Mental Health Services
Earl Howe Excerpts(9 years, 5 months ago)
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The Earl of Listowel
To ask Her Majesty’s Government what plans they have to improve mental health services for infants, children and young people in local authority care, and for care leavers.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, in August 2014 the Government established the children and young people’s mental health and well-being task force, which is looking at how to improve access to services that are more responsive to children and young people’s needs. It has a particular focus on the needs of the most vulnerable children, including care leavers and those in local authority care.
The Earl of Listowel (CB)
I thank the noble Earl for his Answer and for the work of the task force, which is most welcome. Is he considering encouraging the systemic approach to supporting foster carers and staff in children’s homes, whereby clinicians support groups of staff in children’s homes and foster carers? This can be a very effective way of making use of scarce CAMHS resource. Will he also look at undertaking another, very thorough, survey of the mental health of looked-after children? The last very thorough examination of their mental health was carried out in 2002, and it would seem that it is time to look again at their mental health issues.
Earl Howe
My Lords, on the noble Earl’s second point, yes, a survey is most certainly being actively considered. On his first point, he is absolutely right. One of the task force’s focuses will be to consider and make recommendations on how we can provide more joined-up, more accessible services built around the needs of children and young people, looking at sometimes innovative solutions about how to get there and how to improve access to health and support across different sectors, including in schools, through voluntary organisations and online. I am very encouraged by the task force’s terms of reference.
Baroness Tyler of Enfield (LD)
Given that some 60% of children and young people in care are currently reported to have emotional and mental health problems, can the Minister say what plans the Government have to set access standards for these children as part of their wider drive to increase access to mental health services, to ensure that these very vulnerable people get the support that they need?
Earl Howe
My noble friend is absolutely right: there is a high prevalence of mental health issues in those leaving care. The Government are dedicated to supporting NHS England’s work to develop a service specification for the transition from CAMHS that is aimed at CCG-commissioned services. CCGs and local authorities will be able to use the specification to build on the best measurable services to take into account the developmental needs of the young person. A separate specification for transition from CAMHS to adult services is also in development.
Lord Bradley (Lab)
My Lords, does the Minister agree with me and the recent Health Select Committee report into child and adolescent mental health services that it is wholly unacceptable that so many children and young people suffering a mental health crisis face detention under Section 136 of the Mental Health Act in police cells rather than an appropriate place of safety? What action are the Government taking to eradicate this practice immediately?
Earl Howe
My Lords, it is unacceptable for a child in a mental health crisis to be taken to a police cell. The mental health crisis care concordat, launched in February this year, reinforces the duty on the NHS to make sure that people aged under 18 are treated in an environment that is suitable for their age, according to their needs. It also makes it clear for the first time that adult places of safety should be used for children if necessary so long as their use is safe and appropriate. We have seen a reduction in the use of police cells across the country but there is still further work to do.
Lord Crisp (CB)
My Lords, I understand that child and adolescent mental health services are under pressure anyway, and therefore that puts greater pressure on those who are hardest to reach. Perhaps I may therefore ask the noble Earl two specific questions. First, what is being done to ensure that private children’s homes have as good access to CAMHS services as local authority homes? Secondly, when a looked-after child is placed out of an authority or experiences a change in placement, what measures are in place to ensure that he or she receives priority in the new waiting list?
Lord Laming (CB)
My Lords, does the Minister agree that when the state assumes the parenting of a child or young person it takes on an enormous responsibility and a moral commitment to be a good parent to that child? Will the noble Earl assure the House that every effort is made for these children to be given access to all the services, including often some of the basic, ordinary health services that we assume there will be access to?
Earl Howe
My Lords, I fully agree with the noble Lord. He may like to know that my department is currently working with the Department for Education to revise the statutory guidance on promoting the health and well-being of looked-after children. We plan to consult on this later this month and to publish the final guidance early next year. It will make it clear that the CCGs and local authorities are responsible for providing services for looked-after children to give equal importance—parity of esteem—to their mental and physical health and to follow the concordat that I referred to.
Baroness Hussein-Ece (LD)
My Lords, my noble friend will be aware that early diagnosis in terms of getting support for children is very important, but very often these children are excluded from school—they end up in pupil referral units and are just generally not in school when they really need help. Is he satisfied that local authorities are doing what they can to make sure that these children who are excluded are getting mental health support?
Earl Howe
My noble friend raises a very important point. My department has invested £3 million in MindEd, which provides clear guidance on children and young people’s mental health for any adult working with children, young people and their families so that, for example, school teachers and those working with children in schools can recognise when a child needs help and can make sure that they get that help early.
Lord Ramsbotham (CB)
My Lords, can the Minister confirm whether there is a sufficiency of trained mental health nurses and specialists to carry out all the tasks that this welcome task force will undoubtedly identify?
NHS: Health Improvements
Earl Howe Excerpts(9 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by thanking the noble Lord, Lord Kakkar, for having tabled this debate, and all noble Lords who have spoken with passion and insight on these very important matters, and from a rich variety of perspectives.
Our ambition is for the people of this nation to live as well as possible for as long as possible. However, trends show that we can expect ill health in many of our later years, health inequalities persist, and the cost of ill health is increasing. The Government are clear that the National Health Service innovation and research are critical for addressing these challenges and I welcome this opportunity to discuss the impact of our strategies.
In the Five Year Forward View, NHS England and its partners commit to driving improvements in health through developing, testing and spreading innovation across the health system. This encompasses a wide range of activity and is part of the response to NHS commitments in the mandate to support research and innovation. The NHS has a unique position as a population-focused comprehensive health service, so we are building on this to facilitate more cost-effective randomised control trials as well as observational studies to support initial research.
We are setting up real-world innovation test bed sites linked to academic health science networks and centres. In these test beds, combinatorial approaches can bring together innovations where the benefit of combinations could be greater than the sum of their parts. That principle of integrated working in health was well illustrated by the noble Lord, Lord Mawson, in the context of which he spoke. I will be happy to look into the latest developments in Tower Hamlets and write to him.
A core plank of the health service’s approach to innovation will be improving the connectedness of information and data, providing whole data sets that enable the effect of new innovations to be tracked and assessed across all parts of the health system. I listened with great attention to my noble friend Lady Brinton. I agree that unlocking the value of data is a key challenge in improving health outcomes. As she will know, it is a thorny issue but there are exciting developments; for example, Manchester AHSN is exploring how to connect the NHS data across its whole region.
As a result, we anticipate broader adoption of innovations such as the Airedale telecare service, which I visited last week. This has transformed care provision for care home residents where it has been deployed, reducing the number of disruptive visits to hospital by more than half, and cutting the need for hospital admission by 35%.
The Five Year Forward View builds on the progress made under Innovation Health and Wealth, published in 2011. As a result of this work, innovation has a much higher profile within the NHS than it did, relationships with industry are stronger, and we are starting to see very encouraging signs of improvement in the uptake and utility of innovation. Since the publication of Innovation Health and Wealth, the NICE Implementation Collaborative has been established to provide practical solutions to overcome barriers to adoption of NICE-approved innovations. NHS England has launched Innovation Exchange and Innovation Connect, two key platforms to enhance the development and spread of innovation. Medical technology briefings have been introduced to provide the NHS with guidance on emerging medical technologies, and Innovation Challenge Prizes are now celebrating the groundbreaking innovations developed in the NHS and delivering better health outcomes for patients.
Not only that but in 2013 England became the first country in the world to implement a universal system of academic health science networks, AHSNs. These act as system integrators, linking all parts of the health landscape, including every commissioner and provider of health services in their geography, with industry and academia. Through their work to build a culture of partnership and collaboration and to drive adoption of innovation into practice, AHSNs help to improve the health of their local populations. As the noble Lord, Lord Kakkar, is no doubt aware, University College London Partners AHSN has taken major strides forward in the fight to prevent strokes. A preventive strategy is being introduced across the whole UCL Partners region, which could prevent 700 strokes each year and save more than 200 lives. This project is supporting primary care to improve the management and detection of people with atrial fibrillation and increase the number of people on appropriate anticoagulation medicines. Early work over a six-month period in one borough, Camden, has resulted in 131 more people with atrial fibrillation now taking appropriate anticoagulation drugs. Using the learning from this work, they have an opportunity to roll out similar interventions across a further 19 boroughs in the partnership.
I have referred to some of the things addressing the concerns that the noble Lord, Lord Turnberg, raised about the dissemination of innovation. There is also another innovation. The Department of Health is working very closely with NHS England and other key stakeholders to develop the innovation scorecard in order to make it a more useful tool in helping the NHS to understand and address unjustified variation in the spread and adoption of innovative new treatments. It is designed to help users—clinicians, patients, commissioning groups, government and other stakeholders—to understand and monitor the uptake of innovations in the NHS. In doing so, the innovation scorecard should ultimately be used to promote an equitable spread of clinically effective, cost-effective innovations at an appropriately rapid pace, and to encourage the decommissioning of outmoded practice where appropriate. This will help to ensure that innovations have the greatest impact in driving better health outcomes.
In NHS research, our achievements over the past five years are also extensive. Recruitment to trials and studies through the NIHR clinical research network has increased by over 30%. There were more than 600,000 participants in 2013-14; more than 99% of trusts were involved. Recruitment to commercial studies has increased by 26% in just one year, including 35 first global patients.
Following the landmark report by the Academy of Medical Sciences in 2011, we have established the Health Research Authority and awarded £4.5 million for delivery of a unified approval process and we are driving forward financial consequences for poor performance against the 70-day benchmark for recruiting the first patient to a trial. In five years, NIHR revenue spend has increased from £851 million to £987 million which demonstrates our commitment to NHS research even in the prevailing economic climate. In addition, the Health and Social Care Act is a milestone, creating unprecedented powers and duties at all levels to promote research. By the end of this year, NHS England will share a plan with the Department of Health for delivery of its research objective.
In the past, public health research has been neglected, and I particularly want to mention how the NIHR has brought about a step change in building the evidence base to drive health improvement. Fulfilling a commitment in our public health White Paper, we have established the NIHR School for Public Health Research. The NIHR public health research programme is looking at issues as diverse as air pollution, traffic accidents and binge drinking. To help to increase research capability in this field, the NIHR is funding a wide range of fellowships.
The noble Lord, Lord Kakkar, expressed concern about amendments to the proposed EU general data protection regulation, which could prevent health research involving personal data from taking place. Many of these concerns centre on amendments to the proposed regulation that have been agreed by the Civil Liberties, Justice and Home Affairs Committee of the European Parliament. The Government’s view is that the ability of researchers to process personal data in the way that they are legitimately able to do at present must be preserved. We remain attentive to the concerns raised and will continue to engage with representatives of the research community about the processing of personal data for medical research purposes under the proposed regulation.
As noble Lords know, work on the Medical Innovation Bill is ongoing. This Bill, introduced to your Lordships’ House by my noble friend Lord Saatchi, sets out a series of steps that doctors can choose to take when innovating. This is to give them confidence they have acted responsibly, with the intention of reducing doctors’ fears about claims in clinical negligence. The Government are pleased that the amendments that my noble friend tabled to help ensure patient safety were accepted by your Lordships’ House in Committee on 24 October. The Bill will now proceed to Report.
I cannot in the time available do justice to all the questions that have been asked; I shall, of course, write in relation to those questions that I have not had time to answer. I will, however, address as many as I can. The noble Lord, Lord Kakkar, asked about the follow-on from Innovation Health and Wealth and my honourable friend George Freeman’s review. NHS England has stated its intention to increase alignment between different supporting organisations for innovation, which will take account of the work and governance of Innovation Health and Wealth as well as the issue of the innovation culture in the NHS. As regards the Five Year Forward View and the medtech review, the review announced by George Freeman will look at the whole pathway for new treatments from bench to bedside, and these two must closely dovetail, as I am sure is clear to all. Of course, the AHSNs have a key role to play in that connection.
My noble friend Lady Brinton spoke about arthritis research and, in particular, patient participation in research. NIHR investment in musculoskeletal disease research has increased from £15.5 million in 2009-10 to £25.6 million in 2013-14. In May this year, the NIHR published Promoting a ‘Research Active’ Nation. It set out a new programme of work to encourage greater public engagement and participation in research.
I will have to write to the noble Lord, Lord Kakkar, on the sunset review to which he referred. My noble friend Lord Selsdon spoke about the potential of stem cells. He will, I am sure, be interested to know that the Government have an extensive agenda to seize the potential of stem cells for new groundbreaking treatments, and are working in close partnership with industry in this field. I am afraid that time is against me, and while I would like to respond to further questions from the noble Lord, Lord Turnberg, I hope he will forgive me if I pen him a letter about those.
In conclusion, I have outlined some of the major steps that we are taking through our strategies for NHS innovation and research. These are already impacting positively on the health of the population and, I am convinced, hold the promise of health outcomes as good as any in the world.
