Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2011

Baroness Williams of Crosby Excerpts

Monday 31st October 2011 Grand Committee

[Baroness Jolly]

I should like the Minister to clarify one point. Out-of-hours services providers need to register a year early if they are not in the practice of treating patients from outside their area. Can the Minister clarify the situation regarding itinerant or travelling workers? Where I come from, huge swathes of people come in to pick strawberries, daffodils or whatever. They certainly do not register. I am not clear whether the out-of-hours providers would treat them as temporary residents. What is the case in those circumstances? Would GPs who currently provide services in Cornwall in a co-operative be required to register a year early?

[Baroness Williams of Crosby]

My Lords, I, too, have a couple of questions. I very strongly support my noble friend's question about itinerant or temporary workers. In addition to the people about whom the noble Baroness, Lady Jolly, spoke, there is also the Traveller community, which does not stay permanently in a single place, as we know from the Dale Farm episode. I am very concerned—I am sure that others in the Committee are, as well—about the position of mobile workers whose life involves moving from place to place, and about where they will be picked up by the providers.

My second question concerns the position of out-of-hours services. The General Medical Council has raised many concerns about out-of-hours providers who are not familiar with the English language, let alone some of the other languages that we have in this country. Will there be additional requirements for out-of-hours service providers above the basic medical requirements that they will have to meet?

I should know the answer to my third question, but I confess that I do not. However, I am sure that the Minister does. When providers are registered, are the lists of those who are registered made available to local HealthWatch committees, local authorities and Parliament? That is very important. Transparency is almost invariably the best form of inspection.

Finally, with regard to the CQC, we all know—as the noble Lord and the noble Baroness, Lady Thornton, said—that it has been under heavy pressure. My question is: will the practice of non-notified inspections, as well as notified inspections, continue? I note that the Secretary of State referred to this just a couple of weeks ago in respect of the investigation of complaints about the treatment of elderly people when he called on the CQC to do an immediate inspection.

I have one final point. I do not expect the noble Earl to reply if he does not want to. The most effective form of inspection is by protecting whistleblowers. All of us are aware that whistleblowers are a very effective form of informal inspection. It was whistleblowers who came up with the terrible Winterbourne story. Are there any means of protecting whistleblowers, especially among NHS staff, from being forced into retirement or sacked? Among all possible forms of inspection, NHS staff are most likely to be able to alert the system too bad or poor standards. Have we given consideration to the possibility of protecting whistleblowers among NHS staff? I am sure that our colleague from the trade unions would be sympathetic to that idea.

[Earl Howe]

My Lords, noble Lords asked number of questions. The noble Lord, Lord Collins, focused in particular on the capacity of the CQC to fulfil the remit that we gave it. He questioned its ability to register 9,000 providers in 12 months. He will not be surprised to hear that we asked the same question of the CQC. We were assured that it is well placed to do that. It has registered 21,000 providers since April 2010. As I mentioned earlier, it is streamlining its processes to achieve the registration of primary care providers. However, the registration of primary dental care providers and independent ambulance providers in April 2011 highlighted the need for the CQC to make improvements to the registration process. In the light of that, we believed that it was preferable to delay registration by a year, during which time the CQC would be able to modernise and streamline its processes and tools so that the process runs more smoothly and is less burdensome both for providers and the CQC itself.

One of the main purposes of deferring the registration of providers of primary medical services was to provide the CQC with the space to improve its systems. We considered walk-in centres in this context. We perceived that there was a serious risk of capturing a significant number of providers under the definition of an NHS walk-in centre. We have concluded that rather than risk overburdening the CQC with a large number of applications in 2012, we will postpone the registration of these providers for 12 months. We believe that this will provide the CQC with the necessary breathing space. The CQC is already contacting those providers who it believes will need to register in April 2012 in order to start the registration process. The CQC will also work with other providers of NHS primary medical services and their representative organisations to identify and develop proposals to streamline the application process that will apply to those who are required to register in April 2013.

The noble Lord also asked me about the CQC’s resources. Each year the CQC agrees its business plan and financial allocation with the Department of Health. The CQC’s financial position is then kept under constant review during the financial year. The Department of Health has now agreed a business case submitted by the Care Quality Commission requesting approval to recruit additional compliance inspectors and compliance managers in order to undertake more frequent inspections. This approval has been given as part of the ongoing 2012-13 finance and business planning round and the CQC’s indicative revenue budget for next year includes sufficient funding to allow the CQC to recruit the additional 229 full-time equivalent compliance inspectors and the additional 19 compliance managers that it requested.

