Hospitals: Voluntary Sector and Emergency Readmissions

Earl Howe Excerpts

Monday 1st December 2014 Grand Committee

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

My Lords, I begin by thanking my noble friend Lady Scott for tabling this important topic for debate and for introducing it so ably. The Government appreciate, as all speakers have acknowledged, that voluntary and community sector organisations make a substantial contribution to the delivery of high-quality local health and social care services. They have a strong track record of designing, providing and supporting services, based on their insight into people’s needs, and they are often well placed to respond in a flexible way to those needs. Their unique understanding of local communities also means that they are ideally placed to reach those vulnerable and sometimes hard-to-reach groups that statutory organisations might struggle to reach.

Moreover, social action and volunteering contribute to every sphere of health and social care and are fundamental to building strong and resilient communities. For example, the Royal Voluntary Service—mentioned by my noble friend Lady Thomas and the noble Lord, Lord Bradley—is a charity that supports older people to live well at home, in the community and in hospitals. With a network of more than 40,000 volunteers nationally, the Royal Voluntary Service uses its strong community links as a platform to deliver a range of services that improve the hospital experience for older people and their relatives, reduce hospital readmissions by linking hospital and home-based services, contribute financially to patient and community services, and provide people with practical and accessible information about local services. These types of schemes can help to avoid unnecessary emergency readmissions.

The report mentioned by a number of noble Lords makes very interesting reading. The conclusion of the report is that, in the RVS’s estimation, this support could save tens of millions of pounds in public money. That needs testing, as the noble Lord, Lord Bradley, indicated, as there are a number of important assumptions underlying the figure that it quotes. Nevertheless, it points the way to the usefulness and value of the voluntary sector in all the areas that I have mentioned. There are many other voluntary sector organisations that do similar work—for example, Age UK.

I shall now set out the range of actions that the Government are taking to improve integration of care to ensure that people can receive the care that they need and avoid emergency admissions and readmissions, including through use of the voluntary sector. The better care fund is a £3.8 billion pooled budget between health and social care, with areas choosing to pool £1.5 billion extra to bring the fund to £5.3 billion. The vast majority of this is being spent on social care and out-of-hospital community health services, which aim to keep people out of hospital and support them to leave safely as soon as they are well enough to do so.

Underlying the new approach are improvements in seven-day working across health and social care to help quicker, more appropriate discharge from hospital. One of the metrics for the fund is the number of people supported to remain at home at least three months after discharge from hospital. Plans project that, over two years, 11,860 older people will be supported to remain at home at least three months after discharge from hospital. This equates to a 33.7% increase over two years. Schemes in plans typically focus on things such as increasing capacity in reablement or intermediate care services, or multidisciplinary emergency response teams, which focus on avoiding unnecessary admissions to hospital.

We know that the voluntary sector can also play an important role in providing advocacy to people who need it. One of the drivers for the better care fund is to stop people having to undergo multiple assessments and telling their story repeatedly. Having someone to represent them and to help them navigate their way through often confusing health and care services can be invaluable. For example, in Greenwich the hospital ward support scheme trains volunteers to engage with people in hospital to support them to do practical things such as maintaining hygiene or engaging in conversation. The scheme prepares people for discharge, with volunteers on hand to support those identified as socially isolated who will be leaving hospital. Doncaster’s better care fund plan sets out a comprehensive falls prevention programme, through which Age UK Doncaster is being commissioned to help increase physical activity levels in older adults to increase strength, stamina and flexibility. That reduces the risk of falls and fractures, which are a major reason for hospital admissions and readmissions.

As well as providing services directly, we know that the third sector is represented at the strategic decision-making level in better care fund planning, with Nottingham and Southwark being just two examples of the many areas with voluntary sector representatives as members of their integrated care programme boards, as well as the health and well-being board itself.

The £2 million social action fund has delivered improved engagement with the independent, voluntary and community sectors. Eight schemes are being funded, aimed at supporting frail and elderly people. The aim is to scale up and robustly test interventions that use social action to reduce demand on hospital services, with funded projects making their impact over the course of winter 2014-15. We hope to be able to mainstream the most successful interventions down the line, and all evaluations and learning will be shared widely with the sector. The projects will help develop the potential of services that use social action to help older people stay well, manage their conditions or recover from illness or injury, thereby reducing growing pressure on hospitals. Currently, such services are small in scale and piecemeal, and often are not robustly evaluated. By March 2015, the aim for each project will be to contribute to a significant impact in the local area over the winter of 2014-15, develop a robust evidence base on its effectiveness through evaluation by the Nuffield Trust, and lay the foundations for the service to continue and grow on a long-term basis.

I am conscious that I have mentioned only a very few of the many voluntary sector organisations that are relevant to this issue, focusing primarily on the generic services provided. There is also a wide range of different, more condition-specific services provided by the voluntary sector—for example, some of the support provided by charity helplines that enable people to manage their conditions at home. There are also the very important services provided by voluntary sector hospices that support people at the end of their life within their homes, thereby avoiding unnecessary hospital admissions.

I shall highlight one particular example of where I have observed fantastic contributions made by the voluntary sector. Last month, I visited a medical practice in Hertfordshire to see how the role of developing well-being services within local NHS communities works. The Wellbeing Service was developed in order to support patients’ physical, psychological and social needs through improved health and well-being. The practice has engaged with a number of voluntary organisations to help prevent readmissions. I was particularly struck by the help that the volunteers give patients in navigating their health journeys, and I commend their tremendous work on this.