Care Sector
Earl Howe Excerpts(9 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by congratulating the noble Baroness, Lady Kingsmill, on securing debating time for this Motion and on her opening speech. I thank all noble Lords for their excellent and thoughtful contributions.
I say immediately that working conditions in the care sector are very important for the well-being of our nation. We know that there are issues of concern and the Government are taking action. The White Paper, Caring for our Future: Reforming Care and Support, and the Care Act set out clearly what care and support system we want to achieve. Everything we want to achieve will depend on the competence, commitment and sensitivity of care workers. The positive relationships that are formed with people needing care are essential to providing good care.
The Department of Health is committed to ensuring that there are the right numbers of people with the right skills, knowledge and behaviours to deliver the quality, compassionate care that people need. We know that the recruitment and retention of care workers is fundamental to this. In that connection, I listened with great care to the noble Lord, Lord Curry. We published the recruitment and retention strategy in May 2011 in conjunction with Skills for Care, which worked to address the issue of how we attract and retain more people in social care. A refreshed recruitment and retention strategy was launched in September this year. Skills for Care leads the DH recruitment and retention working group, which will progress the implementation of the recommendations in the new strategy.
We have done three things straightaway. We have doubled the number of social care apprenticeships starts; we have launched a new care ambassadors service; and we have launched and piloted a values-based recruitment toolkit for the sector. Our aim is to continue this important work by supporting employers.
Registered managers, referred to in the noble Baroness’s report, have a vital front-line responsibility, and it is imperative that they are supported and do not feel isolated. We have worked closely with the National Skills Academy for Social Care to launch a national programme of support for registered managers.
The noble Baroness, Lady Kingsmill, proposed that we should introduce a licence to practise. I am afraid I need to make it clear to her that we do not think that a licence to practise is necessary or desirable. The idea of compulsory statutory regulation can seem an attractive means of ensuring patient safety, but our view is that regulation is no substitute for a culture of compassion, safe delegation and effective supervision. Putting people on a centrally held register does not guarantee public protection. Instead, the key is for employers, commissioners and providers to make sure that they have the right processes in place to ensure that they have the right staff with the right skills to deliver the right care.
Systems and processes are already in place to provide public assurance, including Care Quality Commission registration requirements and the Disclosure and Barring Service, which are being enhanced with the new chief inspectors. Under the leadership of the Chief Inspector of Adult Social Care, the CQC has put in place specialist inspection teams that subject care providers to more effective scrutiny and result in a rating that celebrates outstanding care as well as identifying where there are problems. Therefore, I cannot agree with the noble Baroness’s contention that the CQC’s requirements are somehow weaker than they were.
Better skills and training are an important part of raising standards overall. Camilla Cavendish told us that social care support workers and healthcare assistants do not have consistent training and do not have a clear status or standard job titles. I can tell my noble friend Lady Gardner that we are on track to introduce a care certificate for new healthcare assistants and social care support workers from 1 April 2015. This means that there will be specific standards for the training of new care workers.
My noble friend Lady Gardner expressed concern that employers and agencies train only for their own organisations and my noble friend Lady Brinton asked about the support that exists to enable staff to build their qualifications. Skills for Care has produced a range of training materials that are recognised across the sector. I mentioned the care certificate that we are introducing. In general, I would say that we are committed to working with employers to ensure that this part of the workforce receives high-quality and consistent training to enable them to deliver the best standards of support and care to patients and service users.
My noble friend Lady Brinton asked specifically about BME staff. The department has worked with the National Skills Academy for Social Care to produce training and development support for BME staff to enable them to progress to higher levels within the sector. As regards incentives for small businesses to train staff, which my noble friend also asked me about, small social care businesses are able to apply to Skills for Care for funding to help train their staff. The department provides £12 million to Skills for Care for this very purpose. However, it is incumbent on small businesses to ensure, like bigger enterprises, that their staff are appropriately trained and competent to carry out their role.
The noble Baroness, Lady Kingsmill, called for a care contract to be held between local authorities and care providers setting out working conditions and employment law. The statutory guidance to the Care Act which we launched recently is clear that when local authorities commission services they should make sure that care providers comply with national minimum wage legislation. The statutory guidance is also clear that, in most circumstances, very short home care visits are not appropriate to deliver intimate care needs. In addition, new fundamental standards will come into force next year. These new standards cover staffing and will allow the CQC to prosecute those providers that are responsible for the most serious failings in care. The CQC has an enormously challenging task in transforming its approach to the regulation and inspection of providers of social care.
We are also asking employers and employees working in care to sign up to the social care commitment, pledging to improve the quality of the workforce. My noble friend Lady Brinton once again asked what can be done to improve rates of pay in the sector, a concern also raised by the noble Lords, Lord Lipsey and Lord Kennedy. Under the Care Act, local authorities will be required to shape their whole local markets to ensure that they are sustainable, diverse and offer high-quality care and support for people in their local area. The Act is clear that a local authority’s own commissioning is a key driver in shaping the market. Ultimately, local authorities, not the Government, are responsible for the commissioning of services. However, when commissioning, a local authority must ensure that it promotes a sustainable market that delivers high-quality services for all local people. The department has developed statutory guidance to support local authorities to meet these new duties when commissioning and we are working with the Association of Directors of Adult Social Services, the Local Government Association and other partners to develop a set of commissioning standards which will, again, help local authorities to improve in this area.
The noble Lord, Lord Lipsey, asked specifically what we are doing to make sure that local authorities pay fair fees, while the noble Lord, Lord Birt, drew attention to the disparity in some instances between the actual costs of care and the fees paid by local authorities. We are clear that local authorities should have regard to the cost of care when setting prices. The Care Act sets out a duty on local authorities to have regard to the importance of sustaining the market as a whole, as I mentioned earlier, to meet the needs of local people. That will include where the local authority commissions services itself, considering the impact of how it contracts with individual providers, including the price it pays in fees. Contracting is of course a local matter, with fees paid to providers best left, in our view, to local negotiations in an open market that reflects local conditions.
My noble friend Lady Chisholm spoke powerfully and knowledgeably about the role of unpaid carers. I would say to her that the Government fully recognise the role of unpaid carers, who do an invaluable job in providing care for their loved ones. My department agrees that unpaid carers need support in the form of breaks. There are examples being provided by local authorities and charities, but as my noble friend knows, the Care Act is ushering in a significant new set of rights, effectively putting—for the first time—their needs on an equal footing with those of the individuals they look after.
We agree with the noble Baroness, Lady Kingsmill, that low pay can be a concern for some working in this sector. It was a concern also raised with particular emphasis by the noble Lords, Lord McKenzie and Lord Curry. The Government do not directly employ care workers, but let me be clear: non-compliance with the national minimum wage is not acceptable. That is why we are working across government on enforcement activity. I can tell the noble Baroness, Lady Andrews, that HMRC is responsible for ensuring that staff receive the minimum wage and it takes that role seriously. It has set out the action it has taken in the care sector in a report published last November. While the CQC does not itself enforce national minimum wage legislation, where its inspections uncover evidence that suggests the employer may not be paying the minimum wage, we would expect the commission to pass that intelligence to HMRC for its consideration. HMRC is continuing to carry out enforcement action in the social care sector. It will investigate all complaints made by care workers that their employer is not paying them the national minimum wage. Between April 2011 and March 2013, HMRC undertook a targeted enforcement exercise in the care sector. The work investigated complaints relating to 224 employers. Evidence of non-compliance was found in nearly half the cases and resulted in payments of more than £1 million in arrears to care workers.
I can tell the noble Lord, Lord McKenzie, and the noble Baroness, Lady Andrews, in particular that we are taking a tough approach to naming and shaming any providers who do not comply with our national minimum wage laws, with a more robust scheme now in place for cases opened after October 2013. Cases involving care workers often take longer to investigate than comparable cases in other sectors for a number of reasons, but we anticipate that the first examples of care providers to be named under the new scheme will appear in the next few months. Social care providers who have not paid the national minimum wage previously will be required to pay workers the money owed to them, to pay a penalty for failing to meet their legal obligations, and to change their practices to ensure future compliance.
The terms and conditions of employment for social care workers are essentially a matter for local employers within the existing requirements of employment legislation. However, it is important that the Department of Health continues to work with local authorities to ensure that the providers they commission services from have a high-quality workforce with fair terms and conditions. That brings me to zero-hours contracts. These contracts, when used responsibly, may be appropriate in some circumstances and can offer flexibility and opportunities to both the employer and the individual. The Government are committed to ensuring that zero-hours contracts are used fairly and have included provisions in the Small Business, Enterprise and Employment Bill banning exclusivity clauses in employment contracts that do not guarantee any hours. The Bill was introduced into Parliament on 23 June. Following feedback from stakeholders on the ban on exclusivity clauses, the Department for Business, Innovation and Skills is consulting further on how to prevent unscrupulous employers evading the exclusivity ban.
The noble Lord, Lord McKenzie, spoke powerfully about 15-minute visits. Short care visits are not normally adequate for the needs of service users. We know that care workers find 15-minute appointments demotivating because they are unable to complete their tasks within the time and develop meaningful relationships. We will continue to learn from the best employers and commissioners about how this situation can be improved. A focused peer challenge that will use elements of the commissioning standards will be piloted with two reviews by ADASS and the LGA in the coming months. We agree that in most cases very short visits are incompatible with high-quality care and the Care Act sends a clear message: commissioning services without properly considering the impact on people’s well-being is unacceptable.
However, it would be inappropriate to introduce a blanket ban on 15-minute home care visits since they may be appropriate in certain circumstances; for instance, when checking medication has been taken. A more fundamental culture shift towards a focus on outcomes through guidance and support is, we think, the way forward. Ultimately, local authorities are responsible for the commissioning of services, as I have indicated, but we agree, as does ADASS, that inappropriately short home care visits should be discouraged.
My noble friend Lady Brinton asked about the repatriation of foreign workers. I will need to write to her about that. Turning to a point raised by the noble Baroness, Lady Kingsmill, in relation to Southern Cross, the new Care Act establishes the CQC as the financial regulator for the largest social care providers. It will look at the finances of these providers and, where financial failure is likely, it will warn the affected local authorities to ensure that there is no gap in care services. The regime will not prop up failing providers but ensure continuity of care services for those affected, which surely is the most important consideration.
In response to some of the remarks made by the noble Lord, Lord Birt, with which I agree for the most part, it is worth reflecting that an effective market has been operating in social care for the best part of 20 years. Increasingly, private providers and third-sector organisations have provided services. They have done so effectively but, as in any market, some providers leave and others join. Exits can happen for any number of reasons but what we do not want to see is the kind of disruption to the market that the Southern Cross debacle could have led to had it not been managed successfully.
Delivering high-quality care is dependent upon a range of factors and uppermost is having a workforce that has the right attitudes, values, skills and qualifications. I hope that noble Lords will accept from my remarks that we have a programme of work in hand that is aimed at improving working conditions. We are working across government to tackle non-compliance with the national minimum wage. We are also making it clear that commissioners of services should ensure fair pay, terms and conditions and compliance with the national minimum wage when commissioning services, and we are ensuring set standards of training are introduced. These are surely the key pillars on which to ensure an attractive and fulfilling career can be built for this vital sector of the workforce.
Lord McKenzie of Luton
I apologise for interrupting the Minister. Is it the Government’s view that in determining whether or not the national minimum wage has been paid, the time spent travelling between client visits should be included?
Earl Howe
It is certainly our view that the time spent travelling between assignments should be paid-for time. But that, as I have indicated, is a matter for the local commissioners to ensure is borne out in contracts; it is not something that we as a Government can enforce. However, it is something that will be looked at very carefully in the ways that I have described.
NHS: Funding
Earl Howe Excerpts(9 years, 5 months ago)
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Lord Kennedy of Southwark
To ask Her Majesty’s Government what action they intend to take to deal with the projected funding gap for the National Health Service in England.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, NHS spending has increased in real terms by £5 billion over this Parliament, underlining the priority the Government place on the NHS. NHS England’s Five Year Forward View set out a range of future scenarios. While NHS funding beyond 2015-16 will be a matter for the next spending review, the Government believe that changes in the way that services are delivered are essential, both to moderate rapid increases in demand and to improve efficiency.
Lord Kennedy of Southwark (Lab)
My Lords, I first declare an interest as president of the Society of Chiropodists and Podiatrists, a small trade union professional association that has members working in the health service.
Is the noble Earl aware of the concerns of the BMA and others that the recent changes to NHS structures, particularly funding structures, actually risk worsening health inequalities? What will the noble Earl do to ensure that that does not come to fruition?
Earl Howe
My Lords, tackling health inequalities is one of the major tasks facing NHS England. It is built not only into its mandate but into legislation, and we expect NHS England to address it at every level—both in the acute area and in the community. It is of course up to local commissioners to prioritise their funding, but we expect to see over the next few years a shift from care in the acute sector to care in the community, both to prevent acute admissions and to ensure that people stay healthy for longer in their own homes.