As I indicated earlier, we considered whether there were different risks in the provision of out-of-hours care to justify registering providers of those services ahead of providers of other NHS primary medical services. The case of Dr Ubani has been mentioned, which is very pertinent in this regard. Many respondents expressed the view that there were strong reasons for us to register these providers next year. While there is little concrete evidence to demonstrate that there are greater risks in the provision of these services, we believe that there are material differences in the type of service they provide which justify their earlier registration. As I indicated earlier, some of the differences revolve around the fact that often out-of-hours services practitioners treat unfamiliar patients and see a higher proportion of vulnerable patients with urgent care needs, sometimes with more complex needs. That persuaded us that there was a more urgent case for registering those providers before the others.

The noble Lord made the very good point that in primary care nowadays an increasing range of services are provided. That is why the previous Government approached the question of regulation in the way that they did. Instead of defining scope in terms of organisational settings; for example, hospital and care homes, there is a list of regulated activities for which registration is required. This means that regulation is based on risk of harm to those receiving the care or treatment rather than inflexible organisational structures.

This system of registration is flexible so that it can adapt to new and innovative service models. Basing the scope of registration on activities rather than settings means that regulation provides the same level of assurance wherever people choose to access care or treatment. In other words, legislation describes what providers must do, not how they must do it.

My noble friend Lady Jolly asked me a number of questions, in particular, about itinerant, travelling workers and how they are treated. The fact that a primary care provider accepts patients temporarily will not itself trigger registration from 2012. Those patients are likely to be temporary residents if they seek to access GP services in a particular area. I will write to my noble friend to clarify that, because I am sure that there are detailed issues within that question and I do not want to mislead her.

My noble friend Lady Williams also picked up that point and asked me about language requirements on out-of-hours providers. The language requirements are currently picked up under the system by which PCTs commission out-of-hours care. It is not open to the GMC, when registering a doctor who is registered abroad, to language-test that doctor, but employers clearly have a duty to ensure that any doctor employed in an out-of-hours service is capable of communicating with patients. The employer should ensure that patient needs in an area are being appropriately met by those who are charged with looking after them out of hours.

My noble friend also asked whether the list of registered providers will be available to local HealthWatch and to Parliament. I am advised that the list is available on the CQC website. Some bodies require notification, and HealthWatch England will be part of the CQC, if Parliament approves our plans, so there will be an automatic route of communication between the CQC itself and HealthWatch England.

My noble friend also asked me about whistleblowers. NHS workers are currently protected by whistleblowing legislation. The CQC is a named body under the Public Interest Disclosure Act, which protects whistleblowers. We are very keen that there should be no deterrent to whistleblowers. It was obviously concerning to see a case reported last week where a whistleblower was put under pressure by colleagues. We are looking at the implications of that case very closely. I cannot say more to my noble friend at the moment on that.

Health Authorities (Membership and Procedure) Amendment Regulations 2011

Baroness Williams of Crosby Excerpts

Monday 31st October 2011 Grand Committee

[Lord Beecham]

My Lords, first, I apologise for not being present for the opening part of the debate. I have just a couple of questions to put to the Minister. The first relates to the appointments to these very large bodies. Four bodies now cover the whole country, which is half the number of the Anglo-Saxon Heptarchy of some centuries ago; they cover very wide geographical areas. I wonder whether the noble Earl can indicate what steps are being taken to strike a geographical balance for the executive and non-executive appointments so that local knowledge across these very wide regions is reflected to the best degree possible—it is of course not completely possible, given their size—in the new arrangements.

The second question relates to the issue of scrutiny and the extent to which, if at all, the new bodies will be subject to the scrutiny of local authorities’ health scrutiny committees under the existing framework. I am not sure the extent to which they would want to pursue that, but there may be cases when they would, and of course geography may play some part in that. It would certainly be welcome if the Minister could be clear that, in principle, the new SHAs, pending the creation of the new special health authorities, will be subject to the scrutiny process.

[Baroness Williams of Crosby]

Perhaps I may take this opportunity to ask the Minister a couple of questions as well. I am grateful to the noble Baroness, Lady Thornton, for raising this issue with a statutory instrument.

I am delighted to hear that some form of the SHAs will continue in the interim period—I think that they have, on the whole, done a very good job—and that there is a real sense that they can continue to play a significant part in the transition. It looks very much like, with the clustering, we are making a clear transition from where we are to where we are going. I, for one, would not object in the least to their remaining like that.

I have a couple of questions for the Minister. The first is whether he envisages that the regional offices of the NHS Commissioning Board—which, admittedly, we have not yet passed through Parliament—are likely to be very closely aligned to where the strategic health authorities are. Obviously, there is a lot to be said for continuity.