The noble Lord, Lord Bradley, asked whether there would be any spend on the voluntary sector from the additional £700 million of winter funding. Planned spend by system resilience groups identified for voluntary sector organisations is approximately £3.9 million. Approximately 110 independent and voluntary sector schemes are planned across the country, covering the expansion of capacity to provide care at home, hospital-to-home aftercare, out-of-hours cover and beds in care homes, the community and hospices. These plans include voluntary sector providers referenced in plans, such as Age UK, the British Red Cross and various hospices and smaller providers. Many schemes are focused around helping with improved hospital discharges, support for patients on return to their homes, community care provisions, and longer-term work to reduce readmissions and prevent admissions in the first place. I think we can be encouraged by that picture.

I conclude by saying that I recognise that the voluntary and community sectors make a substantial contribution to the health and care system. This has been an excellent short debate. Like my noble friend, I regret that there have not been more speakers, but the issues raised by those who have spoken have brought to light what value is available from the voluntary sector in a range of fields in health and social care. I thank my noble friend for having given us this opportunity to look at those areas. I encourage commissioners to engage with voluntary sector organisations to understand the kind of support that they can deliver to prevent emergency admissions, looking at some of the excellent examples that we have heard about this afternoon.

Committee adjourned at 5.02 pm.

NHS: Five Year Forward View

Earl Howe Excerpts

Monday 1st December 2014 Lords Chamber

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

My Lords, I shall now repeat a Statement made earlier this afternoon by my right honourable friend the Secretary of State for Health about the NHS. The Statement is as follows.

“I wish today to make a Statement about the future of our NHS, one that I hope everyone in this House will welcome. In October, NHS England and its partner organisations published an ambitious Five Year Forward View that was welcomed across the political divide. Today, I will announce how the Government plan to implement that vision.

Our response has four pillars. The first pillar is to ensure that we have an economy that can pay for the growing costs of our NHS and social care system: a strong NHS needs a strong economy. Some have suggested that the way to fund extra cost pressures is through new taxes, including on people’s homes. However, through prudent economic policies, the Government can today announce additional NHS funding in the Autumn Statement without the need for a tax on homes. The funding includes £1.7 billion to support and modernise the delivery of front-line care, and £1 billion of funding over four years for investment in new primary care infrastructure. That is all possible because under this Government we have become the fastest growing economy in the G7.

The NHS itself can contribute to that strong economy in a number of ways. It is helping people with mental health conditions to get back to work by offering talking therapies to 100,000 more people every year than four years ago. But the NHS can also attract jobs to the UK by playing a pivotal role in our life sciences industry. We have already attracted £3.5 billion of investment and 11,000 jobs in the past three years, as well as announcing plans to be the first country in the world to decode 100,000 research-ready whole genomes. Today, I want to go further by announcing that we are establishing the Genomics England Clinical Interpretation Partnership to bring together external researchers with NHS clinical teams to interpret genomic information so that we go further and faster in developing diagnostics, treatments and therapies for rarer diseases and cancers. Too often, people with such diseases have suffered horribly because it is not economic to invest in finding treatments. We want the UK to lead the world in using genetic sequencing to unlock cures that have previously been beyond our reach.

The second pillar of our plan is to change the models of care to be more suited for an ageing population, where growing numbers of vulnerable older people need support to live better at home with long-term conditions like dementia, diabetes and arthritis. To do that, we need to focus on prevention as much as cure, helping people to stay healthy without allowing illnesses to deteriorate to the point where they need expensive hospital treatment. Some have argued that to do that we need to make clinical commissioning groups part of local government and force GPs to work for hospital groups. Because this would amount to a top-down reorganisation, we reject this approach. We have listened to people in the NHS who say that more than anything the NHS wants structural stability going forward, and, even if others do not, we will heed that message.

We have already made good progress in improving out-of-hospital care. This year, all those aged 75 and over have been given a named GP responsible for their care, something that was abolished by the previous Government. From next year, not just over-75s but everyone will get named GPs. Some 3.5 million people already benefit from our introduction of evening and weekend GP appointments, which will progressively become available to the whole population by 2020. The better care fund is merging the health and social care systems to provide joined-up care for our most vulnerable patients. Alongside that, the Government have legislated, for the first time ever, on parity of esteem between physical and mental health. To deliver world class community care, we will need much better physical infrastructure. Today, I can announce a £1 billion investment fund in primary and community care facilities over the next four years. This will pay for new surgeries and community care facilities in the places where people most want them: near their own homes and families. These new primary care facilities will also be encouraged to join up closely with local jobcentres, social services and other community services.

Additionally, from the £1.7 billion revenue funding we are also announcing, we will make £200 million available to pilot the new models of care set out in the Five Year Forward View. To deliver these new models, we will need to support the new clinical commissioning groups in taking responsibility, with partners, for the entire health and care needs of their local populations. So as well as commissioning secondary care, from next year they will be given the opportunity to co-commission primary care, specialist care, social care, through the better care fund and, for the first time, if local areas want to do it, public health. The NHS will therefore take the first steps towards true population health commissioning, with care provided by accountable care organisations.

A strong economy and a focus on prevention are the first two pillars of our plan. The third pillar is to be much better at embracing innovation and eliminating waste. We are making good progress in our ambition for the NHS to be paperless by 2018, and last month the number of A&E departments able to access summary GP records exceeded a third for the first time, while from next spring, everyone will be able to access their own GP record online. However, today, I want to go further: £1.5 billion of the extra £1.7 billion revenue funding will go on additional front-line activity. To access this funding, we will ask hospitals to provide assured plans showing how they will be more efficient and sustainable in the year ahead and deliver their commitment to a paperless NHS by 2018.

We also have to face the reality that the NHS has often been too slow to adopt and spread innovation. Sometimes this is because the people buying healthcare have not had the information to see how much smart purchasing can help contain costs, so from next year CCGs will be asked to collect improved financial information, including per-patient costings.