Lord Ribeiro (Con)
My Lords, the 2004 GP contract, which was introduced by the party opposite, forced GPs to come off on-call rotas at night and at weekends, thus removing them from out-of-hours services. The impact of this on our emergency departments has been quite dramatic. Will my noble friend confirm that the introduction of the Better Care Fund will go a long way not only to integrate these services between primary and secondary care but to remove pressure on our A&E services in the acute sector?
Earl Howe
I agree with my noble friend that the primary purpose of the Better Care Fund is clearly to make care better, but it is also a major step forward in making our health and care services more sustainable, and moving to a preventive model that delivers care closer to home and keeps people healthy in the community. GPs have a major part to play in this and I am encouraged by the extent to which they are now engaging in the task of addressing the BCF.
Lord Reid of Cardowan (Lab)
Will the noble Earl correct the inadvertent misleading of the House by the last noble Lord who spoke? The obligation for doctors to serve at weekends and in the evenings was not removed in 2004 but many years before—as it happens, under the Conservative Government. What happened in 2004 was that although they were not serving at weekends or in the evenings, as had been allowed by the previous Conservative Government, doctors were spending an increasing amount of time on the bureaucracy of finding a replacement doctor. That bureaucratic burden was what was removed from them. Will he confirm that that was the case, not for the first time but for the second time, because I asked him last year and he confirmed that by 2004 almost 90% of doctors had already opted out of night work and weekend work?
Earl Howe
The noble Lord has huge experience in this area and his outline is of course right, in that before 2004 we had largely a system of co-operatives in which GPs could elect to work out of hours if they wished. The 2004 contract gave individual GPs and GP practices the option not to do that. While there was no obligation to move away from out-of-hours care, many GPs have chosen to do that.
Lord Patel (CB)
My Lords, as it is nearly Christmas I have not given the Minister the advantage of seeing the question beforehand, but with his dexterity in answering I am sure that he will answer it straight. Can he predict which party, elected into government next May, will keep the NHS free at the point of need?
Baroness Manzoor (LD)
My Lords, the NHS five-year review clearly highlighted that there was a need to upgrade preventive and public health services. Can my noble friend the Minister say how this will be done, particularly when you go back to the 2011 WHO agreement on 25 goals, under which 25% of deaths have to be reduced by 2025?
Earl Howe
My noble friend is right to highlight the role of public health. That is why many people are encouraged that health and well-being boards, which now oversee the planning and prioritisation of healthcare in their local areas, are taking those public health goals into account and building them into the strategic health assessments. So the co-ordination of healthcare and public health is in a much better position than it was before the reforms.
Lord Hunt of Kings Heath (Lab)
My Lords, the Minister referred to the Better Care Fund. How does he respond to the criticisms made by the National Audit Office in the last few days? It said that the programme had poor management and hugely unrealistic expectations, and that it was not going to reduce emergency admissions. Can the Minister explain why the NAO concluded that the programme had no national leadership, limited risk analysis and no analysis of local planning capability?
Earl Howe
My Lords, that report is somewhat out of date. Plans have now been through the nationally consistent assurance review. The results have been published and shared with local areas, which have stated some clear ambitions. They are to have 163,000 fewer stays in A&E, to make £532 million savings for health and care services, and to have 101,000 fewer unnecessary delays spent in hospitals, along with other goals besides. We are very satisfied with progress reached in producing the Better Care Fund plans. Not all plans have been approved, but we are well on course.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Earl Howe Excerpts(9 years, 6 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I am glad, but not surprised, that the noble Lord, Lord Hunt of Kings Heath, has shown such a keen interest in the importance of providing protection for users of health and care services. I thank him for bringing this issue to the Floor of the House. Naturally I am disappointed to understand from his amendment that he feels that the new fundamental standards are not satisfactory and undermine protection of care home residents. I seek to reassure him that that absolutely is not the case.
I begin by emphasising that the Government are serious about improving the protections offered to health and adult social care service users, both through the legislation that we have before us and through the system of regulation of health and adult social care carried out by the Care Quality Commission, of which these regulations form a part. I am sure that noble Lords will agree that the CQC has made enormous strides forward over the past two years, supported by many of the changes that we debated in this Chamber a year ago during the passage of the Care Act. Under the leadership of the three chief inspectors, the CQC’s specialist teams of inspectors are holding providers to account more thoroughly than ever before. The CQC’s inspections now look beyond mere compliance with registration requirements to provide ratings for each provider against five key questions. Are services safe? Are they caring? Are they effective? Are they responsive? Are they well led?
The first of these ratings is now being published. I am sure that noble Lords will agree that the new system provides much valuable information to patients and service users and commissioners, as well as to providers themselves. However, it is axiomatic to say that the key purpose of a regulator is to regulate—to take action where standards of care fall below acceptable levels. The regulations that we are discussing are central to this. They set the requirements for registration with the CQC, the fundamental standards that all registered providers must meet and against which the CQC can use its enforcement powers to protect patients and service users from the risks of poor care.
I will outline briefly how the new fundamental standards are an improvement on the existing registration requirements, before moving on to the detail. We are changing the regulations in order to address the issues raised by Sir Robert Francis, in his inquiry into Mid Staffordshire NHS Foundation Trust. He highlighted that the legislative basis on which the CQC was operating was undermining the effectiveness of the regulator. He criticised current regulations for being “overly bureaucratic” and said that they failed to separate the “essential” from “the merely desirable”. He recommended the introduction of fundamental standards which set the line below which care must never fall. He recommended that there be regulatory consequences for providers who fail to meet these standards, including the possibility of prosecution where breaches result in serious harm.
The new regulations set the following fundamental standards. Patients must receive safe care that meets their needs and reflects their preferences. Patients must be treated with dignity and respect, be properly fed, their views listened to, and be protected from abuse. The environment in which they are cared for must be clean, safe and secure. Care organisations must be well run, properly staffed, and be open with people about their treatment.
In my response to the noble Lord, I seek to reassure him that the fundamental standards do not dilute the current regulations, remove protections or leave people at greater risk of abuse or harm. In fact, they provide much stronger protection for service users from abuse, neglect and unsafe care than the current regulations. They explicitly state that care must be provided in a safe way, that people must be protected from abuse and improper treatment, that care must not be degrading and that is it unacceptable to disregard someone’s need for care and treatment. The requirements covering degrading care and significant disregard of needs are completely new and not covered by current regulations. It will be an offence to breach these standards in a way that causes avoidable harm or presents a significant risk of such harm occurring, and the CQC will be able to bring prosecutions against providers for such breaches without issuing an advance notice, something that is not possible at the moment. This is a major improvement that provides extra protection for patients and service users.
I want to discuss one of the key fundamental standards recommended by Sir Robert Francis: the statutory duty of candour on providers. It is a little over a year since I brought forward an amendment to the then Care Bill that placed an obligation on the Secretary of State to include in the requirements of registration a duty on providers to inform patients and service users where there were failings in care that resulted in harm—the duty of candour. These regulations fulfil that obligation in respect of the NHS by placing a duty of candour on NHS bodies.
In the debate on the duty of candour a year ago, noble Lords made two key challenges: first, that we should give serious consideration to the threshold for the duty of candour; and secondly, notwithstanding any such threshold, that the regulation should enshrine the general principle of being open in all cases. I hope noble Lords will agree that we have met both these challenges. I shall take the second challenge—openness —first. Regulation 20 sets out the duty of candour, its first line setting out the general requirement of candour:
“A health service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity”.
This is a general duty to be open in all dealings with patients, service users and their representatives. Where a provider does not meet this duty, the CQC will have the power to use its civil enforcement powers. However, a failure to meet this general requirement will not be an offence.
The remainder of the regulation sets out the steps that providers will have to take when a “notifiable safety incident” occurs. Noble Lords were quite right in saying that the key issue here is defining the harm threshold for such an incident that would engage the duty of candour formal notification procedures. The Government took expert advice and gathered a wide range of views before setting this threshold. We asked Sir David Dalton and Professor Norman Williams to lead this work. They published their findings in March, and the department subsequently consulted on draft regulations based on their recommended harm threshold.
In the regulations, a notifiable safety incident is defined as any unintended or unexpected incident that has, appears to have or could still result in death or severe harm, moderate harm or prolonged psychological harm. By following the recommendations of the Dalton-Williams review, I believe we have struck a sensible balance between the need to respond formally to patients when significant things go wrong and the need to keep reporting burdens within manageable proportions.
Building on this work, the regulation sets a series of specific steps that an NHS body will have to take where a notifiable safety incident occurs. These are: to notify the relevant person that the incident has occurred, to advise them what further inquiries will be made, and to apologise. A failure to take these steps will be an offence. This verbal notification then has to be followed up in writing.
This new duty of candour will support and underpin the Government’s ambition to transform culture across the NHS and support openness and learning, both between staff and organisations and to patients and service users. We will extend the duty to all health and adult social care providers from next April. Over time, the duty of candour will contribute to safer care. Noble Lords will also be pleased to learn that this week the General Medical Council and the Nursing and Midwifery Council have published for consultation draft guidance on the professional duty of candour, a measure that complements the statutory duty of candour on providers.
I finish by touching on the other new registration requirement that we are introducing—the fit and proper persons test, a requirement for directors of organisations registered with the CQC. The responsibility for providing safe and acceptable care will always rest with providers themselves. The tone and culture of an organisation is set by those people at its head. No matter how effective, regulation cannot be a substitute for good leadership at a provider level. All too often, individuals at the head of an organisation have been out of reach, even where they have overseen the most shocking standards of care. These regulations put an end to this, giving the CQC new powers to remove directors who are responsible for poor care. For the first time, the regulations place a legal requirement on NHS bodies registered with the CQC to ensure that their directors are fit and proper to fulfil their role. By next April, we plan to extend this requirement to all providers of health and adult social care registered with the CQC. This new measure, alongside the ability to bring prosecutions where failures in care harm patients and service users, will greatly increase the ability of the CQC to hold corporate bodies and their senior officers to account.
Effective regulation of health and adult social care is essential to protect patients and service users from the risks of poor care. The fundamental standards will support the Care Quality Commission in holding providers to account for the quality of care that they provide. Taken as a whole, these regulations improve the legal protections offered to service users, underpin and support a more effective regulatory regime, and champion openness and transparency across the NHS. I beg to move.
Amendment to the Motion
Baroness Howarth of Breckland (CB)
My Lords, I will be brief, as I always am. I do not want to repeat what has been said before, much as I would love to be led down the path of talking abut the problems faced by care homes in the present financial climate. I must first declare an interest as a trustee of Livability, which provides a large number of care homes for disabled people and for other groups. I am therefore, as a trustee, in the role of a provider. I also want to speak very briefly on behalf of families and carers.
First, I say to the Minister that I welcome the regulations. I was interested in his spirited defence of them, and I know his great belief in them. There are aspects of the new regulations that strengthen the potential to hold care providers—such as my organisation—properly to account. That is all positive, but I simply want to address myself to the issues around the amendment on the Order Paper, because there is an issue and I would very much like the noble Earl to think about it.
We have been approached by a number of organisations which said that families and residents are very concerned about these three aspects of the regulations. I have looked at the old wording and at the new wording, and I found that the new wording is more elegant but much more obscure for ordinary people to relate to. It is terribly important that ordinary folk in a care home—both the providers and those receiving the service—understand that they have a right to be told about complaints procedures.
Clearly, that is there already. I disagree with those who say it is not. All of it is to be found within the regulations and the follow-up documents by those who actually dig through them. I believe that the noble Earl hoped—as he listened to all the hours of discussion of these issues—that this would be absolutely crystal clear. If these issues are clear, they also help leadership and management. It is much easier for providers to tell their staff how to take things forward if the words are absolutely clear, and if there is some sense of being given flexibility or whatever the expectation is.
When it comes to proper planning for emergencies, providers have an absolute responsibility to ensure not only that they have those plans, but that in the interests of health and safety everybody understands them throughout. Not only the providers but the residents themselves must understand. It is possible to have a great discussion about these issues among those who are receiving care. It is possible to discuss complaint procedures, choice of food and what happens if there is a fire and people can only be got out of certain areas by particular routes.
What I am saying is much simpler than the rest of the discussion. I would like the Minister to look at the wording, because in my opinion this is about language rather than intent. We have excellent regulations but, if families and users are concerned about these three areas, the Government have a responsibility to listen. I know we have a listening Minister.
