Health and Social Care Bill

Baroness Williams of Crosby Excerpts

Monday 27th February 2012 Lords Chamber

Moved by

[Baroness Williams of Crosby]

49A: Clause 22, page 17, line 38, at end insert—
“Patients’ interests to be treated as paramount
The Board must, so far as resources allow, exercise its functions on the basis that the interests of patients are paramount.”

[Baroness Williams of Crosby]

My Lords, owing to the need to make progress I shall speak briefly, but my noble friend Lord Marks of Henley-on-Thames will be speaking in greater detail about the amendment.

It is short, perhaps deceptively short, but it has real significance and is related in this group specifically to Amendment 94A. The government amendments respond to aspects of these amendments, too. Amendments 49A and 94A set at the very centre of the Bill, which has the full support of all of us who want to see the NHS thrive, that the interests of patients should be paramount. The importance of that phrase is that in every single aspect of what we try to do, it shall always be the case that this is the way in which we think—whether it is how CCGs operate or how foundation trust hospitals operate. This has emerged in our debates increasingly as the central concept—the one to which we should always refer back. That will give us the guiding light that we need for the Bill.

It is significant because, in many cases, patients can be very vulnerable. They can be vulnerable through lack of information and in some cases by not being consulted. They can be vulnerable, as the noble Baroness, Lady Hollins, has mentioned, through the lack of advocacy by people who understand the basis of the choices they have to make. This phrase about the significance and the importance of patients’ interests being paramount therefore also affects a recognition that where patients are vulnerable they need the help of counsellors, advisers and in some cases advocates, so the concept behind this covers those areas as well.

I want also to point out briefly that government Amendment 56 is helpful in spelling out the matters on which patients should be particularly consulted. I will not repeat them but the amendment is helpful in setting out very clearly issues of treatment and the way in which patients should be offered different forms of treatment and then to make choices among them.

I do not intend to keep the House. I shall conclude my remarks. Whatever side of the House we may be on, I hope very much that the concept of the paramountcy of patient interest will be something that all of us can support, understand and advocate with respect to the future of health services. I beg to move.

[Lord Marks of Henley-on-Thames]

My Lords, the reasons for Amendments 49A and 94A have been briefly—as she explained—and eloquently expressed by my noble friend Lady Williams of Crosby. One of the fundamental principles which the Government have assured us runs right through this Bill is that the NHS, as reformed by this legislation, will be committed to putting patients first. That is a critical matter for most of us in this House and the public at large. Why do I believe that this principle needs stating in the Bill? It is because the Bill introduces an entirely new structure for commissioning services, with commissioning by clinical commissioning groups within a framework established by the board to requirements and objectives set by the Secretary of State. However well understood here, this proposed structure is widely mistrusted outside this place.

I believe that a legislative statement that the commissioning process will put patients first is very important, both because it will enshrine in law this fundamental principle and because it will give the public an assurance that this is indeed the aim and purpose of the new commissioning process. My noble friend the Minister was kind enough to write to me in relation to this amendment to say that while he completely agrees that we must always put patients first, the Bill already provides for that and that there are “technical reasons” why our amendments should not be accepted.

The Minister is entirely right to point to the commitment to the comprehensive health service in the Bill and to the duties of the board and the clinical commissioning groups, now enshrined in the Bill, to promote the NHS constitution. I agree that those are powerful provisions. The NHS constitution is an important and extremely valuable document. It does indeed contain a commitment to putting patients first. At the back of the document in the expression of NHS values it says:

“Working together for patients. We put patients first in everything we do, by reaching out to staff, patients, carers, families, communities, and professionals outside the NHS. We put the needs of patients and communities before organisational boundaries”.

No one could fail to regard that expression of values as admirable, but it covers the whole sweep of NHS functions and is very general. The provisions that we seek by way of these two amendments are specific to the commissioning process. They will impose a binding obligation on the board and the CCGs of which they will at all times be aware. Moreover, our amendments are directed particularly at responding to what is probably the principal concern that members of the public have about these reforms: that the new commissioning process may lead to the marketisation of the NHS and that patients’ interests may be lost in that process. I do not believe that, but I do believe that these amendments would help make it crystal clear that this concern is unfounded.

The other problem we face is this: all the evidence, even that emanating from within the NHS, suggests that there is widespread unawareness of the very existence of the NHS constitution, let alone of the detail of its provisions. At the very least, therefore, given the emphasis that we are putting on the NHS constitution, it is crucial for the Government to make it quite clear that a great deal is expected of the board and of CCGs in the exercise of their respective duties under the Bill to promote awareness of the NHS constitution. In addition, the department should commit itself to an even wider, more effective campaign to publicise both the existence and the content of that constitution.