The best way to encourage investment in innovation is a stable financial environment, so I can today announce that the Government, in collaboration with NHS England, will give local authorities and clinical commissioning groups indicative multiyear budgets as soon as possible after the next spending review. We expect that NHS England and Monitor will follow this by modernising the tariff to set multiyear prices and make the development of year-of-care funding packages easier.

The NHS also needs to be better at controlling costs in areas such as procurement, agency staff, the collection of fees from international visitors and reducing litigation and other costs associated with poor care. I have announced plans in all these areas and we will agree the precise level of savings to be achieved through consultation with NHS partner organisations over the next six months. That will lead to a compact signed up to by the department, its arm’s-length bodies and local NHS organisations, with agreed plans to eliminate waste and allow more resources to be directed to patient care.

The final pillar of our plan is the most important and difficult of all. We can find the money, we can support new models of care, and we can embrace innovation, but if we get the culture wrong, if we fail to nurture dignity, respect and compassionate care for every single NHS patient, we are betraying the values that underpin the work done every day by doctors and nurses throughout the NHS. We have made good progress since the Francis report, with a new CQC inspection regime, six hospitals being turned round after being put into special measures, 5,000 more nurses on our wards, the My NHS website and 4.2 million NHS patients being asked for the first time if they would recommend to others the care they received.

In the next few months, however, we will go further, announcing new measures to improve training in safety for new doctors and nurses, launching a national campaign to reduce sepsis and responding to recommendations made in the follow-up Francis report, tackling issues around whistleblowing and the ability to speak out easily about poor care.

Under this Government, the NHS has, according to the independent Commonwealth Fund, become the top-ranked healthcare system in the world. In 2010, we were seventh for patient-centred care, and we have now moved to top. Under this Government, we have also become the safest healthcare system in the world. But with an ageing population, we face huge challenges.

How we prepare the NHS and social care system to meet those challenges will be the litmus test of this Government’s ambition to make Britain the best country in the world to grow old in. We are determined to pass that test and today’s four-pillar plan will help us to do just that. Our plan will need proper funding, backed by a strong economy, so I welcome yesterday’s comment by Simon Stevens that when it comes to money,

‘the Government has played its part’.

However, we also need ambitious reforms to the way we deliver care, focusing on prevention, innovation and a patient-centred culture that treats every single person with dignity and respect—proper reforms not as a substitute for proper funding but as a condition of it, with a long-term plan for the economy and a long-term plan for the NHS. I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

My Lords, I normally thank the Opposition spokesmen for their comments, but that was an absurdly negative response, if I may say so. It does the noble Baroness no credit to do that amount of shroud-waving. She knows perfectly well that the case that she has put is grossly overegged. Yes, of course, the NHS is under pressure; we all know that. There is rising demand on a scale that we have never seen, but it ill befits the party opposite, which agrees that more money is needed for the NHS, to take issue with the money that we are announcing today. I would have hoped that she would have welcomed that, but she has not.

I shall answer the noble Baroness’s questions about where the money has come from. We never pretended that the whole £1.95 billion was new money. Some £550 million comes from reprioritised programme work that we have reallocated from the department; £150 comes, similarly from work that NHS England has reprioritised. So the Treasury is providing an additional £1 billion of funding; the department, as I say, is doing its bit; and the Treasury is also providing additional funding of £1 billion over the next four years, to support investment in out-of-hospital infrastructure and facilities. The £700 million that the Treasury is not providing as new money is made up of savings from a number of programmes which come to a natural end in 2014-15. There are back-office savings and there is contingency funding which is no longer needed. These savings have been found without impacting on existing front-line services, so this funding provides a genuinely additional boost to the NHS.

As for the Treasury’s new money, £1 billion from the forex fines will fund the £1 billion fund over four years to invest in out-of-hospital infrastructure, but the Government’s tight financial management has seen departments continue to exceed savings targets. Historical underspends have been quite considerable. The largest were generated by the Ministry of Defence, the Department for Education and the Department for International Development. These underspends demonstrate the Government’s firm grip of the public finances and continued improvements in spending control and financial management. They allow us to be confident in reallocating spending within the overall totals for 2015-16 to priorities in the health service.

The noble Baroness mentioned mental health. We remain committed to investing in mental health services. The Deputy Prime Minister will be making a full announcement soon, outlining how we will invest an additional £45 million on mental health services. As for the current year, to which she also referred, we have already made significant additional funding available for the NHS this year to support winter and system-resilience planning and to tackle long waits for operations. Robust plans are in place to maintain and improve NHS performance through the rest of this year and we are confident that the NHS will live within its budget this year.

The noble Baroness also mentioned social care and the pressures on those services. Through the better care fund we are moving to a position where we see health and social care no longer as separate budgets and services, but rather as the same thing—a position the patient and carer have been in for a number of years. Any investment in the NHS will provide benefit to social care and, as the Five Year Forward View sets out, the NHS will take decisive steps to break down the barriers in how care is provided between health and social care. This funding will help kick-start that.

As for the noble Baroness’s final barb about the Government’s reforms, I put it to her that the NHS is now set fair to work with the system that we have established. In other words, we have established a system that has health and well-being boards looking at the health priorities of a whole area, with clinicians embedded in that prioritisation process, commissioning for the health needs of an area, and public health centred on local authorities, which many regard as its natural home. We have clinical leadership in those clinical commissioning groups, something we did not have before these reforms, and we have saved a packet of money. The noble Baroness referred to the £3 billion cost of the reforms. That figure is fiction, as I am sure she knows because I have said it many times. The gross cost of the reforms was roughly £1.5 billion. During this Parliament, we will be saving, net, £4.9 billion as a result of the reforms, with £1.5 billion recurring year after year. This is a massive boost to front-line capacity in the NHS and nobody should forget that. This was a set of reforms designed to benefit patients and, by that measure, I put it to the House that it has succeeded in spades.