Earl Howe
My Lords, I am grateful for the questions and comments raised by noble Lords. I will do my best to answer them in the time available. Perhaps I may begin with the issues raised by the noble Lord, Lord Hunt. The noble Lord expressed his regret that certain phrases no longer appear in the regulations, and those concerns were echoed by the noble Viscount and the noble Baroness, Lady Howarth. I should like to reassure the House that, although the regulations do not include express references to the three things highlighted in the amendment tabled by the noble Lord, Lord Hunt—informing service users about complaints procedures, having emergency procedures in place, and offering choice of food—nevertheless providers must still demonstrate to CQC that they are doing those things.
This is possible because the fundamental standards work in a different manner from the current regulations. They set the outcomes about quality and safety that must be met, rather than just the processes that must be in place. They set out the ends, rather than merely the means. Because we describe these outcomes in regulation, we no longer need to spell out a long list of processes in regulation as well. However, all the areas highlighted by the noble Lord nevertheless fall within the scope of the new regulations. For example, planning for emergency procedures is covered by the new safe care regulation, which requires providers to ensure that care is provided in a safe way, and that they do all that is reasonably practicable to mitigate the risks of unsafe care. A provider that had no plans in place to deal with emergencies such as floods or staff shortages could not claim to be meeting the regulation, because they would not be doing all that is practicable to mitigate the risks to the health and safety of service users from emergency situations. In practice, not having a plan in place for emergencies will therefore be a breach of the regulations.
The obligation to offer a choice of food and drink falls within the new person-centred care regulation, and the newly drafted nutrition regulation. We have introduced a new person-centred care regulation which requires that a person’s needs must be met, and that their preferences must be taken into account and, where possible, met. I emphasise that this applies not only to food preferences, but to all other aspects of care as well. This is a significant step towards greater person-centred care, advocated by many over recent years.
In addition, the nutrition regulation states that a person’s nutritional needs must be met, and it will be a criminal offence to fail to meet this regulation in a way that causes avoidable harm or significant risk of such harm. These two regulations work in tandem to require that a person’s individual nutritional needs are met and their individual preferences are reflected wherever possible. This is a stronger position than merely requiring that people be offered a choice. Such a requirement could be met by offering a person a choice of two things that are neither desired nor suitable. On the issue of complaints, the new complaints regulation states:
“The registered person must establish and operate effectively a system for identifying, receiving, recording, handling and responding appropriately to complaints, and requests for action to be taken, by service users and other persons”.
A provider who does not make patients and service users aware of their complaints system could not claim to be making it accessible, or claim they had an effective means of identifying complaints. Therefore, they would be breaching the regulation. CQC’s draft guidance about compliance with the regulations, which is currently subject to consultation, includes more information about all of these areas. It is this guidance that sets out in more detail what CQC will look for when checking whether providers are meeting the regulations. If noble Lords are in any doubt or have anxiety after this debate and after what I have said, I assure them that I would be happy to feed in the concerns which have been raised this evening in the context of the guidance that is now in preparation.
The noble Lord, Lord Hunt, described the regulations as light-touch, and the noble Viscount, Lord Hanworth, suggested that the Government were somehow pursuing a deregulation agenda by introducing these regulations. I must say to the noble Viscount in particular that that is a complete misreading of these regulations. Indeed, his speech indicated to me that he is labouring under a number of serious misapprehensions. Past experience has shown that there are limitations to prescriptive regulation. It is very difficult to make regulation exhaustive. The list might come to be the upper limit of what is provided, rather than the floor below which care should never fall. For example, the old national minimum standards for care homes included very specific requirements that set out the minimum bedroom sizes in square metres. In practice, this minimum became the default normal size for rooms.
The guiding principle behind the fundamental standards is that they set an overall outcome that must be met. The responses to our consultation showed that the vast majority of respondents agreed with this, and thought that the regulations were clearer as a result. I hope that that reassures the noble Baroness, Lady Howarth, in particular. Importantly, this approach allows the CQC to take a more rounded look at quality and safety as it inspects, rather than taking a tick-box approach to inspecting done solely against prescriptive regulations.
Health: Pneumococcal Disease
Earl Howe Excerpts(9 years, 6 months ago)
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Lord Avebury
To ask Her Majesty’s Government what assessment they have made of the progress of the Joint Committee on Vaccination and Immunisation in its review of the adult pneumococcal disease programme.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
The Joint Committee on Vaccination and Immunisation concluded a review of the adult pneumococcal vaccination programme in 2012. The committee will begin the next review in early 2015, taking into account the latest information on the epidemiology, cost effectiveness and impact of adult pneumococcal vaccination. It is anticipated that the review will take six months to complete, subject to the availability of the necessary evidence.
Lord Avebury (LD)
My Lords, the JCVI looked at the situation in its June meeting and said that it would like to see the results of recent trials on the effectiveness of PPV in adults, but the subject was not on the agenda for the October meeting. Why are those trials not in the public domain? Since it is likely that the vaccination would be effective against the 5,000 cases diagnosed in adults every year in England, with some savings to the National Health Service, what steps are being taken to accelerate the introduction of the PPV vaccine?
Earl Howe
My noble friend is right to highlight the burden of disease caused by pneumonia in particular in the elderly. As I said in my Answer, what happened at the October meeting of the JVCI was an agreement that a pneumococcal sub-committee should be formed to fully consider the latest evidence on adult pneumococcal vaccination, including the evolving epidemiology of pneumococcal disease in the UK following the introduction of the conjugate vaccine into the childhood vaccination programme. In addition, the review will consider the latest data on the use of the conjugate vaccine in adults. This was discussed at the October meeting, the minutes of which are due to be published next week.
Lord Walton of Detchant (CB)
My Lords, as a young doctor, I saw many cases of pneumococcal meningitis in childhood. This disease caused about a 15% mortality, and 25% of those who recovered were left with serious disabilities such as blindness, deafness and other forms of abnormality. The disease in adults is much less devastating. Vaccination in children has been enormously successful in almost completely eradicating pneumococcal meningitis. Pneumonia in elderly adults, caused by the pneumococcus, is a very serious disease. May we express the hope that the committee will come up with very positive recommendations for a wider vaccination programme with a different group of vaccines for adults?
Earl Howe
My Lords, the noble Lord summarised the position extremely well. I share his hope that we will see an outcome from the sub-committee’s work in which everyone can take satisfaction. He is right that rates of pneumococcal disease in children have fallen dramatically, but it is interesting that the knock-on effect of that has been to reduce the rate in adults as well.
Baroness Wall of New Barnet (Lab)
My Lords, I am sure that the noble Earl would agree that, not only for this disease, effective vaccination and immunisation lead to fewer people being in hospital and rates of infection being reduced. It also means that we have a much better patient flow coming through. Surely, to be successful, immunisation and vaccination need to be encouraged.
Health: Mental Health
Earl Howe Excerpts(9 years, 6 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
Access and waiting times for people with mental health problems are a priority for this Government. We are committed to ensuring that access to services and waiting times are on a par with physical health. That is why we have put in place the first national waiting times standards in mental health.
Lord Dubs (Lab)
My Lords, will the Minister confirm that according to the widely respected Health Service Journal in April this year there were some 3,640 fewer nurses and some 213 fewer doctors working in mental health than two years ago? Surely it is unrealistic—not to say verging on the dishonest—to talk about the Government putting in place controls on access and waiting times when there is no prospect of achieving them.
Earl Howe
If the noble Lord looks across the piece at the workforce statistics he will perhaps be more reassured than he is at the moment. The £400 million that we are putting into talking therapies, for example, will result in a workforce of 6,000 practitioners trained to deliver IAPT. Health Education England has increased the number of mental health nursing training places by 1.5%. In delivering a multidisciplinary workforce, the aim is to have skills that are transferable between different care settings. NICE will be publishing its authoritative guideline on safe staffing. We have already mandated NHS organisations to publish ward-level nursing with midwifery care staffing levels so that there is an incentive for them to make sure that they have their staffing levels right.
Baroness Hollins (CB)
The Government’s five-year plan to improve access to mental health services makes no mention of people with intellectual disabilities who have mental health problems. What steps will the Government take to improve access for this group of patients who have a higher prevalence of mental illness and treatable mental disorders?
Earl Howe
I hope that the noble Baroness will agree that the five-year plan is truly ground-breaking in many respects. We have identified £40 million to spend this year to support people in mental health crisis and end the practice of young people being admitted to mental health wards. Another £80 million has been freed up for next year to ensure that waiting time standards become a reality, not just for those with mild mental health conditions but across the piece. I will write to the noble Baroness if I can glean any further information about those with a specific disability.
Baroness Brinton (LD)
My Lords, one of the worrying consequences of the shortage of mental health beds is the number of patients who leave mental health wards and subsequently commit suicide within a short space of time. If a patient commits suicide within a short period of leaving in-patient care, it should be regarded as a never event. That would provide real parity of esteem alongside parity of funding and ensure that patient safety is at the heart of every patient’s release.
Earl Howe
My noble friend makes an extremely important point. NHS England is currently reviewing the never events framework. My honourable friend the Minister of State for Care and Support will shortly be meeting NHS England officials to discuss the possibility of including suicide following in-patient care as a never event and how the new never events framework will support parity of esteem.
Lord Bradley (Lab)
My Lords, NHS England made it clear last week that mental illness costs the economy an estimated £100 billion annually, which is roughly the cost of the entire NHS budget. How do the Government justify only 5.5% of the UK’s health research budget being allocated to mental health and, according to MIND today, a paltry 1.4% of Public Health England’s budget being spent on mental health? Is this what the Government mean by parity of esteem?
Earl Howe
My Lords, investment in mental health research by the National Institute for Health Research has nearly doubled over the past four years from £40 million in 2009-10 to £72 million in 2013-14. I hope that the noble Lord will take from that that we put a priority on this. Of course, it is very important that local authorities do not downplay the significance of mental health. We have made it very clear that disinvestment is not an option for them. We are discussing with local authorities this very issue.
The Earl of Listowel (CB)
My Lords, will the Minister seek to encourage the very good practice of a few areas in providing a seamless service for young people leaving public care from the age of 16 to 25 or 14 to 25 so they get the mental health support to allow them to be successful in adulthood? Does he recognise that effective mental health services for children will much diminish the demand in adulthood?
Earl Howe
I agree with the noble Earl. On 20 August the Minister of State for Care and Support announced a new children’s task force to look at all aspects of child and adolescent mental health services and how best to improve outcomes for children with mental health problems. Its remit includes an investigation of how access across the whole of children and young people’s mental health services could be improved. The task force will report in the spring of next year.
Baroness Pitkeathley (Lab)
My Lords, following on from the noble Earl’s question, does the Minister agree that in the context of child mental health—and many of us are increasingly concerned about the younger and younger age at which people are being diagnosed with mental illness—prevention is as important as treatment, particularly in view of today’s news that less is being spent on prevention?
Earl Howe
I agree with the noble Baroness. This is a crucially important area. She may like to note that in the current year we are investing an additional £7 million to end the practice of young people being admitted to mental health beds far away from where they live, or being inappropriately admitted to adult wards.
Care Quality Commission (Reviews and Performance Assessments) Regulations 2014
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Baroness Barker
I thank the noble Baroness for that. I trust that if the CQC was doing its job, it would really go to the seat of power in a hospital and interview the porters.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this has been a useful debate. Although the Motion to Regret moved by the noble Lord, Lord Hunt, relates to regulations which, as he said, cover a certain area of the CQC’s activities, I note his broader questions and will come to those.
These regulations set out which health and adult social care providers will be rated following inspection by the Care Quality Commission. They came into force at the beginning of this month. However, it is clear that the noble Lord’s main concern is not so much about the regulations, although he did query aspects of them and I will address those in a second. I think—or, at least, I hope—that there is a good deal of agreement between us about the way in which the CQC now approaches its task of assessing service providers. The noble Lord’s concern lies largely around the accountability arrangements for commissioning. I will begin by setting out the purpose of the regulations and summarise the considerable progress that the CQC has made in inspecting and rating service providers.
Noble Lords will recall that the Care Act put in place a new system of reviews and performance assessments of providers to be developed by the CQC. The regulations referred to in the Motion specify which providers will be rated by it. They cover NHS hospital trusts and foundation trusts, general practices, independent hospitals and providers of adult social care. The CQC has set out its approach to inspection and ratings in a series of handbooks for each regulated sector. Each service is judged against a number of key questions: is it safe; is it caring; is it effective; is it responsive; and is it well-led? The CQC produces a rating against each of these areas at both location and provider level.
This new system is providing information about the quality of care that goes beyond mere compliance with minimum standards. This information is of value to patients and service users, to commissioners and, of course, to the providers themselves. The noble Lord, Lord Hunt, referred to the comments of the Nuffield Trust around hospital ratings and questioned how such ratings could be communicated to the public in an understandable way. We have committed the CQC to publishing clear, authoritative ratings of providers. Not only are these ratings broken down into the five key questions about services that I have just referred to, but the CQC has also published, where it has been possible, ratings of specific hospital services. The CQC is under an obligation to consult on the development of its ratings methodology. It has done so, and will continue to do so as its methodology grows more sophisticated over time. I completely take the point that ratings must be robust and stand up to scrutiny, but the CQC’s view is that it is more than possible to construct indicators that are genuinely representative of an organisation’s performance.