The noble Earl also mentioned the need for flexibility, on which we could not agree more. Perhaps I may ask specifically whether one could raise the question of March 2013 not being a final date. There has, as we know, already been some softening of the original timetable as a result of the Future Forum and the listening exercise, which I think was broadly very much welcomed, partly because it enabled the new system to keep some of the quite distinguished and very experienced staff from the past. The noble Earl had the kindness to say that one of the problems is how one maintains experienced and well qualified staff. The more the transition can copy the strategic health authority structure, the more likely it is that we will be able to retain some of those very qualified and experienced staff. We know that quite a few of them have been lost and that the NHS could do with not more being lost. Is there any prospect of greater flexibility about the timetable, which was strongly supported by the Future Forum?

The second question is a more specific one about SHAs. As the noble Earl knows, SHAs have a large part in education and training, which is still a major area of uncertainty until the education and training legislation comes forward. Under Regulation 2.2 of the 1996 regulations, there was a specific commitment that where a strategic health authority contained medical or dental schools, a member of the authority would come from that background. They specifically stated that he or she should come from the background of education in the medical or dental school that was part of the strategic health authority. Will that be respected in the new circumstance? That would clearly be helpful in addressing future education and training issues.

My last question is a broader one about the Government’s feeling that there was no need for an impact assessment. I confess that I am a little worried about that, because the clubbing together of membership has certain possible impacts. Lastly, as the noble Baroness properly mentioned the issue of the involvement of HealthWatch, will there be an insistence that at least one member of the cluster should be someone with a background on the health and well-being boards—in other words, representing the HealthWatch interests—in the decisions of the new cluster groups?

Let me say loud and clear that all of us regard the cluster groups as a good development; I did not want to quarrel with that. Our questions cluster around the cluster, rather than concerning the cluster itself.

[Baroness Jolly]

My Lords, I will add to the points raised hitherto. I welcome the emphasis on continuity, but I wonder whether there is an opportunity to think whether we are closing the door completely on appointing new non-executive directors. We are moving into a new world with a new mindset and culture. If we are going to retain non-executive directors currently in situ in SHAs, will that opportunity be lost? I should like that to be clarified.

We must not lose sight of the fact that these are enormous organisations geographically. From one end of Cornwall to the other end of Kent is further, distance-wise, than from London to Edinburgh. There are issues about representation on boards. There must be complete understanding of the different issues in metropolitan, rural and urban settings. That will be critical for any board.

Also, does the noble Earl have any figure for what the savings in management costs might be? I seem to remember that when this was done for PCTs and they were all enlarged to become coterminous with local authorities, management savings were promised but not delivered. What is the size of the savings that we hope for? Have the Government factored in the risk with all of this?

Health and Social Care Bill

Baroness Williams of Crosby Excerpts

Tuesday 25th October 2011 Lords Chamber

[Baroness Williams of Crosby]

My Lords, may I briefly address the proposal put forward by the noble Baroness, Lady Thornton? She has made a considerable contribution to the discussion in this House about the health services; not least by organising an impressive series of seminars that were attended by many Members of this House, from all parties and also from the Cross Benches. We are extremely grateful for this.

I am moved very little by the preamble, in the sense that the central issue behind it, which I fully share—that is to say, the clear responsibility of the Secretary of State for a comprehensive health service free at time of need—is primarily, in fact, already embodied in the debate we are about to have on the first group of amendments after the amendments on education and training. The way that this has been addressed by the noble Baroness, Lady Thornton, herself but also by other members of this House, not least the noble and learned Lord, Lord Mackay of Clashfern, provides the basis for a very satisfactory, detailed and careful consideration of what the role of the Secretary of the State is.

We know that there are still fears about ambiguity. On this I agree with what the noble Baroness, Lady Thornton, has indicated. These fears have been very strongly outlined: first, by the Future Forum which said in its report that it had concerns about the accountability of the Secretary of State and, secondly, in the brilliant and concise report of the Constitution Committee, an all-party committee of this House. The committee pointed to its concerns about whether the responsibility and accountability of the Secretary of State emerged sufficiently clearly, and it gave a very impressive argument to the effect that some doubts remain about the position.

Since that time, of course, there have been concerns—rightly so—about some of the knock-on effects of removing accountability of a clear kind from the Secretary of State. All through this Bill, there are situations where the Secretary of State might be or might not be involved. I shall give two examples. The first is about the possibility of conflict between Monitor and the NHS Commissioning Board and how that is to be resolved, where one might suppose that the Secretary of State would be the ultimate decider. The second is on the question of what happens if there is a major emergency in the country of a health nature and whether the public would not, in fact, expect the Secretary of State to be the ultimate source of accountability.

My feeling is that it is better to address these issues very clearly as each one comes up, and to set out in detail, therefore, what the precise responsibilities of the Secretary of State are. Certainly, if one wants simply to assert—which many of us obviously fully understand—a concern and a liking for the NHS, the Secretary of State’s responsibility was reiterated and reaffirmed some time ago after intervention by my right honourable friend in another place, Mr Nicholas Clegg, and others.

