NHS: Hospitals

Baroness Wall of New Barnet Excerpts

Thursday 8th September 2011 Lords Chamber

[Earl Howe]

My Lords, it is clear that one of the causes was that the previous Government—for all the right reasons, I have to say—injected very large sums of additional money into the health service, but alongside that there was no commensurate increase in activity. A lot of the additional money went into settling pay claims. That is not to decry the many benefits that arose from the additional money, but the net effect was a decline in productivity.

[Baroness Wall of New Barnet]

Does the Minister agree that there are dangers in sweeping statements on how NHS hospitals perform and that they perform badly, because that is not the case? In many instances, not just in my own hospital—Barnet and Chase Farm—the improvement in hospital services over the past years has been incredible. Does he also agree that there are already strong and widespread relationships with the private sector in NHS hospitals and that the challenge is for NHS hospitals to be better than private hospitals so that people will choose to go to their local hospital?

[Earl Howe]

The noble Baroness is right to pull me up. If I implied that the NHS was across the board providing a lower standard of care than the private sector, I apologise because that is certainly not the case. There are some shining examples of care delivered by the NHS. However, as she will know, not all hospital trusts are as good as hers. Some give us cause for concern in a clinical sense, and they need to be challenged sometimes on the way they look at quality. That is going on at the moment with the quality, innovation, productivity and prevention programme that she will know very well.

Southern Cross

Baroness Wall of New Barnet Excerpts

Thursday 16th June 2011 Lords Chamber

[Earl Howe]

My Lords, I think I have already indicated that the Government are proactively engaged with all the key parties involved in this situation, not just Southern Cross but the LGA, ADASS, the CQC and others. The precise situation in which we find ourselves with Southern Cross is unlikely to arise again because my understanding is that the business model adopted by Southern Cross is unique. Nevertheless, every privately operated residential care home business will, no doubt, have its own level of business risk, whatever that may be—either slight or something rather less slight. However, the alternative that the noble Lord, Lord Beecham, seemed to desire was a return to the state provision of care homes. The noble Lord is shaking his head, and I am glad of that, because I think neither his party when in government, nor certainly ours, would wish that on the public. I think that all of us believe in choice for the individual, and this is what the current market provides. Nevertheless, there are risks.

The noble Baroness asked about hospitals. To the extent that NHS care is delivered in independent settings, a business risk is inevitably associated with that. However, we are clear in the Health and Social Care Bill that there needs to be a system whereby essential services are protected for the benefit of patients. When the Bill reaches us, we will no doubt debate those provisions.

[Baroness Wall of New Barnet]

I am sure that the noble Earl will be assured that my noble friend did not imply or say what the noble Earl thought he said. It is really important for us to focus on the business side of this issue and the economics of how it is run. The noble Earl is absolutely right to say that there is no complaint at all—in fact, all the carers of residents in those homes are distressed because they may be moved from somewhere that has taken care of their people. It is important, therefore, that none of us loses sight of the real issue—the care of these people, which has been good. Otherwise, the home would be in a very different state and, God forbid, we would be having a very different discussion if the issue was the care of the residents rather than the economics of running the home.

How deeply is the Care Quality Commission involved in this? My own trust has been talking to the CQC because, as the noble Earl will know, there are knock-on effects for hospitals all around the country when those homes are under threat, and on what might happen to elderly people who would normally be discharged from hospitals into those homes. We should all please remember—I am sure that the noble Earl is remembering—that the patients really matter in this, and we should ensure that we get them into safe places where they are looked after. The economics of this are very important, and I am not in any way dismissing that, but we need to measure that up against the care that has been provided for those people in Southern Cross homes, and, I hope, will continue to be provided. The care is valued. It is about the market that goes on out there, and any of us would be foolish to suggest that there is an alternative.

[Earl Howe]

I am grateful to the noble Baroness, and I am also clear about the position of the noble Lord, Lord Beecham. She is of course right. Our first concern should be for the safety and welfare of residents. That is why, as I said earlier, some time ago we asked the Care Quality Commission to engage in close discussion with Southern Cross when the news of the impending redundancies was made public. We did that precisely to ensure that standards would not be compromised. My understanding is that there are no concerns on that front. Southern Cross has, in that sense, behaved impeccably in ensuring that residents have not suffered, other than from the inevitable uncertainty that the publicity over this matter has generated. Going forward, the principles that the noble Baroness has articulated are absolutely right. However, she would agree with me—as I think she did—that questions need to be asked about the financial models adopted by care homes or, indeed, by any independent business providing public services.