[Lord Willis of Knaresborough (LD)]

I thank my noble friend for repeating the Statement. I echo the point that, while many of us on all sides of the House may have disagreed with some of the structural changes in the Health and Social Care Act, the last thing the health service wants is another structural reorganisation. The plan by the party opposite to scrap the Health and Social Care Act is a real worry to many professionals. I say to my noble friend that no matter how much money the Chancellor promised today, it will not be enough to meet the demands of a changing healthcare system, where we are seeing, year on year, because of the success of the NHS, people living longer and with lots of different comorbidities.

I have a concern about the Statement. I actually think that Simon Stevens’s report is an excellent report and one that should have united this House rather than dividing us. After all, his pedigree comes from working with the Labour Party on the early reforms in the last Parliament. What really worries me is that neither in Simon Stevens’s report, nor in the Statement, is there a mention of the other crucial element, which is the workforce. The workforce and, indeed, the work of Health Education England, is not even worth a mention in the Statement—yet it is the 500,000 nurses and the 1.4 million care workers who bind the health and care system together and who will deliver the integrated health and social care which all of us in this House want to see.

Will my noble friend make it clear today that no savings will be made by reducing Health Education England’s budget? Will he state clearly that there will be investment in the skills of our staff in order that Simon Stevens’s plan actually works and that we can make it a realisation rather than a hope?

[Earl Howe]

My noble friend is absolutely right. One of the critical elements of the Five Year Forward View is to ensure that we have the right number of staff with the right qualifications in the right places. While Health Education England is the body charged with ensuring that that happens, it is up to us in government to ensure that there is adequate funding to enable it to do that. I can assure my noble friend that Ministers are very clear that Health Education England should be fully supported to deliver the programme that it has mapped out for itself. That programme is an exciting one. It involves more doctors and nurses in training over the next few years. Our ambition is to see by 2020 an extra 10,000 people working in primary care, for example—and that is only one detail.

As a result of the Government’s reforms to the health service, we have been able to afford a large number of extra posts in front-line care, including doctors and nurses in both primary and secondary care. We have done that by reducing the number of administrators in the system—20,000 fewer than there were in 2010. My noble friend is right to draw attention to this issue; it is one that is very much in our focus.

[Lord Liddle (Lab)]

My Lords, pursuing the point about the integration of health and social care—I declare an interest as a member of Cumbria County Council—we in Cumbria face a situation where already our budget has gone down by over £100 million, we face another £80-odd million of cuts in the next four years, and this does not take account of the cost of the tax reductions that the Conservative Party is promising. The numbers of staff will have declined by 2,500 from 2010 to 2017, out of a staff of about 8,000. In this situation, it is impossible to protect social care. It is interesting that the Government are promising a longer-term perspective on health funding. Does this perspective apply to social care funding as well? What guarantees are the Government able to give that they will continue to fund local councils adequately in order to meet the rapidly growing demands of social care?

[Earl Howe]

My Lords, the noble Lord makes a very good point. It is for precisely that reason that we have looked at the mechanism that we have called the Better Care Fund to bring together budgets for health and social care. It will amount in practice to a transfer of funding into social care from the NHS. We are clear that that is the best way in which we can realise the vision that we have set, which is a preventive one for people—in other words, to forestall admissions to hospital.

Local government is feeling the strain—I do not seek to deny that—but so are many other areas of our national life. Up to now, the Better Care Fund aside, we have found an extra £1.1 billion from the NHS budget to bolster local authority budgets, and we are maintaining public health allocations at the same figure as before, so no cuts there. I realise that the strains are considerable and that local authorities are having to find ingenious ways of moving forward, but I am encouraged by the Better Care Fund plans that are coming forward; they look credible and exciting in terms of the quality of care that local authorities are now looking at.

[Lord Walton of Detchant (CB)]

My Lords, it may be thought inappropriate that someone of my age should comment upon what is called a forward view but which is in fact a five-year plan. Having said that, I have listened carefully to the Statement repeated by the Minister with his characteristic lucidity and authority, and although I have heard many five-year plans discussed by Governments of all parties over the past 66 years since the NHS began, I think that there are features of this one that are quite important, not least the crucial importance of integration between medical and social care. Will the additional funding that the Minister announced be capable of introducing and maintaining a seven-day week in the NHS, in the community and in the hospitals, which has been long awaited? That is a very important point.

I welcome what the Minister said about developments in the training of healthcare professionals; that is a crucial point at this stage in NHS development. I also welcome what he said about developments in biomedicine. In what way are the Government going to be able to handle the many new orphan and ultra-orphan drugs that are now coming on stream for the treatment of rare diseases, as a result of research in the NHS, which are going to be extremely costly? Is this going to be handled by NICE or do the Government have any specific plans regarding that problem?

--- Later in debate ---

[Earl Howe]

My Lords, I thank the noble Lord, Lord Walton, for his welcome of the Statement and indeed of the Five Year Forward View, which I think commanded a great deal of support from many quarters. He asked about the seven-day working plans for the NHS. Part of the Better Care Fund plans involves local areas committing, in one form or another, to seven-day working. Unless we have seven-day working in hospitals, we cannot hope to achieve the smooth and timely discharge of patients. That means a change in approach by a number of professionals. It does not mean that every professional will need to work seven days a week—no one has ever suggested that—but it means a shift in approach by social services, and by consultants in hospitals, in a way that in some areas we have not seen. In other areas this is already happening, and we can build on those models.