This is not an issue for which we should hold up the whole of the Committee proceedings but, in assessing once again the commitment of many of this House to the NHS, it is certainly not objectionable. For the reasons I have given, however, it is perhaps not wise to detain ourselves on this issue at the moment.

I would add two other problems. The wording of the preamble before Clause 1 is mostly fine, but frankly I am a bit worried about subsection (3). One thing we must not do is, as it were, encompass the NHS in a form of unchangeability when all of us know that major changes have to be made within its structure. Therefore, subsection (3) could be a rigidification of the situation. Having said that, however, I believe that we should now move on from this issue to look at the most clear, legally expressed considerations of what should be the clear and accountable responsibilities of the Secretary of State.

[Lord Hennessy of Nympsfield]

My Lords, having suggested during the Second Reading debate that your Lordships might consider the value of a preamble to the Bill which captures the ethos and purpose of the National Health Service, I was grateful to the noble Earl, Lord Howe, in his letter of 20 October to noble Lords, for describing it as “an interesting idea”. The Minister went on to say that,

“preambles have fallen out of use in modern-day legislation, partly because there is a risk that they could lead to unintended consequences, and also because it is considered bad legislative practice to include words in a Bill that have no clear legislative purpose or effect”.

I note and accept that preambles have fallen into disuse, but I continue to see the value of capturing the NHS ethos and purposes firmly right at the top of the legislation, which is why I welcome the proposed amendment in the name of the noble Baroness, Lady Thornton, as a surrogate for a preamble.

I am especially pleased by the NHS constitution occupying a prime position in the amendment’s attempt to capture the principles of the health service in England. The first two principles expressed in the NHS constitution must continue to suffuse the whole enterprise and its legislative underpinnings. The first principle declares:

“The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population”.

Principle 2 explains quite briefly that:

“Access to NHS services is based on clinical need, not an individual’s ability to pay. NHS services are free of charge, except in limited circumstances sanctioned by Parliament”.

Faith in those principles runs deep in our country, powerfully and, very largely I think, consensually. They deserve to be emblazoned at the top of this Bill through a clear reference to the NHS constitution. In fact, apart from the words “not the market”, the amendment before us could, I suggest, represent a common bonding for our deliberations, however fiercely contested will be many of the clauses to come, just as the sustenance of a comprehensive National Health Service free at the point of delivery is one of, or perhaps the most, tenacious common bondings of our people and our country.

--- Later in debate ---

Moved by

[Baroness Williams of Crosby]

3: Clause 1, page 2, leave out lines 2 to 4 and insert—
“(2) The Secretary of State must for that purpose provide or secure the provision of services according to this Act.”

[Baroness Williams of Crosby]

My Lords, this amendment is tabled in my name and those of the noble Baronesses, Lady Jay and Lady Thornton, and the noble Lord, Lord Patel. It is an absolutely central and crucial amendment. I say right away that I am consumed with envy by the success of the noble Lords, Lord Walton of Detchant and Lord Patel, in getting the Government to table an amendment restoring the duties of the Secretary of State in the area about which they were concerned. I only wish that the same thing might happen as regards my amendment.

It is interesting that even in the course of a long debate about education and training we kept coming back to a consistent ambiguity about exactly what the powers and duties of the Secretary of State are, particularly with regard to the possibility of failure. I am afraid that this set of amendments covers some of the same ground. I will do my very best not to repeat what has already been said. The whole point of Amendment 3 is to restore the wording that occurred in the original 2006 Act to indicate clearly what are the duties and accountability of the Secretary of State. There are two reasons for that. First, many of us wish to ensure that what was beautifully described by the noble Lord, Lord Hennessy, as institutionalised altruism—his description of the National Health Service—should survive and continue. In order to retain the trust of the public who care so much about it we have to make absolutely clear that the Secretary of State’s ultimate responsibility is not impaired. There is another reason for that, not just the fact that so many members of the public believe in the NHS; that is, we need to retain their trust while the huge changes that are envisaged to make the National Health Service successful for the future are carried out. We need to do that by indicating that there is no reduction in the ultimate powers of the Secretary of State.

There is also a key constitutional issue. I am sure that the noble Baroness, Lady Jay, will speak to this so there is no point in my going into detail now, but the constitutional issue concerns—to put it in a sentence—exactly who is accountable and responsible for £120 billion of taxpayers’ money which is spent on the National Health Service and on health more generally. The remarkable thing about the NHS, which has been mentioned by many Peers, is that it is taxpayer funded, and because it is taxpayer funded it is in many ways much more efficient and effective than many of its competitors in other parts of the world. Therefore, it is incumbent on Members of both Chambers of Parliament to retain accountability to the people of England for this huge sum of money through Parliament and the Cabinet. That means we have to make it clear that that channel passes through the Secretary of State.