Contracting Out (Local Authorities Social Services Functions) (England) Order 2011

Baroness Wall of New Barnet Excerpts

Monday 13th June 2011 Lords Chamber

[Lord Lee of Trafford]

My Lords, these Benches are happy to support this pilot. However, I wish to ask my noble friend one or two questions. First, will the resources currently spent by local authorities in assessing social care needs and arranging care be passed on in their entirety to the organisations to which this duty is being contracted out? If so, for how long will this contractual arrangement last? Who is conducting the independent review of the pilots and will the findings be made available to the House?

[Baroness Wall of New Barnet]

My Lords, I wish to pursue a matter that has already been discussed and emphasise a couple of concerns that have been raised, which I share. My noble friend referred to the treatment offered by a private consortium being threatened by the financial situation, as has just occurred. If we allow the contracting out to occur—I do not disagree with that—how can we ensure that that does not happen and that the treatment is safeguarded? A couple of noble Lords have asked how the assessment and monitoring will take place. As my noble friend Lord Beecham said, it seems that the trailblazers will also monitor the provision. That might be a bit dubious as their judgment will obviously be biased by their experiences. My noble friend Lady Thornton asked who these trailblazing local authorities are. I should be interested to know that, too.

[Earl Howe]

My Lords, I am very grateful to noble Lords who have spoken, particularly to the noble Baroness, Lady Thornton, for her broad welcome of the order. A great number of questions have been asked. I shall probably not be able to answer them all but I shall be happy to write to noble Lords with the detailed answers. However, I will attempt to cover as much ground as I can.

The right to control trailblazer that has requested this facility is Essex County Council. The social work practice sites are Birmingham City Council, the London Borough of Lambeth, Stoke-on-Trent City Council, North East Lincolnshire Care Trust, Shropshire County Council, Suffolk County Council and Surrey County Council.

I was asked how the SWP pilots would be put in place. The local authority will support the set-up of the SWP and the transition of people to the SWP. Once in place, the SWP will use its income under the contract with the local authority to provide services and improve the experience and outcomes of people in the SWP. As I said, the local authority will then manage the contract, monitor performance and manage the relationship as a whole. The local authority will review the contract with the SWP periodically to set new outcome targets and adjust payments. The Department of Health would expect these reviews to occur annually. In answer to my noble friend Lord Lee as to who will conduct the eventual evaluation, the workforce unit at King’s College, London, will do that. The final report will be an independent evaluation and will be published after the two-year period.

Although the local authority will remain liable for the performance of functions undertaken by the SWP, the authority will be able to sue for any breach of contract. It will work closely with the local authority and each local authority should decide what decisions it wishes the SWP to refer to it for agreement, so everything hinges on the contract. How will the outcomes of the SWP be managed? The local authority needs to maintain a close relationship with the SWP, as I have said, but it also needs to allow the SWP scope to innovate and make decisions about the best packages of support and services for the people involved—the service users—and how to provide these, so there is a delicate balance to be struck here. The department would expect the local authority to monitor outcomes, identify issues early and provide support, while allowing the SWP sufficient autonomy to decide how best to meet the needs of the people with whom it works.

The transfer process will be managed between each local authority and SWP. Where transfers take place, it is for the local authority and SWP to agree as part of their contract clear and transparent criteria for deciding who should transfer. It would be for local authorities to decide where social workers could be most effectively deployed. Ideally, SWPs will provide out-of-hours support directly to ensure continuity of services, but if the SWP is small, and particularly while it is getting started, it could choose to purchase out-of-hours support from the local authority.

The noble Baroness, Lady Thornton, asked how these contracts will operate if there is no guidance. I hope that what I have already said about the importance of the contract has answered that. The contract that each local authority has with an SWP will specify the scope and feasibility of operation of each SWP.