The CQC has made rapid progress on developing and implementing the ratings system. It has already published more than 130 ratings of NHS providers, and has recently published the first ratings of adult social care providers. Over the next few years, it will inspect and rate every provider that is covered by the regulations. Noble Lords will recall the debate we had last year on whether the CQC should also carry out routine inspections of commissioners. The CQC’s primary purpose is to regulate service providers and the Care Act clarified this by removing its power to carry out periodic reviews of commissioners of both health and adult social care.
Some providers argued that the system we were putting in place left them solely accountable for failings in care that could have some of their roots in commissioning decisions. I listened carefully to the comments of the noble Baroness, Lady Wall, and the noble Lord, Lord Hunt. I accept that there is a link between commissioning and quality of care and that, in some instances, it would be appropriate for the CQC to review commissioners. We have therefore maintained a power for the CQC to carry out special reviews of commissioners under Section 48 of the Health and Social Care Act 2008. However, this will be used only where there is clear evidence that failings in commissioning are leading to poor care for patients and service users and it is subject to the approval of the relevant Secretary of State. Let me be clear: where it is justified by the circumstances, the CQC will be able to inspect commissioning.
Although the CQC is not routinely reviewing commissioning, there are other arrangements for the oversight of commissioners. The noble Lord, Lord Hunt, asked me whether any special inspections of commissioners had happened yet. The answer to that is no in relation to local authorities’ commissioning of adult social care, but the CQC is undertaking a special review of children’s safeguarding in Doncaster. I understand that this review will look at both the provision of services and their commissioning by the local NHS. The review is due to be published in the coming months.
For adult social care, the Care Act puts in place clear duties on local authorities to have regard to the importance of ensuring the sustainability of the market as a whole in order to meet the care needs of local people. Last week, my department published statutory guidance for local authorities as part of a package of secondary legislation which implements the Care Act. This includes a chapter on commissioning and market shaping. Furthermore, the Local Government Association and the Association of Directors of Adult Social Services will shortly publish a set of new standards for commissioning services that has been produced with stakeholders. These standards will provide clarity on what good quality commissioning looks like. They will build on best practice and encourage councils to conduct more thorough self-audit and peer review in order to move towards excellence, covering, for example, commissioning for outcomes, integrated commissioning and workforce issues.
Where local authorities struggle to meet these commissioning standards, they are able to seek support through a system of sector-led improvement. Where a need has been identified, a variety of improvement support can be offered. This may include advice and visits from peers in high performing local authorities; mentoring and leadership training for councillors and officers; and bespoke support from national experts. This approach has been developed in partnership with local government partners in order to improve local authorities’ performance and capabilities. It supports local authorities to take responsibility for their own performance and drive improvement, developing a system of performance management by councils for councils. Sector-led improvement is based on the principles that councils are primarily accountable to their local communities; they are responsible for their own performance and improvement; and they have a collective responsibility for the performance of the sector as a whole.
Turning to commissioning of NHS services, NHS England is responsible for the performance management of clinical commissioning groups and has a statutory duty to carry out an annual performance assessment of each CCG. NHS England must be assured that commissioners are acting efficiently and effectively on behalf of local patients. Using the principles set out in the CCG assurance framework, NHS England supports and challenges CCGs to meet the needs of their local population. The assurance process is informed by robust and diverse sources of evidence, including the CCG outcomes indicator set and a detailed delivery dashboard.
Where concerns are identified, improvement actions are agreed. NHS England has broad powers to ensure that these improvements are made, whether this is through the provision of support and advice or by taking action when a CCG is at significant risk of failure. Examples of the support that can be made available are advice and expertise, facilitating peer review and partnership with other CCGs, or the brokering of conversations between CCG and providers by the area team.
The CCG assurance process has so far worked well. NHS England’s year-end CCG assurance assessment for the year 2013-14 showed that 210 out of 211 CCGs were assured, with 132 receiving some support to improve in particular domains of the assurance framework. An NHS England-commissioned survey of stakeholders, including local health and well-being boards, Healthwatch and patient groups, found that 68% had confidence in CCGs to commission high quality services.
The approach taken in this first year rightly focused on developing the capacity and capability of CCGs, as relatively young organisations, building on the domains which were the foundation of CCG authorisation. This focus on developing the organisational health of CCGs has meant that, as of July 2014, only 13 CCGs still have conditions or directions remaining in relation to their authorisation, compared with 153 CCGs initially authorised with conditions. In one case, a CCG was not assured and NHS England has put legal directions in place to improve its performance. As intervention is the element of the assurance framework which most affects CCG autonomy, careful consideration is, of course, required before NHS England will take this course of action.
Assurance ratings are based on the area team’s assessment of the level of the CCG’s insight of the identified issues and its willingness to take the necessary steps to improve. In cases where serious concerns arise, NHS England has shown that it will take necessary and appropriate intervention action. These legal interventions can take many forms, such as directing the CCG how to perform a certain function or asking another CCG to perform that function. They may even require the removal or replacement of the accountable officer or dissolution of a group.
Noble Lords may have seen recent reports of how NHS England is considering developing the CCG assurance framework to emphasise CCG achievement as well as capability. The detail of the assurance framework is, of course, a matter for NHS England but I am sure that noble Lords will be encouraged that NHS England is reflecting on how the assurance system can be improved. Ultimately, the Secretary of State is accountable to Parliament for the performance of the health system and will hold NHS England to account for how it has fulfilled its responsibilities, including how it has ensured that the health services which both it and CCGs commission are high quality and deliver value for money.
The noble Lord, Lord Hunt, asked about how NHS England is held to account by the department. The Secretary of State has formal accountability meetings with the chair and chief executive of NHS England every two months, which are structured around the mandate objectives and NHS England statutory duties. These are also attended by other NHS England board members, Ministers, the senior departmental sponsor and the Permanent Secretary. These meetings focus on strategic issues and any issues of delivery. Actions for NHS England are agreed in the meetings, recorded in the minutes and followed up in subsequent Secretary of State meetings. This process feeds into an annual assessment of NHS England by the Secretary of State. It is a legal requirement that this is laid before Parliament in response to NHS England’s annual report and covers NHS England’s performance in respect of mandate objectives and fulfilment of its statutory duties.
Meanwhile, NHS England is holding itself to account internally for its commissioning responsibilities. Just as there is a CCG assurance framework, a reciprocal direct commissioning assurance framework has been produced to demonstrate that NHS England is also exposing itself to similar scrutiny of its own commissioning responsibilities. NHS England has made a commitment to CCGs and wider stakeholders that it will apply the same level of scrutiny to its own direct commissioning responsibilities as it does to CCG commissioning. The assurance framework is used to identify concerns where the direct commissioning functions of area teams are particularly challenged. In these circumstances, the issues will be escalated through the line management arrangements in order to ensure that extra scrutiny or support is given as required. Ultimately, NHS England’s board will assure direct commissioning processes.
The noble Lord’s particular concern was around specialised commissioning and the overspend that we saw last year. In quarter 4 last year, NHS England forecast an overspend in specialised services of £172 million, an adverse variation to plan which was in excess of £291 million. Departmental analysis found that last year’s overspend in specialised services was due to a combination of factors, some historical and intrinsic, others unique to 2013-14. In April this year NHS England established a specialised commissioning task force in order to make some immediate improvements to the way in which it commissions specialised services and to put commissioning arrangements on a stronger footing for the longer term. The task force is led by Richard Jeavons, Director of Specialised Commissioning, NHS England. Additional resource from within NHS England has been diverted to the task force to ensure that it has the right mix of skills and expertise to enable it to meet its objectives. The task force comprises seven distinct work streams, which are focusing on financial control during the current year and planning for the 2015-16 commissioning round.
NHS England provides updates on the work of the task force to external and internal stakeholders every three to four weeks. There are also briefings given at key meetings and to key groups—for example, the Patient and Public Voice Assurance Group. Updates can be found on the NHS England website. NHS England describes its specialised commissioning task force work as a way to secure financial control in 2014-15 and to plan for 2015-16; it is not a wholesale review of specialised commissioning. The aim is to improve ways of working and to ensure that specialised commissioning is undertaken in the most efficient and effective way possible. The department is working closely with NHS England as it develops proposals for change. NHS England will continue to be held to account through the regular accountability meetings and the annual assessment that I have referred to.
Although these arrangements for the oversight of commissioning are new, I am confident that they are robust. The CQC’s new approach to inspection and the information that it provides about the quality of care through ratings is itself of use in commissioning, and where there is evidence that commissioning decisions are leading to poor care, it will, as I have said, be possible to escalate this to the CQC. I believe that these arrangements strike the right balance, allowing the CQC’s focus to remain on its core task of inspecting and regulating health and adult social care, but retaining an ability to look at commissioning issues when necessary.
Medical Innovation Bill [HL]
Earl Howe Excerpts(9 years, 6 months ago)
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Lord Turnberg
I accept entirely what my noble friend has said. The surgical aspects of the Bill are quite tricky.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this large group of amendments, all in their own separate ways, seek to ensure that patients are protected against negligent or irresponsible treatment. As we have heard, these amendments take many different approaches in seeking to achieve essentially the same goal. The Government are absolutely committed to safeguarding patients. That is why my right honourable friend the Secretary of State for Health asked Sir Bruce Keogh, the medical director of NHS England, to work with the medical profession to devise a package of amendments that would make this Bill safe for both patients and doctors. Like my noble friends Lord Kirkwood and Lord Cormack, I take this opportunity to commend my noble friend Lord Saatchi for listening to concerns and agreeing to table the amendments recommended by Sir Bruce Keogh in full.
I now address the amendments themselves. On Amendments 1, 7, 17 and 33, the Government do not feel that there is anything to be gained by restricting the scope of the Bill in the way proposed. To set out specific medical treatments or circumstances that would or would not be covered by the Bill would make it complicated for doctors to follow and less flexible to individual patients’ circumstances. That was well exemplified by the exchange that we have just heard. This might limit the Bill’s usefulness to patients and doctors alike. I say to the noble Lord, Lord Turnberg, that there is no question of the Bill applying to unregulated practitioners: it applies to doctors. In answer to the noble Baroness, Lady Wheeler, about what constitutes an appropriately qualified doctor, we believe that to define the required level of experience and expertise would create an overly burdensome requirement on doctors looking to innovate responsibly. A requirement that a doctor is appropriately qualified provides a sufficient safeguard to patients. New Clause 1(3)(b) requires the doctor to take full account of the views of an appropriately qualified doctor in a way in which a responsible doctor would be expected to do.
The provisions in Amendment 7 outlining the process that a doctor must follow to reach a responsible decision are largely addressed by my noble friend Lord Saatchi’s Amendment 12. The provisions in Amendment 7 which require doctors to consult a specified range of other doctors are too restrictive and would make the Bill complicated for doctors to follow. My noble friend’s amendment for doctors to take full account in a responsible way of the views of one or more appropriately qualified doctors in relation to the treatment is less burdensome and is a better equivalent to the existing law.
The noble Lord, Lord Pannick, raised concern that a responsible decision under the Bill is defined as relating to the process rather than the substance of the decision. I listened very carefully to that point. The steps that a doctor has to take under new Clause 1(3) include taking account of substantive factors as well as process. This includes taking full account in a responsible way of the views of one or more other doctors about the proposed treatment. In addition, the doctor must consider the risks and benefits of the proposed treatment as compared to other treatments and to not carrying out any treatments at all. This strays outside the realm of process.
The Government’s view is that it is not necessary in this Bill to require doctors to record their innovation in medical records as set out in Amendments 7 and 15. The General Medical Council’s Good Medical Practice guidance already sets out requirements on doctors to record their work clearly in clinical records, including clinical decisions made and discussions with patients. On Amendment 19 and the related Amendment 34, the Government believe that requiring doctors to record the results of innovative treatments in order to demonstrate that they have not been negligent is not the right approach. This is too bureaucratic and risks deterring doctors from innovating. As regards the idea put forward by the noble Lord, Lord Winston, that there should be some sort of oversight by a clinical or research ethics committee, that would add a very significant level of bureaucracy. Considering the time it would probably take to receive a response, it would act as a barrier to innovation. As the noble Lord knows, research ethics committees are specialists in considering research proposals and would not necessarily be qualified to comment on innovative clinical practice. They do not necessarily have universal coverage and they would not necessarily have the requisite knowledge to advise doctors on very specialised innovative new practices.
However, I have heard the legitimate concerns of noble Lords today, and I commit on behalf of the Government to explore this issue further and constructively with the relevant professional bodies. It will clearly be helpful to understand, should this Bill become law, what might be useful in terms of record keeping and reporting in relation to medical innovation. Furthermore, I commit to ensuring that any guidance that may be appropriate is developed and made available in a timely manner. I hope the intention to issue guidance will be of help to my noble friend Lord Kirkwood.