The brilliant and concise report of the Constitution Committee chaired by the noble Baroness, Lady Jay, traced its concerns about ambiguities and uncertainties with regard to the duties and powers of the Secretary of State. The noble Baroness will express this matter better than I can, but I simply want to draw the House’s attention to the concluding remarks not of the Constitution Committee but of the Government themselves in responding to the Future Forum’s concerns about accountability. The Government state:

“As the Future Forum’s report highlights, some people are concerned that the Bill could weaken the Government’s accountability for the health service”.

They go on to say:

“There have even been some fears that the core principles of the NHS could be weakened”.

Then, encouragingly, the Government went on to say that,

“the Forum is right to point out that the current drafting of the Bill is not clear enough, and we will amend it”.

I am responding to that promise by the Government in the hope that we can as a Committee ensure that that amendment takes place in ways that we regard as satisfactory.

Health and Social Care Bill

Baroness Williams of Crosby Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Williams of Crosby]

My Lords, I agree completely with the noble Lord, Lord Ribeiro, that major changes have to be made. Those of us who are raising major issues in this debate are not arguing against change; we are not bound to the status quo. But I want to say right away that one of the things that I find deeply depressing about this long debate on the National Health Service is the number of references to the NHS as if it has somehow failed. One of the most remarkable assessments of the NHS, a copy of which I have left in the Library, is made in a report by the Commonwealth Fund of Massachusetts. It shows that on every issue from access, value for money, share in expenditure and patient satisfaction—which achieved 92 per cent—puts Britain uniquely ahead of everyone else in reply to the question, “Are you confident that you will receive the most effective treatment if sick?”. It is a staggering statement about this remarkable public service.

First, I want to underline and repeat what was said by the noble Baroness, Lady Jay. Those of us who take the view that this Bill needs to be looked at carefully, not least the issue of the responsibility of the Secretary of State, are not saying for a moment that there is no role for the independent sector, for innovators or for those with radical ideas, but straightforwardly that that must be within the framework of the National Health Service as a public service, which is what many of us believe in so profoundly.

My second point is one that I also believe to be very important. We have referred repeatedly to patients in the debate, but patients are also people. As people, they have registered time and again their belief and trust in and commitment to the NHS. We want to carry them with us through some of the biggest changes that have to be made. Those changes reflect our ageing population, which is one of the greatest successes of the NHS, along with the survival of many people with inherited or chronic illnesses. All this can be directly attributed to the work of the NHS over the past 65 years. However, now they have become a problem because we have to find ways to pay for them. Even so, they are a direct consequence of success, not of failure.

What also needs to be said loud and clear is that patients have indicated their trust in the NHS. We need that trust deeply in order to bring about the changes that must be made. I agree with the Minister, the noble Earl, Lord Howe, that those changes require that the NHS should become, among other things, more community based and that we should move away from an essentially curative, hospital-directed form of health service. But in making that huge change with all the exciting possibilities it offers, we have to carry the public of England with us. We will not carry them if their single greatest fear appears to be sustained. It was put beautifully this morning by the noble Lord, Lord Hennessy, on the “Today” programme: it is to move away from the concept of an altruistic health service to one that is essentially market based.

I have spent the past week in the United States and returned yesterday. The first thing I read when I got there was the estimate of the Kaiser Family Foundation, probably one of the best of the private health services in the United States, that the cost of health insurance has doubled since 2001, has increased by 9 per cent since last year—much more than the rate of inflation—and that the average cost of a family insurance package in 2010 was over $15,000. Not all of that is paid by the insuree as some is paid by employers, but they are running away from those costs as fast as they know how. I also read a proposal from the National Institutes of Health that great care should be taken about offering tests for prostate cancer in men when one of the side-effects is probably incontinence and impotence. Despite the advice of the central authorities, the attitude of many doctors is that they cannot give up these tests because they happen to be extremely profitable. For those who wish to read more about it, I have left the story in the Library. It is a frightening account of the conflict between medicine and its values and the pursuit of profit.

I turn now to the four big issues that confront us, and in doing so I pay tribute to the noble Lords, Lord Darzi and Lord Owen, and to others who pointed to them. The first was referred to by the noble Baroness, Lady Jay. It flows from the findings of the Constitution Committee, which has specifically raised concerns about the responsibility of the Secretary of State. At the beginning of his remarks, the noble Earl, Lord Howe, whose empathy and understanding is known throughout the House, spoke as if there might still be some meeting of minds on this crucial issue. But the letter he sent us all this morning appears to sound a little different. Why are we so concerned about this issue? It is because it remains ambiguous, unclear and obscure. Let me give one example. I think that I have been pursuing the issue of the accountability and responsibility of the Secretary of State for at least a year, and time and again I have gone back to the Department of Health and talked about the need to make it absolutely clear. Why is it not absolutely clear?