On the noble Lord’s question on biomedicine and orphan drugs, he is of course as well informed as he always is on these matters. Orphan drugs, as and when they come forward, can indeed be expensive, particularly if they are termed a stratified medicine applicable to only a narrow cohort of patients. In those instances we will expect NICE to make an assessment of these high-cost, low-volume treatments under its new methodology for those drugs. NICE is already engaged in a number of work streams in those areas. It is right that we take that approach. We have to have some methodology that commands confidence, to ensure that the NHS receives treatments that are not only clinically effective but provide value for money.

[Lord Cormack (Con)]

My Lords, I thank the Minister and congratulate him on what he has said. However, does he not accept that at the end of five years, welcome though this new injection of money is, there will be even greater demands and greater needs? Will he reflect on the debate introduced last year by the noble Lord, Lord Patel, where almost every speaker from all sides of this House indicated that there is a need for a plurality of funding if our National Health Service is to avoid further problems and disasters? Will he therefore reflect on the wisdom of establishing, with all-party support, a royal commission on the funding of the NHS that can look at everything and rule nothing out? If we are to have a world-class service through this century, we cannot resort to sticking plasters from time to time; we must have a new model of funding.

[Earl Howe]

My Lords, my noble friend, as ever, has rightly identified the likelihood of greater and greater demands on our health service over the coming years. Certainly, building a non-partisan consensus is something to be desired regarding the way that we fund our health service. Having said that, I can tell my noble friend that there has been no thinking whatever on the part of Ministers to depart from the current model of funding for the NHS. We believe passionately that the NHS should be free at the point of use, regardless of ability to pay. That is one of the core principles on which the NHS has been founded since 1948 and it is paid for out of general taxation. While I take on board my noble friend’s desire to look afresh at this area, I think that we have some way to go before cross-party talks need to take place. We are clear that we can proceed on the current basis.

[Lord Davies of Stamford (Lab)]

The noble Earl has always taken a very serious attitude towards his ministerial responsibilities and he has just spoken about the desirability of moving to an all-party consensus on health matters. Does he not therefore rather regret, in retrospect, that the Government decided to spin this announcement, leaking it in advance of the Statement in the House of Commons and putting it about that there was £2 billion of new money for the NHS—the implication being that this was the result of more buoyant government revenues because of a higher growth rate? In fact, it is nothing of the kind as the noble Earl has now revealed to the House. It is roughly £1 billion being reallocated within the NHS budget and £1 billion being reallocated from other department budgets, including from defence where there has been underspend, which is very damaging to this country’s interest. Would it not have been better, and easier to develop a consensus in this country—to which the noble Earl quite rightly looks forward—if in fact the Government were slightly more straightforward and candid with the public over announcements of this kind?

[Earl Howe]

I do not think one can develop a consensus prior to a government Statement—that is probably wishing for the moon. The charge that the noble Lord levels against the Government is also, if I may say so, misplaced. We have never pretended that all the money being announced today is new money. I do not seek to suggest that, as I have already explained. As regards the timing, I think it is standard practice for key elements of the Autumn Statement to be trailed ahead of the formal announcement. However my right honourable friend the Chancellor will confirm everything we have said today in the Autumn Statement on Wednesday, and that is as it should be.

[Baroness Masham of Ilton (CB)]

My Lords, the Minister has not said anything about specialised units. I declare an interest as president of the Spinal Injuries Association. Spinal units are vitally important when patients need treatment, yet some spinal units have cut the services of physiotherapists and occupational therapists, who are vital for rehabilitation. The answer is always, “It is up to the trusts”. The trusts can be wrong and in this case they are. Can the Minister give an assurance that there will be enough trained doctors, nurses and therapists for the next five years in spinal units?

[Earl Howe]

My Lords, I will have to take advice about that question. What I can say is that we now have in place a system of workforce planning that is better than its predecessor. I do not think there can ever be such a thing as a perfect system of workforce planning. We now have a national body, Health Education England, that is responsible for making sure that we have adequate numbers of professionals with the right skills. However, we also have local education training boards whose members include representatives from the acute trusts. It is up to those boards to make clear what the requirements are for trained staff and feed those requirements up to Health Education England so that planning over the coming years can be done in a rational and sensible way. I would expect that spinal units should make their case in that fashion so that if there is a need for physiotherapists in spinal units, and those physios are—for any reason—not available, then they will come forward in adequate numbers in years to come.

[Lord Patel (CB)]

My Lords, the Minister started his Statement by saying that the Government recognise the importance of life sciences in both economic growth and in delivering mental health care. Of course, I would agree with that and I take it from the Statement that the Government therefore have no intention of cutting the budget of either clinical or medical research in the spending review to come. I welcome the suggestion that the Government will recruit more people to decode genetic information. Of course, we will need that if we are to develop better biomarkers or drugs for treatment, but the personalised medicine that would lead to is expensive and the budgets it will require will be far greater that what we have now.

I also welcome the idea that we integrate the care of patients and do not have a demarcation between primary care, community care and hospital care, but the model that he suggested might not quite do that. He might like to reassure us that the model he has in mind is of complete integration of care, otherwise we will not win the battle for better care for people suffering from long-term conditions.

The comment about future budgets requires a greater debate. I have read the review in detail and it is a bold statement to say we can conduct a five-year review of healthcare without any further restructuring. I, for one, do not mind some restructuring if it will lead to better delivery of healthcare.