My noble friend Lord Lee asked whether the terms and conditions being contracted out are comparable to current conditions. That would depend on the individual SWP and the individual local authority. There will be flexibility here. We are encouraging diversity so that we can find out from different models what works best.

The noble Baroness, Lady Thornton, asked how the SWP would link with the approved provider for independent mental capacity advocates. The SWP would have access to whatever independent mental capacity advocate services exist locally. I think that there will be no bar to that. She also referred to the very important issue of safeguarding and how that would be ensured. Any body that is carrying out regulated activities in adult social care must be registered with the CQC. We are working with the seven councils to establish which sites are carrying out regulated activities. It is likely that most will need to be registered with the CQC, but the pilots vary greatly. They may therefore be subject to different registration requirements. Ultimately, it is the responsibility of councils to ensure that SWPs, if applicable, are registered individually with the CQC. Organisations registered with the CQC are required by regulations to carry out CRB checks on staff who have contact with patients or service users. Keeping patients and service users safe involves providing training, regular supervision and development and feedback from patients, service users and relatives. It will be for the councils and the SWPs to ensure that CRB checks are carried out as appropriate. The noble Lord, Lord Beecham, asked whether the overview and scrutiny committees would have a role here. I see every reason why they should take an interest in what is happening. No doubt the message will go out that they should be encouraged to pay particular attention to these pilots.

The noble Baroness, Lady Wall, asked how we can ensure that SWPs do not go down the same path as providers such as Southern Cross. We do not, of course, yet know the final models of the SWP pilots and whether there is likely to be much, if any, private sector involvement. Local authorities can decide what they put in their contracts with the SWP pilots to ensure that those risks are mitigated.

Disabled people taking part in the right to control trailblazers will have a legal right to be told how much support they are eligible to receive, and to decide and agree with the public body the outcomes they want to achieve, based on the objectives of the funding streams they access. They will have a right to choice and control over the support they receive, and be able to choose how they receive the support.

Some aspects of the right to control process, such as the extent to which administrative processes are aligned, will be subject to some flexibility and may be different in each trailblazer. However, the broad framework of how the right to control will be tested is already agreed. Disabled people accessing the right to control will be told how much money they are eligible to receive for their support. They will be able to choose, in consultation with the public authority delivering the funding stream, how that money is used to meet agreed outcomes. I should say for the information of noble Lords that the seven trailblazing local authorities are Barnsley Metropolitan Borough Council, Sheffield City Council, Essex County Council, Greater Manchester, Leicester City Council, the London Borough of Barnet, the London Borough of Newham and Surrey County Council.

I was asked whether the trailblazers will be consulting with service users. The answer is yes—the evaluation will include consultation with service users.

A number of other issues were raised in the debate and I shall cover just one before I conclude. The noble Lord, Lord Beecham, asked whether direct payments were prohibited from buying council services in this context. There are no plans to change current arrangements and, indeed, the Law Commission, in its recent report on social care, did not recommend a change in this respect.

Once again, I am grateful to noble Lords for their pertinent questions and comments. As I mentioned at the beginning, I shall endeavour to respond to those questions that I have not covered in my reply.

Motion agreed.

Winterbourne View

Baroness Wall of New Barnet Excerpts

Wednesday 8th June 2011 Lords Chamber

[Earl Howe]

The noble Lord is quite right. There has clearly been a serious failing in management here. We are looking at that urgently and, no doubt, important lessons will be learnt. All agencies have acted immediately on being alerted to the situation by the “Panorama” team and, as I have mentioned, appropriate inquiries are under way.

[Baroness Wall of New Barnet]

I agree with the Minister about the response around the Care Quality Commission. When such a result as this comes out, the undermining is quite damaging right across the whole spectrum of its work. In hospital trusts and everywhere else, the CQC’s inspection and report are held in great esteem if they are good and are very worrying if they are not. I wonder whether that is denigrated by this unfortunate incident and this awful opportunity that it has had and missed.

[Earl Howe]

My Lords, I take the noble Baroness’s point. It is very easy to blame the CQC whereas we should in fact first point the finger at those who perpetrated these awful acts and at the management of the hospital. There are a number of other agents involved besides the regulator. We are committed to developing the role of the Care Quality Commission to make it a more effective regulator of health services in England. Those efforts can be supplemented by the role of HealthWatch, which she will know we proposed in the Bill before the other place to strengthen the arrangements for the patient and public voice. I am sure that there is more that we are able to do, but it is important that we learn the facts first before pointing the finger at the regulator or anybody else.