Those noble Lords who have a copy of the Bill need only look at Clause 4, which sets out a specific commitment to the autonomy of the bodies, the quangos —Monitor and, even more important, the NHS Commissioning Board—which now have responsibility for our health. The Secretary of State makes a specific pledge to the autonomy of those bodies in the phrase:

“In exercising functions in relation to the health service, the Secretary of State must, so far as is consistent with the interests of the health service, act with a view to securing … that any other person exercising functions in relation to the health service … that it considers most appropriate, and … that unnecessary burdens are not imposed on any such person”.

In legal language, “any such person” is very wide indeed. The autonomy clause indicates that only in the rarest circumstances would the Secretary of State interfere in that autonomy. So where would he interfere? The answer is that he would interfere if there was evidence of a significant failure. But my legal colleagues tell me that “significant failure” is a difficult bar to reach and that it is normally interpreted by the courts as meaning almost totally essential.

We all know about the danger of reactions to such things as necessary hospital closures, mergers and so on. But if the Secretary of State is unable to take any part in those until the failure becomes significant, heaven help us in making the changes that lie in front of us as effectively, cheaply and sensibly as we can. I wish very much that I could ask the Minister of State to tell the House at the conclusion of this debate that the ministry will now reconsider the autonomy clause in the light of the responsibilities of the Secretary of State. To put it simply, the expenditure of £128 billion of taxpayers’ money requires the presence of a Minister who is responsible and accountable for that huge sum. It is an essential part of parliamentary responsibility and of a democratic system. I fear the consequences if we fail to address this issue.

That does not mean to say for a moment that I do not wholly agree with the noble Lord, Lord Ribeiro, about the dangers of micromanagement; all of us recognise that. Endless interference with the discretion of clinicians, GPs and the professions ancillary to medicine runs against the need for change and for sensible outcomes. But there is no reason whatever why micromanagement cannot be ruled out—much of the rest of the Bill suggests it—without having this vast reorganisation thrust upon us. So let me say to the Minister of State, for whom I and the rest of the House have immense respect, that I hope that before the debate concludes he will be able to say something more about the autonomy clause and the responsibility clause.

There are several other issues of crucial importance: the failure of the Bill to address the education and training of doctors in any serious way at a time when those services are in chaos, and the Bill’s failure actually to be clear about the duties towards inequality, because the phrase “have regard to” is, in legal parlance, paper white. It does not mean very much at all. There are other points, but given the time I will not pursue them. I simply beg my friends and colleagues on whatever Bench they may sit on in this House to put the responsibilities of parliamentary democracy and accountability ahead of the detail of the Bill and recognise the significance of what has been addressed by the noble Lord, Lord Owen, and the noble Baroness, Lady Jay.

NHS: Cost-effectiveness

Baroness Williams of Crosby Excerpts

Monday 12th September 2011 Lords Chamber

[Earl Howe]

My Lords, in my opening words I said that we welcomed the report. I stressed that we fully acknowledge the improvements that have been made by the NHS over the past few years, which the report highlights. However, it is limited in its scope. The difficulty with all these reports is comparing like with like, particularly with different health systems. I am not decrying the work that went into the report, but I will say that perhaps some OECD reports take us closer to how well the UK's health system is performing in relation to those of other countries.

[Baroness Williams of Crosby]

My Lords, will the Government take a larger look at the scope and permanence of the NHS’s success in recent years? Does the Minister agree that a key factor is the share of GDP devoted to the NHS and the results that it produces? The NHS has consistently produced better results with a much lower share of GDP than some comparative health services, including that of the United States.

[Earl Howe]

My noble friend is right. There is also another measure that counts—not just the percentage share of GDP, but the absolute amount of money in the health budget that goes into our NHS. As she will know, the amounts of money have increased substantially over recent years. That produces a rather different ratio from the one in the report referred to in the Question.

NHS: Reorganisation

Baroness Williams of Crosby Excerpts

Thursday 24th March 2011 Lords Chamber

Asked By

[Baroness Williams of Crosby]

To ask Her Majesty’s Government what is their latest estimate of the cost of the reorganisation of the National Health Service and what proportion of that is due to redundancy and early retirement.

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

My Lords, the Government published an impact assessment alongside the Health and Social Care Bill. This estimated the costs of the transition at £1.4 billion. Just over £1 billion was estimated to be as a result of redundancy. The £1 billion has not been split into redundancy and early retirement as these decisions will be made at a local level. The proposed reforms will save £1.7 billion per year from 2014-15 onwards.

