health Education England to co-operate with both the Care Quality Commission and Monitor. I hope noble Lords will feel reassured by that and will be able to withdraw this amendment.

[Baroness Wall of New Barnet]

Is the Minister in a position to respond to my points? I understand the importance of the medical royal colleges and the professional bodies, but the noble Earl described earlier how Health Education England has responsibility for the whole workforce. I sought from him the opportunity to describe where Skills for Health and Skills for Care come in. I should point out that I have spoken three times and have not declared an interest as chair of Barnet and Chase Farm NHS Trust. I hope noble Lords will forgive me for that.

[Earl Howe]

I am grateful to the noble Baroness. I have to go a little further, so if I may I will cover her point in a moment.

Amendments 40 and 42 to 46, tabled by the noble Lord, Lord Hunt, and the noble Baroness Lady Wheeler, focus on the need for expertise on the local education and training board. Specifically they seek to change Clause 91(3) to require a LETB also to have as members persons who deliver education and training to healthcare workers, a registered nurse, persons with experience in staff groups that are not professionally registered, healthcare workers who receive education and training from within the area, patients and carers or their representatives, and a representative of the local health and well-being board.

I fully expect Health Education England and the LETBs to work closely with and seek advice from a range of key stakeholders, including those providing education and training, members of staff, patients and carers. That requirement is clearly set out in Clause 89. I appreciate the position of noble Lords but do not agree that we need to specify all these groups in the governance structure.

In establishing the LETBs, the Government are committed to driving up standards and the quality of education and training provided. I suggest that that can happen only if those directly involved in the provision of education and training are at the heart of the new system. By their very nature, local education and training boards will be representative of local healthcare providers, who play a critical role in educating and training our workforce. They are the health professionals who support and supervise clinical placements and training programmes across the country, providing professional leadership and support to students and trainees.

If we mandate a requirement for a nurse, others will ask why there is no requirement for a doctor, a dentist, an allied health professional or any of the many other professions. I completely agree that these professions, and the bodies that represent, regulate and support them, need to be closely engaged in the work of the LETBs, but it is not practical to require all of them to be members of the board. The Bill makes provision in Clause 91 for those involved in the provision of education and training, such as universities, to be eligible to sit on an LETB. We know from the 13 LETBs established by the HEE special health authority that all of them have a university representative on their boards, and many different health professionals are also represented on them.

HEE will appoint independent chairs of the LETBs. These will be people who are not directly involved in the delivery of health services, or education and training, in the geographical area. Having an independent chair will ensure that the local education and training board acts independently and in the interests of all healthcare providers represented.

To be appointed in the first place, local education and training boards will need to demonstrate to HEE that they have the right governance arrangements and the right mix of people on their boards with the necessary capacity and capability. In going through that process it will be for HEE to assess whether the local education and training board has the right mix of skills, knowledge and expertise with which to carry out its functions. However, as the intention is for local decisions on education and training to be made by the LETBs, it is important that we give them the flexibility to determine who sits on their boards.

To sum up the position, I can reassure noble Lords that LETBs are already developing strong partnership arrangements in their patch to engage with all education institutions involved in education provision in their area. The HEE special health authority has reinforced the importance of this in the appointment criteria that it set the LETBs, which have to be approved by the Secretary of State. These demand that LETBs demonstrate meaningful engagement and collaboration with many stakeholders with an interest in education and training, including students and trainees, and patients and carers. As a result, they are putting in place appropriate advisory and partnership arrangements to support the decision-making of the local education and training board.

--- Later in debate ---

[Lord Rix]

My Lords, I wish to speak to Amendment 24, which explores the benefits of placing a duty on the Secretary of State to consult on the objectives and priorities of Health Education England. In particular, I wish to explore how the Secretary of State will consult vulnerable people, including people with a learning disability, to ensure that education and training provided by this body will create a workforce that meets this group’s needs. Consulting and listening carefully chimes with the Government’s intentions through their response to the Francis inquiry, which stated:

“We will listen most carefully to those whose voices are weakest and find it hardest to speak for themselves. We will care most carefully for the most vulnerable people—the very old and the very young, people with learning disabilities and people with severe mental illness”.