[Earl Howe]

I think that the restructuring the Government believe is necessary is the restructuring of the delivery of care and the culture, as the Statement made clear. What we do not think necessary is a restructuring of the architecture of the National Health Service. That has been done and, as I have said, we are set fair for the future. As regards integration, will it be complete integration? “Integration” is a word that is bandied about and it will mean different things in different areas, depending on what is necessary. We are clear that the better care fund plans, for example, which focus on this idea of integration, should most definitely involve the acute sector and social care along with primary and community care, and in many cases other disciplines as well. Pharmacy, for example, has a major part to play in reducing unplanned hospital admissions and I could cite many other professional disciplines. It depends on what each area requires.

I cannot give an answer on the research budget in the next spending review because that spending review will be conducted by the next Government, whoever they will be. Meanwhile, we are clear that the research budget is an absolutely essential part of the NHS’s future ability to provide quality care for patients over the long term. As the noble Lord knows, we have protected that budget during this Parliament.

Nursing and Midwifery (Amendment) Order 2014

Earl Howe Excerpts

Thursday 27th November 2014 Grand Committee

Moved by

[Earl Howe]

That the Grand Committee do consider the Nursing and Midwifery (Amendment) Order 2014.

Relevant document: 9th Report from the Joint Committee on Statutory Instruments.

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

My Lords, the Government have identified improvements that can be made to the legislation within which the Nursing and Midwifery Council operates, to improve public protection and increase public confidence in the Nursing and Midwifery Council. Therefore, the department carried out a UK-wide consultation on proposed changes to the Nursing and Midwifery Order 2001, which is the Nursing and Midwifery Council’s governing legislative framework. The majority of respondents supported these amendments.

The first of the proposed changes is to enable the Nursing and Midwifery Council to appoint case examiners who will be given powers currently exercised by the investigating committee to consider allegations of impairment of fitness to practise, following an initial screening which has considered that an investigation is appropriate. Two case examiners—one lay and one registrant—will consider the allegation, following the procedure set out in amendments to the Nursing and Midwifery Council (Fitness to Practise) Rules, which are being developed in parallel to this order by the Nursing and Midwifery Council.

The case examiners will then agree their decision on whether or not the registrant has a case to answer—this is the same process used by General Medical Council case examiners—and whether the allegation should therefore be considered by the health committee or by the conduct and competence committee. If case examiners fail to agree on whether there is a case to answer, the allegation will be referred to the investigating committee for determination. The introduction of case examiners should lead to the swifter resolution of complaints and thereby improve public protection and the efficiency of the Nursing and Midwifery Council’s fitness to practise processes, as well as reducing the stress to registrants caused by lengthy investigations.

The second change is to introduce a power for the council to review “no case to answer” decisions made at the end of the investigation stage in fitness to practise cases, and to make rules in connection with the carrying out of such a review. This will bring the Nursing and Midwifery Council’s power in line with the General Medical Council’s power.

The third change is to introduce a power to allow the council to delegate this function to the registrar—the chief executive. The amendments to the fitness to practise rules being developed by the NMC will provide that the registrar may review a “no case to answer” decision where new evidence comes to light that has a material impact on the original decision or if it is considered that the decision may be materially flawed, and in both cases that it is in the public interest to review. Save in exceptional circumstances, a review of a “no case to answer” decision cannot be commenced more than one year after the date of that decision.

The fourth change is to revise requirements for the composition of the registration appeal panel by removing the requirements for a Nursing and Midwifery Council member to chair the panel, which is intended to establish a clear separation of duties between the operational and governance functions to avoid suggestions of perceived bias and conflict. Additionally, it will remove the requirement for a registered medical practitioner to be on the panel in cases where the health of the person bringing the appeal is an issue. It is intended that medical advice will be provided by independent medical witnesses and reports to ensure the panel remains detached from that part of the process, and therefore making the process more robust and transparent. This will also ensure more consistency between registration appeals and fitness to practise appeals.

The fifth element is to clarify existing legislation that the Nursing and Midwifery Council’s Health Committee or Conduct and Competence Committee has the power to make a strike-off order in a health or lack of competence case upon a review of a final suspension order or conditions of practice order, provided the registrant has been the subject of such a final order for at least two years. This is not a new power but provides clarification of the existing legislation to protect patients and the public by ensuring that those whose fitness to practise is impaired cannot continue to practise.

The sixth change is to introduce a power for the Nursing and Midwifery Council to disclose to a third party certain information relating to a person’s indemnity arrangements for the purpose of verifying that information for the Nursing and Midwifery Council’s purposes. This will enable the Nursing and Midwifery Council to verify the information it receives to ensure that indemnity arrangements are in place and provide sufficient cover against the liabilities that many be incurred by a practising nurse and practising midwife registrant.

The seventh change is to give the Investigating Committee a new power to also make an interim order after it has referred a case to the Health Committee or to the Conduct and Competence Committee if that committee has not begun its consideration of the case. At present, once the Investigating Committee refers a case, the power to make an interim order rests only with the Conduct and Competence Committee or the Health Committee. This will ensure that if new information is received which suggests that an interim order is necessary for the protection of the public after a case has been referred to another practice committee, but before the committee has started to consider it, the Investigating Committee will have the power to make an interim order.

The introduction of case examiners and the power to review “no case to answer” decisions, made at the end of the investigation stage in fitness to practise cases will bring the Nursing and Midwifery Council in line with the General Medical Council. The implementation of these recommendations requires a Section 60 Health Act 1999 order to amend the legislation governing the Nursing and Midwifery Council. I commend this order to the Committee, and I beg to move.

[Baroness Brinton (LD)]

My Lords, this amendment to the Nursing and Midwifery Order is to be welcomed. A regulatory body has to balance the respected traditions and structures of an informed 150 years of experience with the urgent needs of the current issues that the council faces when there may be rare problems with registered nurses and midwives. Much of what is proposed follows good practice. However, there is one area in which I have some minor queries and I wonder whether my noble friend the Minister can help.