[Baroness Williams of Crosby]

I thank my noble friend for that Answer, but I am aware that the National Audit Office, on the basis of its own surveys, has indicated a considerably higher figure. In an important article written by the professor of medical health at the Manchester Business School, the estimates are between £2 billion and £3 billion. Could my noble friend tell us the cost of the redundancies that have arisen from PCTs being brought to an end and people moving into the new consortia, and whether that figure is part of the figure that he has given to the House?

[Earl Howe]

My Lords, I would do best to refer my noble friend to the impact assessment, which provides a detailed breakdown of the figures that I have just given. I acknowledge that we have had to make assumptions in drawing up the impact assessment. Those can be challenged, and I am aware of the figures that my noble friend has referred to. But I do not believe that changing the figures—and they are bound to change in the nature of the exercise—will make a significant difference to the overall cost. The assumptions made in the modelling are based on the best available evidence that we have at the moment.

Human Fertilisation and Embryology Authority/Human Tissue Authority

Baroness Williams of Crosby Excerpts

Tuesday 1st February 2011 Grand Committee

[Baroness Williams of Crosby]

My Lords, I also congratulate the noble Baroness on securing and introducing this debate. One thing that she pointed to, which concerns many of us, is the extent to which there are huge commercial pressures in this field, which have led in other countries to an almost complete abandonment of what one might describe as the ethical limits that are widely understood in the medical profession. With an issue such as whether a grandmother’s frozen eggs should be used for the purposes of fertilisation, one has to say that the difficulty in reaching a proper conclusion rises daily.

I wish to raise the issue of inspection and the issue raised by my most admired poacher on the question of medical research. First, there clearly has to be some inspection of the clinics that fall under the HFEA. I would be grateful if the Minister could tell us his view of how that inspection will function. It may be more limited than it used to be, as the noble Lord, Lord Winston, and the noble Baroness, Lady Thornton, said, but it must be maintained at the level of day-to-day practice. It is very important that that should be so in order that patients can have some sense of the safety of the enterprise.

On the much bigger issue of medical ethics, raised by the noble Baroness and the noble Lord, we are looking at a tremendous multiplication of the issues around ethics and the massive advance of life sciences. I accept that that cannot be dealt with by the HFEA, with its rather limited terms of reference. We must try to bring together a much more significant body to look at the whole issue of the relationship between ethics and life sciences. In that context, may I sweeten that pill by suggesting to the Minister that one way in which one could develop the great idea of a great society would be to look at a marriage between a body that had status in government terms with the other great bodies that look into these matters—the Nuffield Council on Bioethics, the Royal Society and others? In that way, one might get a genuinely wide spectrum of opinion, including great scientists and ethicists, on the issues that now confront us with life sciences. I believe that, unless we do that, we will quickly run into real problems where dogmatic forces take up resistance to any advances or other dogmatic forces look at the commercial elements as the way to guide our consideration of biological and biochemical ethics in future years.

NHS: Reorganisation

Baroness Williams of Crosby Excerpts

Thursday 16th December 2010 Lords Chamber

[Baroness Williams of Crosby]

My Lords, I, too, thank the noble Lord, Lord Touhig, for introducing this crucial debate in such an effective way. I strongly agree with my noble friend Lord Rodgers of Quarry Bank when he suggests there should be more opportunities for this House—which has a very substantial level of medical knowledge which is not so clear in another place—to debate and discuss reorganisation, an issue which is still very much in the making. The greater the discussion and debate, the more likely it is that we will get an outcome on which everyone can agree.

I should like to add a personal note, and I hope I will not in any way embarrass my noble friend in saying it. My noble friend Lord Rodgers of Quarry Bank is a remarkable example of the successes of the NHS. Anyone who knows what he has climbed back from will, I think, agree with me. On another personal note, my family and I have always been NHS patients and never private patients. I have to thank the NHS for, on at least two occasions, saving the lives of relatives in the most remarkable conditions. I can find very little to fault it with when it comes to critical illnesses and accidents as compared with other health services, some of which I know very well indeed.

I should like to begin by considering the current position, and here I find myself in some agreement with the noble Lord, Lord Hunt of Kings Heath. If you read—as I hope every noble Lord will, especially those involved in health discussions—the quite remarkable report of the Commonwealth Fund, which is nothing to do with the United Kingdom but to do with the Commonwealth of Massachusetts, which is where the word comes from, you would be standing on the rooftops cheering—or at least you would if you were in any other country except our own. The report is remarkable. It shows that our NHS, along with the one in New Zealand, is almost certainly the most cost-effective system we know. Surprisingly—indeed, amazingly—it also shows that the gap between the service provided to those in very low income groups and those in very high income groups is less than in any other developed country. The gap here is 5 per cent whereas in other countries it ranges from 20 per cent in what one might call core Europe, to as much as 60 per cent in the United States. Perhaps even more amazingly, it also shows that the amount of time taken up in waiting to see a consultant or senior clinician in the NHS is very near the bottom of the list. In other services, some of which are much more inclined to be clinician-led, the time spent waiting is much greater.