This is a most welcome commitment, as currently people with a learning disability are not receiving appropriate care. On Tuesday 21 May, the Parliamentary and Health Service Ombudsman published its report into the death of Tina Papalabropoulos. Tina was 23 and had a learning disability. She died on 30 January 2009 at Basildon hospital in Essex. The ombudsman found that the hospital did not give her the treatment she needed or even meet her basic care needs. Unfortunately, this is not an isolated incident, and there is substantial evidence that poor care exists across the health service.

Early this year, the confidential inquiry into the premature deaths of people with learning disabilities in the south-west reported on its study of the deaths of 233 adults and 14 children with a learning disability. It found that 42% of the deaths were premature and that 37% would have been avoidable if good quality healthcare had been provided. On a national level, this equates to over 1,200 adults and children with a learning disability across England whose deaths should have been avoidable with good quality healthcare. This comes as no surprise to many. The Department of Health highlighted the issue back in its Valuing People and Valuing People Now strategies, and the excellent report by Sir Jonathan Michael, Healthcare for All, set out a series of recommendations for improving care for people with a learning disability. It is these people whom the Secretary of State should consult when setting objectives and priorities for this most important of public bodies. Without the input of people with a learning disability and their families, we will fail to change a system and a culture that in many cases provide substandard care for the most vulnerable in our society.

I realise that the Minister will probably reply that in order to publish the objectives and priorities for the forthcoming year of Health Education England, the Secretary of State will have consulted the parties concerned. However, as an actor who, years ago, used to drop his trousers for a living, I nowadays prefer the security of belt and braces, and I hope that the Minister will be able to offer this.

[Baroness Wall of New Barnet]

My Lords, I would like to understand what Amendment 14 is suggesting, and maybe express some reservations. If I have read it wrongly, I apologise. It is important that Health Education England takes official guidance into account, but we have this dilemma in my own trust about what the Francis report is saying. To have a national edict about what staffing levels ought to be, and the ratios and numbers of staff as well as the skills mix, is not really ideal from the point of view of people operating in the health service, particularly in hospitals. Times change throughout the day on hospitals and on wards, and different levels of skills and different grades of staff are required at different times. You would have to have a permutation that was so huge that it would be less than helpful to have a national edict. I would be concerned that we should take notice of official guidance, but nothing more than that.

I support Amendment 27 and the view about longer-term stuff. In particular—I am sure this will come up later in our deliberations on the Bill, and it is very much in line with what we talked about for a long time in our consideration of the Health and Social Care Bill—the change that is happening as we speak, the evolution of moving, quite rightly in my view as the chair of a provider trust, from acute hospitals to other opportunities to deliver care, is hugely important.

I will share an anecdote with your Lordships. In a discussion with a previous director of nursing in my own trust, I asked her, with my vision of where things ought to be in the future, with nurses following the patient out to their home, how many nurses working on our wards are equipped and skilled to follow Margaret Wall or another patient out and say, “OK, she is now going home”. Her view was very frank: not many would be. I think that is hugely important, because different skills are required to work with someone at home and they need to be incorporated with the skills of nursing overall. It is important when looking at five-year plans, never mind 10-year plans, that we consider the education process in the sense of how people are going to deliver in different environments, which we are all working hard to make sure happens.

NHS: 111 Telephone Service

Baroness Wall of New Barnet Excerpts

Monday 13th May 2013 Lords Chamber

[Earl Howe]

My noble friend, with his experience, is very wise on these matters. I think it would be quite difficult to turn the clock back completely, but I take his point. There is enormous scope for GPs to contribute to the drive to keep elderly, frail people in particular out of hospital. Too many people are landing up in hospital with chronic diseases who should never have been allowed to get there.

[Baroness Wall of New Barnet]

My Lords, the Minister has just stolen my thunder in his response to the noble Lord. Does the Minister have any idea when the failings in the system will be sorted? At the Barnet and Chase Farm Hospitals NHS Trust, of which I declare an interest as chair, we see extra people coming into A&E who, as he has just said, are very poorly and should not really be in hospital because they need antibiotics or something like that and would get better much quicker either in their own home or in a nursing home.

[Earl Howe]

On the issue of A&E, there is no doubt that the NHS has been under very heavy pressure over the past few weeks. I am pleased to say that over the past two weeks the NHS as a whole has met the 95% standard, but obviously that statistic masks difficulties that are still being experienced in particular locations. The challenge now is to ensure that we are ready for next winter, and all the work that is now being done in NHS England, by clinical commissioning groups and within providers is designed to ensure that we are much readier for the pressures to come.