NHS: Waiting Times

Baroness Wall of New Barnet Excerpts

Tuesday 3rd May 2011 Lords Chamber

[Earl Howe]

My Lords, I agree with much of what the noble Lord said. There is no doubt that great strides were made under the previous Government to reduce waiting times. That is entirely to the advantage of patients. However, the noble Lord will know that, as I mentioned earlier, the NHS constitution still retains the right for treatment within 18 weeks and the contracts between commissioners and providers still retain the financial penalties if the 18-week target is broken.

[Baroness Wall of New Barnet]

My Lords, will the Minister reflect on the discussion that he and I have had in the past around how important waiting times are to patients? Despite the new six-week “more quality” input into how the analysis is done and the processes to which my noble friend Lady Finlay has just referred, there is still an issue when people leave hospital. They say they waited longer. We need to rethink what that really means. In the context of waiting lists, if we separate elective and A&E, as my husband is proposing, then we will do away with all of that.

[Earl Howe]

My Lords, the central point that the noble Baroness makes is absolutely right. We have to look at quality in the round. There is more to quality than simply timeliness, although, as I have said, timeliness of treatment is important. We need to develop indicators that show the full range of the level of care and service that patients receive. We are doing that.

NHS: Consultation on Reform

Baroness Wall of New Barnet Excerpts

Tuesday 26th April 2011 Lords Chamber

[Earl Howe]

My Lords, the forum, as I understand it, is now fully composed. The appointments were made over the past 10 days or so. I am not aware of any further appointments. The plan is for the forum to produce a report which will be published at the end of the day. I will, however, write to the noble Baroness as regards the minutes, which are a matter for the chair of the forum, which is independent of the Government, as she will know.

[Baroness Wall of New Barnet]

My Lords, does the noble Earl agree that the pause and the mechanics that he has talked about have to be dealt with—there are lots of issues around that—but that the pause or gap is causing great concern to people working in the health service? Pause is an incidental word as regards the feelings of people who are going through this process and are caring for patients but are not sure what method they are supposed to be using. Will the noble Earl please tell us when we will know what is happening and how these people can get on with the job that they want to do?

[Earl Howe]

My Lords, I am aware of that concern. This matter has occupied the minds of Ministers. I say to those who are serving in the NHS day by day and, indeed, to the pathfinder consortia and the early implementer local authorities that they should continue with the work that they are doing because it is from them that we most wish to hear about the practical lessons that our proposals may point to. It is, I am sure, an unsettling time for them but we hope that after this period of reflection we can continue with the passage of the Bill with proper momentum.

Health: Cancer

Baroness Wall of New Barnet Excerpts

Wednesday 2nd March 2011 Lords Chamber

[Lord Roberts of Llandudno]

My Lords—

[Baroness Wall of New Barnet]

My Lords—

[Lord Mawhinney]

My Lords—

NHS: Prebiotics

Baroness Wall of New Barnet Excerpts

Wednesday 17th November 2010 Lords Chamber

[Earl Howe]

My Lords, we regard the departmental budget as being there to enable those who have good-quality and well-designed research projects to bid for those funds. I will take on board my noble friend’s implicit suggestion that the department should pursue the issue but, in doing so, I bear in mind that these products are commercially produced and that it is really for the manufacturers to come up with robust clinical data.

[Baroness Wall of New Barnet]

My Lords, is the noble Earl aware that there are more trials on probiotics than on the prebiotics mentioned by the noble Baroness, Lady Masham? Although there are no Department of Health trials that I am aware of, was the Minister suggesting in his earlier response that he is seeking the opportunity for such trials to take place?

[Earl Howe]

My Lords, I merely meant to indicate that we would welcome good-quality proposals. On probiotics, I understand that one study using live yoghurt showed a patient benefit but my advice is that the study methodology was flawed and its findings were not generalisable. Probiotics are not therefore recommended, as studies have failed to show any convincing evidence that they either treat or prevent C. difficile infection.