We have to think very carefully about how to ensure that reorganisation improves the existing NHS and not try to indicate that the NHS has been a failure. By any international standard it is not a failure. It is one of the most remarkable, dedicated public services anywhere in the world.

There is another truly important point. It is clear that the NHS has, over more than 60 years now, won an astonishing level of public trust. The noble Lord, Lord Hunt, mentioned that. Anyone who cares to look at, for example, the recent study of social attitudes in the United Kingdom will see that the NHS is rated as being at the top of all the large public services. It is, rather sadly, ahead of education, but also ahead of almost all other public services. That means that we have to consider very carefully what we do to reorganise it. The bar has been set very high indeed in terms of public trust and public attitudes.

I should like to say one word to the noble Lord, Lord Kakkar, who is no longer in his place. There is a great importance in giving clinicians the widest public say and influence in the services that their patients can expect. I think that all of us in this House—some of us in this House are clinicians, although I certainly am not—would recognise the importance of their influence on the NHS and any other health service. Picking up on the words of my noble friend Lord Alderdice, I suggest that clinicians on their own will not be an adequate response to the need to change the health service for the better.

Wonderful men and women though many of them are, they are not, any more than the rest of us, completely immune from occasional selfish attitudes. I will give an example, which, in the spirit of a bipartisan approach to the problems of the health service, I hope even the noble Lord, Lord Hunt, might conceivably nod at. Many of us recognise that one of the things that went wrong with the NHS in recent years, apart from the increases in expenditure which were clearly good, was the unfortunate contract that enabled GPs to get very much more money and to do so without making any commitment at all to out-of-hours service. I have quite a lot of GP friends, including my own GP NHS trust, who are embarrassed at the way in which they got so much more money for less work at a time when almost all of us can expect not much more money for a great deal more work. The outcome of this debate would be improved if most of us were able to hang up for the moment our tribal loyalties and look at the responsibilities all of us owe to the NHS and to the reorganisation of the NHS. Those responsibilities are honesty, frankness and admission of our own mistakes.

I move on to what most worries me about the reorganisation, apart from the fact that it did not appear in the coalition agreement in any shape or form. Indeed, the coalition agreement specifically promised no more top-down reorganisation and, at least as important, there is reference after reference to PCTs, which would mean that anyone who read it carefully would think that PCTs were likely to survive and not suddenly to disappear.

I want to suggest to my right honourable friend the Secretary of State—and perhaps at least as much to the greatly admired Minister of State, my noble friend Lord Howe, whose devotion to the National Health Service is known to us and who we all, I think, trust and respect very deeply—that a reorganisation needs to carry with it changes that are seen by the public to be improvements. One of those was referred to by my noble friend Lord Alderdice and he is absolutely right. I suggest that clinicians look at the significance of accountability in a public service that is massively financed by the taxpayer.

The provisions for accountability are very weak and not clearly spelt out. I do not understand why it would not be possible with the White Paper to move towards a different system. PCTs are disappearing very fast, as the noble Baroness, Lady Masham, and others have suggested. Commissioning bodies should include not only clinicians but also representatives of the public, some from local areas. The noble Lord, Lord Hunt, was right when he said that there should be an executive lay chairperson whose responsibility would be to the community and not to clinicians or any other group which is bound to have its own concerns and special interests, rather than the wider interests of the public as a whole. The public would buy strongly into that kind of reorganisation. One which leaves that issue of accountability so vague and so little spelt out will not carry the trust that we need. My right honourable friend in another place who is today the Minister of State in the Department of Health, Paul Burstow, has suggested on several occasions the strengthening of accountability. The outcome has been existent certainly, but not strong. We need a much clearer system of accountability.

I will not detain the House for very much longer, but next I want to refer to my noble friend Colwyn who, in discussing the issues of NHS dentistry—I defer to him because he is much more knowledgeable on that subject than I could ever hope to be—referred to trial or pilot schemes.

[Baroness Northover]

My Lords, I hate to do this, but this is a strictly time-limited debate. When the figure seven shows, noble Lords have exceeded their time.

[Baroness Williams of Crosby]

I apologise. I did notice that it was not completely stuck to in several other speeches, but never mind. I will wind up quickly. First, if there were to be a trial period with an outcome that would be open to discussion and debate, I would support it. But that is not my understanding. I believe that these are called pathfinders and are the first wave of the reorganisation. Lastly—

[Baroness Northover]

I am sorry, but no one has got close to this length of time. I realise that this is very significant and I hope that we will come back to it in debate.

[Baroness Williams of Crosby]

I apologise. I said that I would wind up in two sentences and here is the second. I am very worried that if we do not think about the reorganisation thoroughly, we will be in real trouble with the public.