The move away from independent consultants forming an investigation committee to having an in-house employed case examiner raises two minor concerns that are not reflected in the consultation response at paragraph 8.6 of the Explanatory Memorandum. Will the case examiners have extensive training in gathering the evidence that they will have to present to the quasi-judicial relevant committee considering each case? Will the benefits that other investigating groups such as Ofsted and local government inspectors have, given that at least one member of those teams comes in from outside, ensuring that there is always fresh challenge, be lost with this new arrangement?

Secondly, as employees of the council, will their job specification make it absolutely clear that they must conduct their role without fear or favour? It may be obvious when they are dealing with people outside the council but occasionally—very rarely—there may be a case where, for example, a decision not to have an interim suspension might have resulted in further injury or damage, and therefore members of the council themselves and other judgments might be being examined. The case examiners must be truly free to examine the council’s own processes and to feel no pressure from their own managers.

The no case to answer decision and the independent chair of the appeals panel are important and to be welcomed. However, given what I have just said about the case examiners, I find it slightly peculiar to remove the requirement for a registered medical practitioner to be on the panel, because that person in the past has provided that independent voice from the members of the council.

The points that I have raised are minor ones, and I welcome the order. However, I hope that I can have some reassurance on these points relating to the new role of case examiners.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, am very grateful to the noble Earl, Lord Howe, for explaining the details of the order so clearly. However, he did not mention the Law Commission proposals for legislative changes relating to all health regulatory bodies. I note that the Explanatory Memorandum says that the Government will publish a response in due course, but I have to say that there is huge disappointment among the regulators that no Bill appeared this Session—not even one for pre-legislative scrutiny. Essentially, we are now faced with a series of Section 60 orders dealing with the regulatory bodies in an individual and piecemeal way, without the consistency and modernisation of the regulatory landscape that was promised by the Law Commission work. I hope that the noble Earl will be able to say a little more about when the Government will publish their response to the Law Commission proposals and perhaps give a little more information about how he sees the pipeline for Section 60 orders coming forward.

In particular, he will know that, in relation to the NMC, part of the Law Commission proposals were that there would be a reduction in the number of public hearings that have to take place. That would reduce the cost to the NMC and the time it takes to deal with cases. Given that we are not having primary legislation, is it the Government’s intention to bring forward as quickly as possible a Section 60 order in relation to that? As far as the proposals in this order are concerned, they seem sensible and unexceptional. I hope that they will lead to the NMC being able to be more efficient in its processes.

Having read the consultation document, I would just like to raise a couple of points on it. First, I will follow up what the noble Baroness, Lady Brinton, said about case examiners. The consultation document refers to a small number of people who are unsure about this proposal. I am particularly worried that as case examiners will be employees of the NMC, they will be target driven rather than acting as independent professionals. The consultation response from the Government says this will not be the case. It states:

“Although employed by NMC, Case Examiners will be both registrant and lay (non-registrant) and experienced senior decision makers who are used to making independent decisions”.

I very much endorse the comments of the noble Baroness, Lady Brinton, on training and the need for people to be brought in to provide fresh challenges. However, this issue about targets is a very important one, and I wonder whether the noble Earl can give me a reassurance that there will not be targets—even unseen ones—in relation to cases and their outcomes. Can he just say a little more about how we can ensure that case examiners will be wholly protected when they carry out their duties? If they are in a managed organisation, they will be accountable to a manager, and we need to have some assurance that there is not going to be interference by the hierarchy of the NMC in case examiners’ decisions.

I would like to ask about another point raised in the consultation document. One response was about the need for more diversity on panels,

“in particular a point that black, minority and ethnic (BME) employees are disproportionally represented within the disciplinary systems of both employers and regulators”.

The consultation says:

“These comments have been fed back to the NMC to consider”.

Has the NMC now given consideration to that issue?

Turning to the Deregulation Bill, the noble Earl was present at our debate last week and will know that we have some concerns that, according to a list issued apparently by the Government, the Professional Standards Authority is subject to the economic growth duty within that Bill. I do not expect the noble Earl to answer me on that today. But, given that the Professional Standards Authority is to be involved, can I take it that by implication that duty will fall also to the NMC, the GMC and other professional regulatory bodies? Obviously, we will come back to this issue when the Deregulation Bill returns on Report but we are finding it difficult to find out the list of organisations that the Government consider should be encompassed within it.

Of course, the issue is that there may be an impediment to the non-economic regulators taking regulatory action because they now have to consider the economic growth duty. In the main, that will apply more to the CQC when dealing with organisations than it will to the individual regulatory bodies. But as the Government think that the PSA is encompassed within the Bill, I would be interested in a response from the Government.

Will the noble Earl say something about the overall performance of the NMC? He will know that this has been the subject of some concern and indeed scrutiny by the Health Select Committee. At the most recent accountability hearing in 2013, the Health Select Committee concluded:

“The NMC is an organisation with a recent history of poor performance, including lack of focus on its core regulatory activities, financial mismanagement and long delays in processing Fitness to Practise cases”.

The PSA’s 2013 performance review of the nine healthcare regulators it oversees, which was published in July this year, stated that the NMC,

“is not yet meeting eight of the 24 Standards of Good Regulation”.

I know that in the 2013 accountability hearing the Health Select Committee concluded that,

“the NMC has made progress”—

indeed, I pay tribute to the chief executive and the chairman, who have done a lot to ensure that this happens—but it also says that,

“more progress is required before the NMC can be regarded as an effective regulator”.

Would the noble Earl care to comment on that?