As to my noble friend’s second point, I regret that I do not understand the technical reasons which are said to require the rejection of these amendments. It is perfectly true that the NHS will always have to face resource constraints which may necessarily determine many, even most, commissioning decisions, but our amendments accept entirely that the paramountcy of patients is always subject to resource constraints. The board or a CCG must, so far as resources allow, exercise its functions on the basis that the interests of patients are paramount. Nor do our amendments, either expressly or impliedly, reduce the ability of commissioning groups or the board to prioritise the treatment of particular groups of patients where they think appropriate. They simply make the interests of patients in general paramount or, to use my noble friend the Minister’s phrase, make sure that commissioners put patients first.

The use of that word “paramount” in these amendments was modelled on the Children Act 1989 and the principle which runs like a golden thread through that legislation that the interests of children are paramount. That legislation has been widely applauded for embodying that principle, which firmly governs its interpretation and its implementation. It is precisely because it is embodied in the legislation itself that that Act is so well respected.

I still hope that my noble friend the Minister might reconsider whether he is not prepared to accept in this Bill the expression of the principle which he has so often expressed: that, throughout the commissioning process, the interests of patients must be paramount.

--- Later in debate ---

I am extremely grateful to them for their support in ensuring that the Bill is as strong as possible on this point.

[Baroness Williams of Crosby]

My Lords, I thank the noble Earl very much for the amendment, and I am grateful to him for what he had to say. I beg leave to withdraw the amendment at this point but hope very much that he will come back to it at Third Reading.

Amendment 49A withdrawn.

--- Later in debate ---

Emergency medicine acts as a portal. The vulnerable come in with their life stories. There is no pressure group to argue for patients who access emergency medicine because they are a completely heterogeneous group. Disease groups, such as those for neurological diseases, cancer, diabetes and so on, can argue for their patients but emergency medicine covers just about everybody. It has been estimated that, on average, a member of the population accesses an emergency department once every three years, compared to once every six years for out-of-hours primary care services. Therefore, I hope that the Minister will be able to reassure me that emergency medicine will be looked at in its totality and across the spectrum from primary to secondary care; and that commissioning will take into account that it is in a different position, with its constantly open access portal, from the other services in the NHS. I beg to move.

[Baroness Williams of Crosby]

My Lords, perhaps I may briefly intervene in the debate on this extremely important amendment. In countries like the United States, where there is no effective health system for those who cannot afford very substantial sums of money, emergency admission has become the last resort for such people. The noble Baroness, Lady Finlay, is right but we should take it one stage further. We know, from very recent reports on the difference between the likelihood of survival in an emergency situation between weekdays and the weekend, that out-of-hours provision is of substantially lower quality than that provided by regular doctors in a good hospital. This is very serious. One of the great mistakes made in the last contract for general practitioners was the almost complete transfer of out-of-hours work to private agencies which did not demand the same standards in respect of doctors, ranging from their ability to speak different languages through to experience of medical treatment. In consequence, we now have a troubling kind of medical roulette where a great deal depends on whether you get ill on Thursday or on Friday. The statistics are quite frightening, showing not a narrow but a very substantial difference.

Before the noble Lord, Lord Hunt, comes in—if he does—and before the Minister responds, I would like to raise two points. The first is about the degree to which the noble Lord believes we can begin to re-establish out of hours work to a higher level of quality broadly equivalent to that offered by general practitioners and other medical staff to patients who conveniently fall ill on Monday through Friday but not later or after that. Secondly, what does the Minister feel about the dependence of some groups in our community on emergency services, not because they want to use them but because they are not familiar with ways to establish their proper relationship with people who could look after them in difficult conditions? This goes back to one of the particular concerns of the noble Baroness, Lady Finlay, which is the impact of alcoholism on emergency entry. This is not just another amendment; it is a crucial one which points to a very troubling discrepancy which could grow worse if we do not succeed in addressing it.

[Lord Walton of Detchant]

My Lords, it would be difficult to overstress the crucial importance of this issue, which has been a matter of grave concern to the specialist medical community. People with less common conditions often require specialist services for treatment unavailable through generic NHS support. At Question Time today, I posed a Question to the Minister about the report of the National Audit Committee which had demonstrated the serious inequalities of neurological services throughout the United Kingdom. People with neurological conditions rely not only on skilled neurologists but on a specialist multi-disciplinary team of nurses, physiotherapists, occupational therapists, speech and language therapists and others to maximise their independence and quality of life. The Bill proposes that these services be commissioned at a local level by clinical commissioning groups which will be able to determine the size of the population for which they have responsibility and which, as matters stand, will have no duty to collaborate with other clinical commissioning groups in the commissioning of services. Grave anxieties have been expressed by the Rare Disease Consortium and by the Neurological Alliance, which is the only collective voice for more than 70 national and regional brain, spine and neuromuscular organisations working together to make life better for 8 million children, young people and adults in England with a neurological condition.