NHS: Out of Hours Service

Baroness Wall of New Barnet Excerpts

Tuesday 26th March 2013 Lords Chamber

[Earl Howe]

We have known that out-of-hours care has been in need of reform for some considerable time. The much strengthened commissioning arrangements that we have put in place, including the national quality requirements that I mentioned earlier, will enable that to happen.

[Baroness Wall of New Barnet]

The noble Earl will, I am sure, recall the discussion we had just a few days ago about the inspection of patients at home. That discussion was about ensuring that patients at home who were poorly in the evening did not end up in hospital. My noble friend has just indicated the tremendous pressure that all hospitals are under in terms of length of stay because of older people arriving and staying in hospital. If this GP out-of-hours service worked well, we would prevent that. We need to ensure that the accuracy and rigour of that service permeate throughout the whole country.

[Earl Howe]

The noble Baroness is quite right; this is an integral part of good primary care and we are determined to see it joined up with GP practices and the other services on which patients rely.

Care Quality Commission

Baroness Wall of New Barnet Excerpts

Thursday 14th March 2013 Lords Chamber

[Earl Howe]

My Lords, the Care Quality Commission has a full range of powers open to it which enables it to take action where it discovers a major failing in the quality of care. We are not aware that that menu of options needs to be expanded. I will write to my noble friend as regards specific instances, having consulted the CQC, but I do not think that there is a general call to expand the CQC’s powers in this area.

[Baroness Wall of New Barnet]

My Lords, I am sure that the noble Earl will welcome this report, as my noble friend has, because there are many good news stories in it. I am sorry that I have had time to read the report only quickly. In the inspection, the Care Quality Commission looked for opportunities to maintain older people in their homes, rather than have them come into hospital; that is hugely important. The evidence is that if an elderly person turns up at A&E at 8 pm, they will be in hospital for many days, and that is not always necessary. Can we look more closely at how, in the care that is given, we can prevent people coming into hospital?

[Earl Howe]

The noble Baroness is right to focus on that issue. There are a number of things that we can do. We will shortly introduce new minimum standards to improve training for care staff, which will help in that regard. We aim to double the number of apprentices in care services by 2017 because there is clearly a workforce imperative here. We are proposing to expand the current care ambassador scheme, which promotes a positive image of the sector. That again will assist in recruitment. We are also launching an online tool to support recruitment and provide information about working in care and support, all of which is designed to address workforce concerns and concerns around skills.

NHS: South London Healthcare Trust

Baroness Wall of New Barnet Excerpts

Tuesday 8th January 2013 Lords Chamber

[Earl Howe]

My Lords, it is important to stress to my noble friend that a trust will be put into special administration only when all other options have been exhausted. I think that the noble Lord, Lord Warner, is aware that that was the situation we faced in this instance. Where possible, NHS providers will be supported to return to sustainability in both the clinical and financial sense. Our priority is to do what is best to ensure that patients receive high-quality care and special administration is a last resort. However, as my noble friend knows, a number of trusts are facing financial challenges. The department is working with Monitor and the NHS Trust Development Authority to oversee the performance of those trusts. I would just say that while some organisations are in difficulties, currently there are absolutely no firm plans to trigger the regime for any other trusts at all.

[Baroness Wall of New Barnet]

My Lords, I am sure that the noble Earl recognises the experience I have had as chairman of the Barnet and Chase Farm Hospitals NHS Trust, which went through a similar exercise that took many years. First, however, I want to associate myself with the comments made by my noble friend Lord Warner, and I support the action that has been taken. I recognise what my noble friend said about the concerns of the local community, but that will always be the case. However, what is most important is to make the decision and secure the support of outlying hospitals. My own trust is working towards a partnership with the Royal Free Hospital, although we are not there yet. The move could have been considered much earlier, which would have prevented a lot of pain and heartache for many people. My advice and plea is to stick with what is being done. That did not happen for Barnet and Chase Farm. As noble Lords know, a number of holds were put on what we were doing that made things worse for the community and for the staff. They almost ensured that the services we were providing were harder to deliver.

[Earl Howe]

As ever, I am grateful to the noble Baroness for her perspective from the front line. I think it was with that in mind that the previous Government drew up the legislation which my right honourable friend now has to abide by, in that there is now a very tight timescale of 20 working days for him to take a decision. That is not a long time but it is indicative of the need for urgency in arriving at the right solution. The TSA has done his work and we must now judge whether the recommendations are the right ones.