The Select Committee also looked at the issue of revalidation. Following the introduction of revalidation for doctors, the need for revalidation for nurses is self-evident. The Health Select Committee says that it welcomes,

“the commitment of the NMC to introduce revalidation for nurses and midwives from the end of 2015”,

but that,

“it does not believe the NMC yet has a workable plan to deliver this commitment”.

That is the 2013 report of the accountability hearing. The Select Committee has not yet had the 2014 hearing, which I think will take place in January. Will the noble Earl update the Committee on whether he now thinks that the NMC has a workable plan?

Overall, this is a sensible order. We need to do everything we can to help the NMC improve its processes. I express my thanks to the current leadership of the NMC and the work that it has done. It clearly needs to do more and Parliament needs to be prepared to help it. If we are not going to have a substantive Bill, I would have thought it a priority to bring further Section 60 orders in relation to the Nursing and Midwifery Council, particularly on the question of whether we can help it streamline its fitness to practise hearings.

[Earl Howe]

My Lords, I am grateful to my noble friend and the noble Lord, Lord Hunt, for their questions and comments. My noble friend Lady Brinton asked for reassurance about the case examiners. Under the proposals, the two case examiners will independently review the evidence and then agree their decision. This is the same process as used by GMC case examiners, and I am not aware of any particular difficulties that it has encountered in this connection. If the case examiners cannot agree the decision, the case will then be referred to the investigating committee for determination, as I explained.

My noble friend asked about training of the case examiners. Two case examiners, one lay and one registered nurse or midwife, will consider an allegation of impairment of fitness to practise, whereas three investigating committee members are required at present. Co-ordinating meetings of the investigating committee members is time-consuming due to panel members having other commitments or requiring refreshed training. A case examiner will be a skilled role. They will develop expertise that will lead to greater consistency when making decisions because they will be considering a greater number of cases on a regular basis than individual members of a large pool of investigating committee members. This will speed up the fitness-to-practise process and result in reduced costs.

My noble friend asked whether the job specification of case examiners, as employees of the council, must specify that they carry out their roles without fear or favour and be truly free to make comments. Case examiners will be employed by the NMC, whereas investigating committee members, who currently consider allegations of fitness to practise, are chosen from a pool of around 100 individuals who provide their services to the NMC as independent contractors. But, once again, there is no reason to suppose that, as professional people, they will feel inhibited from voicing their full and frank views whenever they feel the need to do so. Despite their being employees, it is more than any professional’s self-esteem is worth to feel inhibited in that sense. It is a very responsible role. While the individuals will need to be carefully chosen, I have confidence that this arrangement will work.

My noble friend asked about the removal of the requirement for a registered medical practitioner to form part of the panel where health is an issue. We consider it more appropriate for medical advice to be provided by independent expert witnesses and medical reports. Having an independent medical witness will ensure that the panel remains detached from that part of the process and is therefore more able to make an independent decision so making the process more robust and transparent. This would ensure consistency between registration appeals and fitness-to-practise appeals.

The noble Lord, Lord Hunt, expressed concern that case examiners might be target driven, and this was an issue raised in the consultation. We do not believe that this will be the case. Although they will be employed by the NMC, case examiners will be both registrant and lay; that is, a registrant nurse or midwife and a lay person. Their role will be distinct; they will be responsible only for making an assessment of whether a registrant has a case to answer against an allegation that is made to the NMC that their fitness to practise is impaired. They will make their decisions impartially and independently, and based solely on the information provided for the case, including any representations made by the registrant. Any such decision would be made by a pair of case examiners. The NMC will seek to appoint people to these roles who have demonstrated sufficient skills and experience to make robust decisions. The NMC’s case examiner resource will be sufficient to ensure that all decisions will be considered on their merits, without any undue time pressure. Case examiners will not be involved in undertaking the fitness to practise investigation itself, nor in presenting cases at any final hearing.

NHS: Health Improvements

Earl Howe Excerpts

Wednesday 26th November 2014 Grand Committee

[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.

Committee adjourned at 9.09 pm.

Mental Health Services

Earl Howe Excerpts

Wednesday 26th November 2014 Lords Chamber

[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?

[Earl Howe]

My Lords, both of those issues will be looked at by the task force. There have been concerns on both fronts that the noble Lord raises about access to services, and we are clear that the task force must come up with recommendations in those areas.

[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?

[Earl Howe]

There are concerns about the sufficiency of mental health nurses and professionals, particularly in certain areas of the country. Workforce issues therefore will be under the spotlight for the task force.

Care Sector

Earl Howe Excerpts

Tuesday 25th November 2014 Lords Chamber

[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?

--- Later in debate ---

[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

Monday 17th November 2014 Lords Chamber

[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?

[Earl Howe]

My Lords, I cannot speak for a party other than my own, but I can tell the noble Lord firmly that we are averse to any system of charging and wish to keep the NHS free at the point of use, regardless of ability to pay.

[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

Wednesday 5th November 2014 Lords Chamber

Moved by

[Earl Howe]

That the draft Regulations laid before the House on 7 July be approved.

Relevant documents: 6th Report from the Joint Committee on Statutory Instruments and 8th Report from the Secondary Legislation Scrutiny Committee

[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

Moved by

--- Later in debate ---

[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

Monday 3rd November 2014 Lords Chamber

[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.

[Earl Howe]

The noble Baroness is of course quite right. It is important to emphasise that part of the benefit of the seasonal flu vaccination campaign is to reduce the risk in adults and children of pneumococcal disease. That is another good reason to get the flu vaccination.

Health: Mental Health

Earl Howe Excerpts

Tuesday 28th October 2014 Lords Chamber

[Lord Dubs]

To ask Her Majesty’s Government what steps they are taking to reduce delays in the provision of mental health treatment.

[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.