Healthcare: Costs

Baroness Wall of New Barnet Excerpts

Monday 15th November 2010 Lords Chamber

[Earl Howe]

My noble friend is right to pinpoint this area. If my memory serves me correctly, the average annual increase in management and administration costs over the past 10 years has been 6.2 per cent per year, which is by far and away higher than the increase in costs in clinical areas, for example. That is why we are determined to reduce the administrative cost of running the NHS, and we are in the process of planning for exactly that.

[Baroness Wall of New Barnet]

Does the noble Earl agree that that is an opportunity for us to look at saving costs in the health service by ensuring that we think of methods to persuade people to attend their day clinics? The cost of people not attending—DNA, as it is called in the health service—is huge, particularly in day surgery.

[Earl Howe]

The noble Baroness is quite right, and I am well aware that she speaks from personal experience. Many hospital trusts, and indeed GPs’ surgeries where applicable, have devised inventive ways of reminding patients of their appointments, either on the day or on the day before, perhaps by text. Good practice in this area is something that we need to focus on.

Healthcare

Baroness Wall of New Barnet Excerpts

Thursday 28th October 2010 Lords Chamber

[Baroness Wall of New Barnet]

My Lords, I too, thank the noble Lord, Lord Hunt of Wirral, for giving us the opportunity to debate this subject. The contributors to the debate will know just how important it is to everybody. I declare an interest as the chair of Barnet and Chase Farm Hospitals NHS Trust, an acute trust delivering general and highly specialised healthcare to a large area of north London.

The policies of any Government have a direct and profound effect on the quality and outcomes of patient care. For some time our trust motto has been, “Patients First and Foremost”. Our staff work towards this vision at every stage of their careers and throughout all government policies regardless of the party, or parties, in charge. That is why I have paid great attention to the Government’s policy on patient-led healthcare.

Much progress has been made on the timeliness of services within the NHS through the target-driven process initiated by the previous Administration—my Government. The present Government’s moves to dismantle this structure must not be allowed to lead to the loss of these crucial improvements, but rather build on them. However, the time may be right to move from the assessment of service quality by time, which was an imperative at the point these processes were introduced, to combine this with the more clinically sensitive indicator of outcomes. I feel that it is a pointer to the success of the previous Administration in upholding the original vision of the founders of the NHS that we are now able to consider such a transition. Within my own trust great strides have already been made in many areas, particularly with the reorganisation of the A&E services and acute medicine, leading to shorter waiting times and a better service for our patients. Future progress in these areas may be better measured by combining quality of outcome rather than timing alone, important as this has been in increasing our standards to the present levels.

In other areas such as modern cancer services, which received a massive investment under the previous Administration, the question of timeliness of care has again largely been addressed. Perhaps we should move to realising the benefits in terms of quality and outcome measures made possible by previous investment. However, I caution that we should do this without taking our eye off the ball as regards acknowledging the importance of timely action for those diagnosed with or suspected of having cancer of any kind—for those people, time is of the essence. In my trust, great changes have taken place in providing local, modern, advanced cancer services, with the use of laparoscopic and robotic techniques. It is important that this is maintained and monitored against the highest national and international standards.

Many patients served by my trust are elderly. We must recognise the demographic changes, as other noble Lords have said. The country as a whole must think about this in the design of its services. For this enlarging sector of our population, true quality of service demands not only timeliness and excellent outcome but an additional vital ingredient: local provision. Some services that my trust provides are excellent by national standards, and the outcomes are very important. We must not in any way threaten them by an ill thought-through, centralised agenda. The knock-on effect of removing these local services will, if allowed to progress, threaten to undermine excellence in other areas that they support. The White Paper says exactly the opposite of this. Localism is really important. I ask the noble Earl for that confirmation today. Localism is important: people know what is important to them locally. I am sure that the noble Earl, who is smiling at me, understands that from the recent visit that he made to my trust.

I finish by saying that the role of front-line health professionals is paramount in ensuring that the delivery of this White Paper, and more importantly of health services overall, is recognised by patients. The implementation of government policy is a weight that they carry. It must not become such that it interferes with the delivery of services. Make no mistake: we are being watched by everybody. As a trust, we think that it is very important that we are able to step up to the plate, as the saying goes.