Amendments 12, 14, 18 and 21 seek to ensure that consent is sought and that proper consideration is given to the views of the patient. My noble friend Lord Saatchi’s Amendment 12 ensures that to fall within the Bill a doctor must obtain any consents required by law. This amendment also ensures sufficient protection for the views of the patient. Furthermore under the existing law of consent patients already have the right to information about the testing and treatment options available to them.
The noble Baroness, Lady Masham, posed questions about drugs. She asked me whether the NHS would pay for unapproved drugs or whether the patient would have to do so. It is worth noting that nothing in the Bill allows doctors to bypass any processes or requirements set by the trust that they are working for. This would include ensuring that the trust would fund any treatment if it were to be provided within the National Health Service. She was fearful that this could result in a two-tier health system in which a patient would be required to pay for innovative treatment. The Bill does nothing to alter funding arrangements for accessing innovative treatments within the NHS, as I have said. That will be governed by whatever rules apply in the trust concerned. However, the Bill also does not change the ability of patients to pay for private medical treatment, as they are able to do now.
Lord Turnberg
I am sorry to interrupt the Minister’s flow. Does he not think that that is confusing for doctors in an emergency situation, wondering which route to take and about the options at that stage, rather than just getting on with the job?
Earl Howe
Personally, no, I do not—although my noble friend may choose to address that point. I believe that what initially motivated my noble friend to introduce the Bill was a perception on his part that there are doctors out there who are afraid to innovate, and perhaps afraid to innovate even on the spur of the moment, for fear of being litigated against. If that situation were to apply, that doctor could regard the Bill as a useful way forward. I do not think that that poses any confusion, because my noble friend is proposing to bring the Bolam test forward, as he has clearly explained, so that the essence of the principle that the courts look at would apply in whichever course the doctor chose to take.
The noble Baroness, Lady Wheeler, made a point about conflict of interest. The Bill makes it clear that the doctor will be protected from a successful claim in negligence only where they have reached a responsible decision. That includes a requirement to consult with one or more appropriately qualified doctors. In choosing which doctors would be most appropriate to consult, a doctor would need to be confident that their views would enable him or her to reach a responsible decision in order to benefit from the protection offered by the Bill. Just to make the point absolutely clear, I say that the Bill does not change the law of consent in relation to children or people who lack capacity, whereby any treatment provided to them by a doctor must be in their best interests.
Amendment 10 would add a requirement on doctors to act in manner that is reasonable and proportionate. My noble friend Lord Saatchi’s Amendment 11 would ensure that a doctor must be acting responsibly in an objective sense when making a decision to depart from the existing range of accepted medical treatments for a condition. Under the law of negligence, “reasonable” and “responsible” have the same meaning. Therefore, the Government’s view is that Amendment 10 is unnecessary.
Amendment 24 would clarify that doctors would not have to follow the steps of the Bill in an emergency. My noble friend Lord Saatchi’s Amendment 29 ensures that it is for the innovating doctor to decide whether to take the steps set out in the Bill or to rely on the existing Bolam test, as I have just explained. There is no requirement to follow the Bill.
My noble friend’s package of amendments ensures that the Bill comes as close as possible to achieving the policy intent of bringing forward the Bolam test to before treatment is carried out. The amendments would do this in a non-bureaucratic way by avoiding the creation of new approval structures or alteration of the remit of existing groups such as multidisciplinary teams. They provide a critical safeguard in ensuring that there is both expert peer review of the doctor’s proposal and that the doctor acts responsibly. The Bill would not provide any protection to a doctor who carried out an operation or procedure negligently. The Government would not support any Bill that sought to prevent patients who receive negligent treatment from seeking compensation or which sought to remove the requirement of doctors to behave responsibility and in the best interests of their patient.
I will turn briefly to the questions put to me by my noble friend Lord Kirkwood. First, he asked me whether the Bill would apply to pharmacists who dispense medicines. The Bill applies to a decision by a doctor to innovate, which would include a decision to prescribe an innovative medicine. The Bill does not impact on the reliability of a pharmacist who provides a patient with a medicine in accordance with a doctor’s prescription.
My noble friend also asked whether the Bill would apply in Scotland. It would apply in England and Wales but not Scotland or Northern Ireland. Medical negligence law is within the legislative competence of Northern Ireland and Scotland, but not Wales. He also asked me whether there is a conflict between the Bill and the common law. Under both the Bill and the common law a doctor will not be negligent if they have acted responsibly. The Bill, so far as possible, brings forward the common-law Bolam test, as I have explained, to before the doctor offers treatment. There is therefore no conflict between the requirements under the Bill and the common law. The Bill simply offers doctors a way to demonstrate and be confident before providing treatment that they have acted responsibly and thus not negligently.
As regards the cost of implementing the Bill, which my noble friend also asked me about, my reply to him at this stage is that there is not sufficient evidence for us to arrive at a cost figure. The impact of the Bill is by its very nature hard to predict.
I hope that noble Lords will accept my noble friend’s package of amendments in this group—that is to say, Amendments 8, 9, 11, 12, 16, 20, 25, 26 and 27. It is the Government’s view, based on medical and legal advice, that together these amendments do all that is necessary to protect patients, while freeing doctors to innovate responsibly without undue bureaucratic burden.
Lord Saatchi
My Lords, I thank all noble Lords who have spoken on this group, which was initiated by the noble Lord, Lord Turnberg. Many interesting points have been made on ethics, law, science and medicine. I am sure that we will all agree that the Minister has dealt with them all admirably. He certainly put the points better than I could have myself, and I hope that he has covered most of what was said.
What can I add to what my noble friend has said? I do not want to descend into anecdotage, but if any noble Lord sensed a reluctance on my part in relation to these amendments, perhaps this will help. I was taught the importance of what the noble and learned Lord, Lord Mackay, and the noble Baroness, Lady O’Neill, said as regards trying to maintain the simplicity of the Bill in an exchange with the noble and learned Baroness, Lady Butler-Sloss. At an early stage Daniel Greenberg, the Parliamentary Counsel, who has been the draftsman of the Bill throughout, showed her the first or second draft and said, in effect, “What do you think?”. She replied, “Make it shorter”.
Over the course of the last two years we have tried very hard to keep the Bill in a state which I think the noble and learned Baroness and the noble and learned Lord, Lord Mackay, would approve of. I learnt from her that the courts want to have an Act of Parliament that is absolutely crystal clear in its intent, so that there is no doubt and confusion at all in the mind of the court about what Parliament intended with this or that clause, phrase or wording. We have tried very hard to do that. I reassure your Lordships that if that has in any way given the appearance of reluctance on my part, I am deeply apologetic.
I would certainly welcome following up the suggestion of the noble Baroness, Lady Wheeler, and those of many other noble Lords. The noble Lord, Lord Kirkwood, had an excellent wish list of following up Committee today—with your Lordships’ approval—with discussion between now and Report to see where we can get to. I am trying only to deliver to the noble and learned Baroness, Lady Butler-Sloss, and her fellow judges in the courts, an Act of Parliament that is simple, completely straightforward and totally clear, and which does what it is supposed to: provide clarity and certainty at the point of treatment both to the doctor and the patient. As noble Lords can see, I am resisting the enormous temptation to revert to a Second Reading speech, so I will now sit down, after a long group of amendments, so that we can go on to the next group.
Baroness Finlay of Llandaff
My Lords, I added my name to the amendment deleting “reckless” because I felt quite strongly that it detracted from the overall intention of the Bill. This is not about reckless innovation; it certainly must deter irresponsible innovation, but it is about encouraging responsible innovation. I also added my name to Amendment 3, on treatment for the “relevant conditions”, because many of these patients who are seriously ill will have multiple co-morbidities and may have many things happening to them. This Bill is aimed, as far as I have understood, at the principal condition—the condition for which patients are often desperate for some innovative treatment. It should not inadvertently allow lots of other strange things to be presented to patients to cope with many of the other co-morbidities that they may have.
My feeling about that comes particularly from my own specialty, which the House knows is palliative medicine, where we see time and again patients who are very emotionally vulnerable, psychologically fragile and potentially in despair, so they are unable to make sense of what is going on. In that state, they are quite vulnerable to people presenting all kinds of strange treatments with false claims. I will give a specific example from my own practice. We came across a group of patients on a ward who all had small crystals by their bed, and we discovered that a member of staff strongly believed that holding on to these crystals would shrink the patients’ cancers. The evidence for it was absolutely zilch; I think that the patients had paid to have the crystals given to them. That type of so-called experimentation is completely outside the scope of the Bill—and must be outside its scope. That is why it struck me that the wording about the relevant medical condition should feature in the Bill, because of the potential for exploitation otherwise.
Earl Howe
My Lords, this group of amendments seeks to alter the purpose clause of the Bill. Under the law of negligence, the words “reasonable” and “responsible” have the same meaning, as the noble Lord, Lord Pannick, reminded us. As such, the addition of “reasonable” is not necessary and risks creating confusion. Existing clinical negligence law commonly refers to a responsible body of professional opinion. The addition of “reasonable” may suggest that the test under this Bill differs from the existing Bolam test.
The noble Lord, Lord Pannick, asked me whether the Bill required a rational judgment of success. Proposed new subsection (3)(d) in Amendment 12 requires the doctor to consider a number of factors in relation to the proposed treatment. This includes a requirement to consider,
“the risks and benefits that are, or can reasonably be expected to be, associated with the proposed treatment”,
other accepted treatments, or,
“not carrying out any of those treatments”.
In weighing this up, the doctor must apply an objective standard as to what could reasonably be expected in relation to those treatments. This provides a further safeguard for patients in ensuring that a doctor may not offer an innovative treatment in accordance with the Bill unless he has acted in an objectively responsible way. I hope that that helps the noble Lord, Lord Pannick.
My noble friend’s Amendment 11 seeks to ensure that a doctor must be acting responsibly in an objective sense when deciding to depart from the existing range of accepted medical treatments.
On Amendment 3, the Government do not feel that there is anything to be gained by restricting the scope of the Bill in this way. To set out specific medical treatments or circumstances that would or would not be covered by the Bill would make the Bill complicated for doctors to follow and less flexible to individual patients’ circumstances. This might limit the Bill’s usefulness to patients and doctors alike.
On Amendments 4 and 5, the Government support the amendment to remove the reference to deterring “reckless irresponsible innovation” from the purpose clause. Recklessness has a very specific meaning in criminal law, and the term is out of place in a Bill about the law of negligence. Furthermore, the substantive provisions of the Bill focus on how a doctor can demonstrate that he has acted responsibly. This amendment therefore ensures that the purpose clause better reflects the focus of the Bill. I hope that noble Lords will accept Amendment 4, which brings clarity to the purpose of the Bill.
Lord Saatchi
My Lords, I thank my noble friend the Minister for what he said. I think that there is a consensus on Amendment 5 in my name, that of the noble Lord, Lord Turnberg, and that of the noble Baroness, Lady Finlay, to remove the word “reckless”. I think that we are agreed on that. My noble friend dealt with the point under Amendment 3 from the noble Baroness and the noble Lord. We understand the wish to exclude certain treatments and types of surgery, and perhaps that is something that we can discuss between now and Report.
I share the Minister’s wish to accept Amendment 4 from the noble Lord, Lord Pannick, which removes the reference to deterring quackery from the purpose clause. We are agreed on the view that, if the noble Lord, Lord Pannick, believes that it is important to confine the purpose clause to the positive, we should not insist on the inclusion of both limbs—positive and negative—since as a matter of law the negative flows naturally from the positive in any event. If the noble Lord, Lord Pannick, presses that amendment, I shall support it.
Baroness Butler-Sloss
It seems to me that if one is going to have Amendment 6, instead of saying that it “means”, it should say that it “includes”. That would then leave open everything else that might come in as medical innovation.
Earl Howe
This group of amendments seeks to define innovation and the scope of the Bill. This is a uniquely difficult task as innovation is, in essence, about constant improvement, change and progression. It is essential that in the act of defining we do not inadvertently limit responsible innovation. I ask the Committee to take on board the point neatly made by my noble and learned friend Lord Mackay.
Amendment 8 to Clause 1(2) in the name of my noble friend Lord Saatchi limits the scope of the Bill to situations where a doctor departs from,
“the existing range of accepted”,
medical treatments for a condition. This will be well understood by doctors, who are best placed to know whether they are following accepted treatments. This amendment also ensures that the Bill applies only to medical treatment.
A further provision, Clause 1(4)(a), ensures that the Bill applies not to research but only to the care of individuals. This exclusion of research is sufficient to achieve the same effect as Amendment 6 in the name of the noble Lord, Lord Winston. I hope that that clarifies that point for the noble Baroness, Lady Wheeler.
The Bill’s definition of innovation allows for situations in which doctors choose to carry out no treatment in the best interests of the patient. The definition of innovation in medical treatment proposed by the noble Lord, Lord Winston, would exclude that. I hope that that point, if no other, will give him pause when he decides what to do with Amendment 6.
There is another basic point to make here. Defining innovation on the face of the Bill would restrict the application of the Bill and could risk uncertainty for doctors as to whether the protection offered by the Bill would extend to the treatment that they are proposing. It is important that the scope of the Bill is clear to the medical profession.
Moving on to Amendment 28, the Government do not believe this to be necessary. The Government are already fully committed to promoting innovation which can save and improve lives. The Committee may be aware that NHS England has a full programme of initiatives to unblock innovation and disseminate the benefits to the NHS and beyond—something that the Government fully support. These include Innovation Connect, a programme to help innovators in the health service and industry to realise their ideas, embed them into clinical practice and exploit new opportunities in international markets, NHS innovation challenge prizes to encourage, recognise and reward front-line innovation and drive the spread and adoption of these innovations across the NHS, and the NICE Implementation Collaborative, which supports work streams by providing essential support to overcome identified barriers to innovation. Those are just some examples.
My noble friend Lord Blencathra asked in particular about off-label treatments. Without repeating the answer that I gave earlier to the noble Baroness, Lady Masham, on a similar issue, the Bill sets out a series of steps which doctors can choose to take when innovating to give them confidence that they have acted responsibly and with the intention of reducing the risk to doctors of successful claims of clinical negligence. With that threat diminished, the intended effect is that doctors will be confident to innovate appropriately and responsibly. That applies in full measure to off-label treatments. I would say as an aside that the cancer drugs fund, which has enabled access to a number of novel medicines, including off-label treatments, has benefited more than 55,000 patients since September 2010. So the decision on whether to prescribe unlicensed or off-label medicines will remain a matter for the doctor or prescriber who has clinical responsibility for the patient’s care, taking into account their individual clinical circumstances.
In response to the noble Baroness, Lady Masham, about funding, I should make the simple point that the Bill does not add any extra funding for drugs. Funding may be a consideration in certain circumstances, but the Bill does not affect the situation one way or the other.
I hope that noble Lords will take into account the Government’s view that innovation is best defined as a departure from the standard range of existing medical treatments, and that on reflection the Committee will not accept Amendments 6 and 28.
Lord Saatchi
My Lords, as we have just heard, Amendment 6 attempts to make a definition of “innovation”. I myself think that that is quite difficult to do, even though the noble Lords, Lord Pannick and Lord Winston, made it clear that they are trying to provide a definition in order to assist the purposes of the Bill. I find it difficult to do for the reasons given by my noble and learned friend Lord Mackay. The word is clear and the Minister has just defined it even more clearly, which is that innovation is a departure from the standard procedure. I am advised that that definition of the concept is sufficiently clear for doctors, patients and the courts to be able to judge in the light of the circumstances of each case. I am told that the proposed definition also refers to some procedures, so that the legislation may become outdated at some point.
The main point in plain English is that the noble Lord, Lord Winston, himself described innovation elsewhere as being serendipitous; in other words, the term has in it the concept that what is about to happen is unheard of and unknown, and therefore it is a true innovation because it has not been conceived of. It is quite difficult to make a definition, but perhaps that is something we can talk about with the noble Baroness, Lady Wheeler, when we meet before the Report stage.
I wish I could say something more encouraging to the noble Baroness, Lady Masham, about funding. Many people have said to me over the course of the long journey of this Bill that, “This is all very well, but what we actually need is more money. If we had more money, we could have more innovation for every disease”. I really do not know whether that is true because there are completely different views about it. However, the one thing that is certain is that this Bill, as my noble friend the Minister said, does not do anything to increase the UK GDP, nor does it increase the percentage of UK GDP that is spent on health, nor does it increase the percentage of UK health spending that is spent on innovation. As my noble friend has just said, it has no impact on what the noble Baroness is interested in hearing, which is on the subject of funding. It is completely neutral.
I will come to Amendment 28 in a moment. Perhaps at this point I could say that it is wonderful to hear my noble friend Lord Blencathra speak because we are hearing the true voice of the patient, as I understand it. We all say that what we do in this House and in the Department of Health is putting patients first. If that is what we are doing, your Lordships have just heard the true voice of the patient and nobody has ever expressed it better.
Baroness Wheeler
My Lords, we have had a very authoritative and detailed contribution on the issues raised by Amendment 29 from the noble Lord, Lord Saatchi. Opinion among noble Lords and indeed the stakeholder medical and patients’ organisations is still divided on: first, whether a change to the law is required or whether the existing law and professional ethics arrangements will allow responsible innovation; and secondly, whether the potential two options/processes—or three as my noble friend now makes it clear will be available if the Bill becomes law—will improve and speed up the administering of innovative treatments or will cause considerable confusion among doctors about which system they should use, lead to more bureaucracy and deter them from embarking on the course?
As we said earlier, we welcome the attempts of the noble Lord, Lord Saatchi, to ensure that with this amendment the Bill does not affect the common-law Bolam test. On the overall Bill he has led a powerful campaign and is reported to have won the support of patients responding to the consultation and the publicity from Cancer Research UK, Marie Curie Cancer Care and other patient organisations. I was pleased that the noble Baroness, Lady Masham, raised a number of questions from Marie Curie about palliative care and the use of drugs arising from issues in the Bill, and I was grateful for the Minister’s very helpful response.
The General Medical Council has now given its support to the amended Bill and the Medical Defence Union has said that the amendments cover the main objections to the previous Bill. However, we have to acknowledge that some key stakeholders maintain that the Bill is not necessary because the existing law already ensures protection for doctors to innovate, and the current law and ethical guidance from the General Medical Council are clear. The Royal College of Surgeons still has strong reservations about the Bill, particularly about it applying to surgery, as we have heard. The Medical Protection Society still believes that it confuses rather than clarifies the law. The Association of Personal Injury Lawyers says that the amendments make a confusing Bill even vaguer. The BMA still strongly questions the necessity and desirability of clarifying or changing the law. Action Against Medical Accidents, one of the leading patient organisations, still says that the Bill is fraught with unintended and dangerous consequences and will create a more bureaucratic system. Sir Robert Francis QC, while considering that the amendments have produced an improvement in safeguards over what was originally proposed, has said that serious problems remain. In particular, he is concerned, as my noble friend Lord Turnberg pointed out earlier, that the Bolam amendment, while restoring a level of safeguard, also has the disadvantage of restating Bolam in different language, leading to a real risk of confusion. His question is: why not just stick to Bolam? I would be grateful for the noble Lord’s comments on that.
Will the noble Lord, Lord Saatchi, and the Minister tell the Committee whether they consider that the amended Bill now meets Dr Dan Poulter’s key test that I referred to earlier; namely, of not placing an undue bureaucratic burden on the NHS or not exposing doctors to a risk of additional liabilities?
I welcome the response of the noble Lord, Lord Saatchi, on the question of convening a round table, which I think will be a very helpful way of going forward. Obviously, it will never be possible to satisfy everybody’s concerns but, if the Bill is to be further supported, what steps will be taken by the Government to engage with stakeholder concerns?
Earl Howe
My Lords, the Government support these two amendments, which ensure that the Bolam test will remain unaffected by the Bill. In practice, this will mean that it is for the innovating doctor to decide whether to take the steps set out under the Bill or to rely on the existing Bolam test. In other words, there would be no requirement for doctors to follow the Bill when innovating.
The amendments clarify that, separate to the existing Bolam test which is applied by the courts, the Bill provides doctors with an alternative option for showing that they are acting or have acted responsibly. Furthermore, subsection (2)(b) of the proposed new clause provides that doctors are not negligent, and thus will not be judged adversely if their actions are later challenged, merely because they have not followed the Bill.
My noble friend Lord Kirkwood asked how the proposed new clause affects how a regulator approaches a complaint or fitness-to-practise procedures. This Bill addresses clinical negligence law and how the courts will assess these cases, not how the regulators will process fitness-to-practise cases.
The noble Baroness, Lady Wheeler, asked whether the Bill was necessary. The Department of Health’s consultation on the Bill revealed that some doctors find the threat of litigation to be a block to innovation, although this view was not universally held. The Bill is aimed at reassuring those doctors who feel unable to innovate due to concerns about litigation. There will also be many doctors who are not afraid to innovate and for whom litigation is not a material concern. Those doctors can continue to act as they have done previously and rely on the existing law of clinical negligence, or, as I have explained, they may choose to take advantage of the Bill instead.
I hope that noble Lords will accept these two amendments, which give flexibility and choice to doctors who want to innovate.
Lord Winston
There is something troubling me here. Let us say that somebody in an emergency or other situation does not have a chance to go through the required tests stipulated by the Bill, consulting other individuals who may be confident about or more experienced in that position. I still do not understand in the context of what the Minister has just said where that individual stands in innovating without those permissions. Is that still part of the Bill? How does that work? Is there a risk of that person being irresponsible in view of his not fulfilling what is required in the Bill when he is innovating?
Lord Woolf (CB)
My Lords, before the Minister replies, perhaps I could just make a comment. I have resisted getting involved in the various excellent speeches that have been made so far. While I am on my feet, I make it clear that I strongly support the noble and learned Lord, Lord Mackay. There is a danger in looking at these as alternatives. If the matter comes before the court—of course, one hopes that it will not—the court’s approach would be to say that there is nothing in the Bill, because of the amendment we are now considering, which prevents the Bolam test being relied upon as it is today, without the Bill.
On the other hand, if the situation is one that enables the Bill to be relied on, that is another matter that the person can rely on. In some situations, such as a state of emergency, it may not be possible to rely on the Bill, but that does not prejudice the doctor involved in any way, because the Bill leaves the Bolam test intact. It is supplementing the Bolam test, and the importance of the fact that it is supplementing it is apparent in the fact that it states that if the doctor can comply with the Bill, he knows that he is safe and does not have to wait until the Bolam test has been applied to find out whether he is in danger. I think that that is understood. Does the Minister agree with my approach, which is that these are not alternatives?
Earl Howe
I completely agree with the noble and learned Lord’s analysis of the situation. I hope that that has been helpful to the noble Lord, Lord Winston. Earlier, the noble Lord cited an example where a doctor was confronted by an emergency requiring innovative practice. Whether the doctor was acting responsibly or not, and the consequences, will depend on a number of factors. It will depend on the extent to which the doctor is confident in his or her judgment, based on experience in previous clinical practice and can, if necessary, show to a court that what he or she did was responsible and, at least in intent, in the best interests of the patient.
The noble Lord asked whether there was a risk of a doctor being found to be irresponsible in some emergency situations where innovative treatment is practised. Yes, there would be a risk if the process outlined in the Bill were not followed—but that situation obtains today.
Lord Winston
Both the Royal College of Surgeons of Edinburgh, of which I am a fellow, and the Royal College of Surgeons in London, absolutely support the idea that surgery should be excluded from the Bill for this very reason: they consider that there might be situations where the courts become unnecessarily involved. That involves extra expenses to the health service because of our current concern with litigation. As the noble Earl well knows, in obstetrics, for example, litigation already accounts for a huge proportion of the expenses devoted to maternal care. There are considerable knock-on effects where litigation may be started because of lack of clarity. It is possible that I am being stupid—I recognise that I am not nearly as intelligent as the noble and learned Lord, Lord Woolf—and I will have to go away to think about this, but there seems to me to be a misconstruction here which is puzzling and, I think, worrying.
Baroness Gardner of Parkes
Can I seek some clarification? I wonder whether anyone could make clear for the Committee whether, if the doctor says that he does not want to do the innovative treatment, there is a defence in court on the grounds that he thought that it would be unwise or unsatisfactory. I say this because everyone seems concerned about the effect of not doing something innovatory.
Earl Howe
My Lords, the Government’s view is that it is not necessary to include in the Bill a provision for the Secretary of State to issue codes of practice about the Bill, but I hope that I can reassure the noble Lord, Lord Hunt, on the last point that he made. If the Bill is passed, the Government will work closely with the professional bodies, including the General Medical Council, to help doctors to prepare for the changes to the law. This will include producing any guidance that may be helpful.
I listened carefully to the points that the noble Lord made about the adoption of innovative treatments in the National Health Service. He knows from his experience as a Minister that this issue has been with us for quite a long time. We have silos of innovation and forward-thinking practice throughout the health service. The challenge has been to spread that innovative behaviour more widely and for the diffusion of innovative treatments to become second nature to the health service. It is a cultural issue.
The noble Lord is right to say that in many cases the non-adoption of NICE-approved drugs is a particular feature in parts of the NHS. That is exactly why the document Innovation, Health and Wealth was published some time ago. It is why we now have the NICE implementation collaborative, which is designed to bring together the key players in the system to ensure that NICE-approved medicines are adopted. There is the innovation score card, which helps in this regard. The academic health science networks are there to shine a spotlight on promising new innovative devices and medicines and to spread them at pace and scale throughout the health service. The early access to medicines scheme is another example of where we are trying to give patients access to innovative treatments, even before they have been licensed.
There is on occasion a good reason why a NICE-approved medicine may not be adopted by a particular trust. That is quite simply that for a given condition there are many alternative treatments, many of which have been endorsed by NICE. The Government cannot mandate clinical decision-making by individual doctors. Where there is a choice between one and another NICE-approved medicine available to a doctor, it is open to the doctor to make that choice. Nevertheless, the noble Lord’s basic point is well made and I hope that he will accept that the Government are taking a number of measures in conjunction with NHS England to ameliorate the situation.
I hope that, with the remarks that I made earlier about producing guidance, the noble Lord will be reassured and the noble Lord, Lord Turnberg, will not press his amendment.
Lord Saatchi
My Lords, perhaps we could add this point to the discussions that we are going to have before Report. My noble friend the Minister expresses a modest view of what the Government should and should not do and wants to leave it to the regulatory bodies to make this happen.
I refer once again to anecdote. The noble Lord, Lord Turnberg, said to me at an early stage in this process, in which he has been a great inspiration, “What are you going to do after the Bill becomes law?”. I said, “I am going to go on a very long vacation”. He said, “Oh no you’re not”. I said, “Why not?”. He said, “Your work is only just beginning”. His point, and he speaks as an expert, is that a culture change is contained in this Bill. “Culture change” is a phrase that my noble friend just used, and it was used by Dame Sally Davies, the Chief Medical Officer, many months ago. A culture change is being sought, but it will not happen overnight. It will follow, exactly as the noble Lord, Lord Hunt, says, a great deal of education and discussion in the medical profession.
Not to go on, but the noble Lord, Lord Turnberg, said that this will fall largely not just on the regulatory bodies, such as the GMC and NICE, but on the royal colleges. They will have to be involved in the process of educating people about what this means. This is the beginning of the process and I am rather with my noble friend in not wanting to have the Government set out the rules. I hope that that is acceptable to the noble Lord, Lord Hunt.
Lord Turnberg
My Amendment 36 has a similar effect to that of Amendment 35. Mine seems somewhat simpler, but I am quite happy to bow to Amendment 35 in the name of the noble Lord, Lord Saatchi.
Earl Howe
My Lords, this group of amendments addresses how the Bill would come into force. My noble friend Lord Saatchi’s Amendment 35 would ensure that the Bill came into force in accordance with regulations made by the Secretary of State rather than on Royal Assent as under the Bill as introduced. This would allow the Government and the medical profession time to prepare for the changes to the law made by the Bill—for example, to produce any guidance that might be helpful. This amendment also enables transitional and saving provision to be made if necessary. My noble friend’s Amendment 35 achieves the same objective as Amendment 36, which the Government therefore do not consider necessary.
The Government also support minor technical Amendments 37 and 38, which clarify that the section in question comes into force on the day on which the Act is passed. I urge noble Lords to accept Amendments 35, 37 and 38, which would ensure a smooth commencement of the Bill, and I hope that my noble friend Lord Kirkwood will allow me to write to him on the question that he posed a minute ago.
Baroness Finlay of Llandaff
My Lords, I will be brief; this will probably turn out to be a probing amendment. We have an interesting situation in Wales because health and healthcare provision is completely devolved. The experience of patients under the Welsh NHS falls completely within the legislative competence of the Assembly. However, if I am right, this relates to the law of negligence, and the Ministry of Justice does not have any devolved functions. The concern expressed to me within Wales has been about the use of resources and the possibility of practitioners being answerable as regards legislation that covers England and Wales, when the provision of healthcare is something for which they are answerable to the National Assembly. I tabled this amendment with a view to seeking clarification over that.
Sadly, we have had experience of extremely strange medical practices sometimes being put forward in the past. The Assembly is particularly concerned that, with its move toward prudent healthcare, which is a whole policy direction for NHS Wales, the Bill should not inadvertently cut across the principles of prudent healthcare, the first of which is, of course, to do no harm. I tabled the amendment with that in mind.
Earl Howe
My Lords, this amendment seeks to ensure the Bill would not apply in Wales unless a legislative consent Motion had been passed. The operative provisions of the Bill relate entirely to modifying the law of tort, which is a reserved matter. The Bill can fairly and realistically be classified as relating to a non-devolved subject, and therefore not within the competence of the National Assembly for Wales. The Government cannot accept this amendment, and I urge noble Lords to resist it.
Baroness Finlay of Llandaff
I am grateful to the Minister for the clarification. I expected that answer, but it is important to have it on the record. I beg leave to withdraw the amendment.
NHS: Five Year Forward View
Earl Howe Excerpts(9 years, 6 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I shall now repeat in the form of a Statement the Answer given by my right honourable friend the Secretary of State for Health to an Urgent Question earlier this morning in another place. The Statement is as follows.
“NHS England, along with other NHS organisations, has today published its independent Five Year Forward View, which sets out its view of how the health service needs to change over the coming years.
It is a report that recognises the real challenges facing the NHS but is essentially positive and optimistic. It says that continuing with a comprehensive tax-funded NHS is intrinsically doable, and that there are,
‘viable options for sustaining and improving the NHS over the next five years’.
The report says that the challenges of an ageing population can be met by a combination of increased real-terms funding, efficiencies and changing the models of care delivered. It also says that,
‘decisions on these options will need to be taken in the context of how the UK economy overall is performing’.
In other words, a strong NHS needs a strong economy.
The report suggests detailed new models of care, putting out-of-hospital services front and centre of the solution, delivered through greater integration between primary, community and specialised tertiary sectors alongside national urgent and emergency networks. These can help reduce demand significantly for hospital services and give older people in particular the personal care that we would all want for our own parents and grandparents. It talks about continued opportunities for efficiency savings driven by innovation and new technology, and suggests that they could be increased above the long-term run rate of efficiency savings in the NHS. It talks about reducing variation in the quality of care in the wake of the tragedy in Mid Staffs and how the new CQC inspection regime is designed to drive up standards across the system. It says that to do this we will need to move to much greater transparency in outcomes across the health and social care system. Finally, it makes important points about better integrating the public health agenda into broader NHS activity, with a particular focus on continued reductions in smoking and obesity rates.
The Government warmly welcome this report as a good blueprint for the direction of travel needed for the NHS. We will be responding to its contents in detail in due course but we think it is an important contribution to the debate. We are proud of how the NHS has coped with the pressures of financial constraint and an ageing population in the last four years, but we also know that to sustain the levels of service people want it needs to face up to change: not structural change, but a change in culture about the way we care for people.
Given that the report has been welcomed by all sides of the House, I also hope that this can be the start of a more measured and intelligent debate about the future of the NHS, where all sides of the House recognise our shared commitment to its future and focus on the best way to achieve the strong and successful NHS the whole country desires”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord for his welcome of the report which I am sure is shared by all noble Lords. It is, as the Statement says, a very useful set of conclusions jointly reached by the leaders of our health service and their partners. The noble Lord is right to say that there are common areas of agreement between the Government’s view of how we should move forward in the NHS and the view of the Official Opposition. I refer in particular to the role of integration, not only integration between health and social care, but also between hospital care and out-of-hospital care and between public health and health services. The report endorses the direction of travel that the Government are already taking in initiatives such as the Better Care Fund.
I turn now to the noble Lord’s specific questions. On GPs, we are not of the same mind as regards making GPs salaried employees of the health service. The independent practitioner model has served the country well and we do not think that there is any appetite in the general practitioner community to move in the direction that the party opposite would like. However, I certainly agree that there is a powerful role for health and well-being boards to play, and in many areas they are already doing so by bringing together the key players in a local area to decide on the health priorities of that area and to work out the right strategies to meet them.
On public health, as the Five Year Forward View emphasises, obesity is one of our major public health challenges and will continue to be so. I do not agree that the responsibility deal has been inadequate. It is only a part of a menu of options which the Government have available. We have seen major advances resulting from the responsibility deal and we should not throw those away. It means bringing business along willingly with us: business with its power and reach which goes far beyond that of the Government to influence consumer behaviour.
On GP services, I agree that many GP practices are under strain, but our vision and, I am pleased to say, the vision in this report, really centres around remodelling primary care in the round so that GPs consider themselves part of a wider primary and community care team. Yes, we need more GPs, and we have undertaken to ensure that the NHS has at least 5,000 more by 2020, but more broadly we should look at the multidisciplinary mix of those teams and expand nurse numbers and allied health professional numbers to supplement the work that GPs do.
On parity of esteem, we shall have a useful Oral Question next week which will give us a short opportunity to debate it. As I am sure the noble Lord is aware, a lot of work is going on to make parity of esteem a reality, including for the very first time defining waiting times for mental health patients and ensuring that mental and physical health are looked at on a par by both commissioners and providers.
Lord Fowler (Con)
My Lords, the strategy seems to be very sensible, but I hope that not only the Government but also all the parties will do what the chief executive of the National Health Service said on the radio this morning and recognise that there is no appetite inside the health service for any further top-down reorganisation. Will they also recognise that we need to put much more emphasis on preventing ill health? Pharmacists, who are highly qualified and well trained, should have a much bigger role to play, which would reduce the present burden on general practitioners.
Earl Howe
My noble friend is absolutely right in what he says. The report lays great emphasis on the prevention agenda, not only through the work done in the public health arena by Public Health England and local authorities, but also through secondary prevention by the NHS itself: preventing the need for people to enter hospital in the first place. I fully agree with my noble friend about the potential role of pharmacists. Actually, that role has been enlarged over the past few years in an encouraging way with such things as medicines use reviews and the Healthy Living Pharmacy agenda. We want to go further and pharmacists are keen that we should do so.
Lord Kakkar (CB)
My Lords, I declare my interest as chairman of University College London Partners. This ambitious programme will require very strong leadership. What arrangements are going to be put in place to develop strong clinical leaders across the different sectors and environments of the health delivery system that will be required to ensure that this become reality?
Earl Howe
One of the great features of the Government’s reforms is to put clinical leaders in charge of designing the way that care is delivered throughout the country. That point is often overlooked. It is, of course, the quality of that leadership that we should focus on. That quality is variable and why NHS England, Health Education England and partners in the system are looking as carefully as they can at how to improve that quality of leadership. I direct the noble Lord’s attention to certain passages in the Forward View, which talk about the need for all the bodies in the system to work together: NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Health Education England, NICE, Public Health England—all working together to achieve greater alignment and greater common purpose in the way that these proposals are implemented.
Baroness Blackstone (Lab)
My Lords, on the subject of the prevention of obesity, can the Minister say what steps the Government are taking to introduce a tougher regulatory environment for food companies whose products are damaging the health of many thousands of people in this country?
Earl Howe
Many food companies—not all, but many of the larger ones—have already taken steps, for example, to reduce the levels of salt and saturated fat in their products. We need to go further. This has been done by the previous Administration and the current Government on a voluntary basis. We think that that has worked well. Nevertheless, we have never excluded the possibility of regulation, where we think that it is justified. At present, we believe that there is sufficient scope to make progress without regulation, but that is a matter we will keep under review.
Baroness Brinton (LD)
My Lords, from the Liberal Democrat Benches, we also welcome the five-year report, particularly because it accepts that the business-as-usual model needs to move on. In particular, we welcome the public health aspects and the fact that strong democratic accountability with councillors and local authorities is providing substantial change in public health. Does the Minister agree with the report that there should be more enhanced powers for local authorities to develop this further? If so, can he guarantee that there will be cross-departmental discussions to make sure that there are more responsibilities, powers and funding?
Earl Howe
My noble friend has alighted on an area to which the whole Government will have to give very careful thought. It is not simply a matter for my department. This will entail cross-departmental scrutiny and agreement. However, on the strength of the performance of local authorities in grasping the public health agenda, as they have very enthusiastically, I am sure that we should look at that particular proposal very constructively.
Baroness Hanham (Con)
My Lords, as chairman of Monitor, which is one of the signatories and contributors to this document, may I ask the Minister to confirm further that the Government will not see any wholesale managerial reorganisation in the health service, which is not what the document is looking for, but that they will see change coming about in the way that services are developed? Will they ensure that services will not all be developed in the same way, but that there will be local elements? Will they also support initiatives to help the organisations make this a realisable objective within five years?
Earl Howe
I agree with my noble friend. We neither want nor need further structural reorganisation; but we do need cultural reorganisation. I also agree that a one-size-fits-all model will not work: indeed, the Forward View expressly states that. We need to allow local areas to work through the solutions that are best for them. That can be done on a collaborative basis, with the benefit of health and well-being boards, which are now working so well in many areas.