Care Quality Commission (Reviews and Performance Assessments) Regulations 2014
Earl Howe Excerpts(10 years, 8 months ago)
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Baroness Barker
I thank the noble Baroness for that. I trust that if the CQC was doing its job, it would really go to the seat of power in a hospital and interview the porters.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this has been a useful debate. Although the Motion to Regret moved by the noble Lord, Lord Hunt, relates to regulations which, as he said, cover a certain area of the CQC’s activities, I note his broader questions and will come to those.
These regulations set out which health and adult social care providers will be rated following inspection by the Care Quality Commission. They came into force at the beginning of this month. However, it is clear that the noble Lord’s main concern is not so much about the regulations, although he did query aspects of them and I will address those in a second. I think—or, at least, I hope—that there is a good deal of agreement between us about the way in which the CQC now approaches its task of assessing service providers. The noble Lord’s concern lies largely around the accountability arrangements for commissioning. I will begin by setting out the purpose of the regulations and summarise the considerable progress that the CQC has made in inspecting and rating service providers.
Noble Lords will recall that the Care Act put in place a new system of reviews and performance assessments of providers to be developed by the CQC. The regulations referred to in the Motion specify which providers will be rated by it. They cover NHS hospital trusts and foundation trusts, general practices, independent hospitals and providers of adult social care. The CQC has set out its approach to inspection and ratings in a series of handbooks for each regulated sector. Each service is judged against a number of key questions: is it safe; is it caring; is it effective; is it responsive; and is it well-led? The CQC produces a rating against each of these areas at both location and provider level.
This new system is providing information about the quality of care that goes beyond mere compliance with minimum standards. This information is of value to patients and service users, to commissioners and, of course, to the providers themselves. The noble Lord, Lord Hunt, referred to the comments of the Nuffield Trust around hospital ratings and questioned how such ratings could be communicated to the public in an understandable way. We have committed the CQC to publishing clear, authoritative ratings of providers. Not only are these ratings broken down into the five key questions about services that I have just referred to, but the CQC has also published, where it has been possible, ratings of specific hospital services. The CQC is under an obligation to consult on the development of its ratings methodology. It has done so, and will continue to do so as its methodology grows more sophisticated over time. I completely take the point that ratings must be robust and stand up to scrutiny, but the CQC’s view is that it is more than possible to construct indicators that are genuinely representative of an organisation’s performance.
The CQC has made rapid progress on developing and implementing the ratings system. It has already published more than 130 ratings of NHS providers, and has recently published the first ratings of adult social care providers. Over the next few years, it will inspect and rate every provider that is covered by the regulations. Noble Lords will recall the debate we had last year on whether the CQC should also carry out routine inspections of commissioners. The CQC’s primary purpose is to regulate service providers and the Care Act clarified this by removing its power to carry out periodic reviews of commissioners of both health and adult social care.
Some providers argued that the system we were putting in place left them solely accountable for failings in care that could have some of their roots in commissioning decisions. I listened carefully to the comments of the noble Baroness, Lady Wall, and the noble Lord, Lord Hunt. I accept that there is a link between commissioning and quality of care and that, in some instances, it would be appropriate for the CQC to review commissioners. We have therefore maintained a power for the CQC to carry out special reviews of commissioners under Section 48 of the Health and Social Care Act 2008. However, this will be used only where there is clear evidence that failings in commissioning are leading to poor care for patients and service users and it is subject to the approval of the relevant Secretary of State. Let me be clear: where it is justified by the circumstances, the CQC will be able to inspect commissioning.
Although the CQC is not routinely reviewing commissioning, there are other arrangements for the oversight of commissioners. The noble Lord, Lord Hunt, asked me whether any special inspections of commissioners had happened yet. The answer to that is no in relation to local authorities’ commissioning of adult social care, but the CQC is undertaking a special review of children’s safeguarding in Doncaster. I understand that this review will look at both the provision of services and their commissioning by the local NHS. The review is due to be published in the coming months.
For adult social care, the Care Act puts in place clear duties on local authorities to have regard to the importance of ensuring the sustainability of the market as a whole in order to meet the care needs of local people. Last week, my department published statutory guidance for local authorities as part of a package of secondary legislation which implements the Care Act. This includes a chapter on commissioning and market shaping. Furthermore, the Local Government Association and the Association of Directors of Adult Social Services will shortly publish a set of new standards for commissioning services that has been produced with stakeholders. These standards will provide clarity on what good quality commissioning looks like. They will build on best practice and encourage councils to conduct more thorough self-audit and peer review in order to move towards excellence, covering, for example, commissioning for outcomes, integrated commissioning and workforce issues.
Where local authorities struggle to meet these commissioning standards, they are able to seek support through a system of sector-led improvement. Where a need has been identified, a variety of improvement support can be offered. This may include advice and visits from peers in high performing local authorities; mentoring and leadership training for councillors and officers; and bespoke support from national experts. This approach has been developed in partnership with local government partners in order to improve local authorities’ performance and capabilities. It supports local authorities to take responsibility for their own performance and drive improvement, developing a system of performance management by councils for councils. Sector-led improvement is based on the principles that councils are primarily accountable to their local communities; they are responsible for their own performance and improvement; and they have a collective responsibility for the performance of the sector as a whole.
Turning to commissioning of NHS services, NHS England is responsible for the performance management of clinical commissioning groups and has a statutory duty to carry out an annual performance assessment of each CCG. NHS England must be assured that commissioners are acting efficiently and effectively on behalf of local patients. Using the principles set out in the CCG assurance framework, NHS England supports and challenges CCGs to meet the needs of their local population. The assurance process is informed by robust and diverse sources of evidence, including the CCG outcomes indicator set and a detailed delivery dashboard.
Where concerns are identified, improvement actions are agreed. NHS England has broad powers to ensure that these improvements are made, whether this is through the provision of support and advice or by taking action when a CCG is at significant risk of failure. Examples of the support that can be made available are advice and expertise, facilitating peer review and partnership with other CCGs, or the brokering of conversations between CCG and providers by the area team.
The CCG assurance process has so far worked well. NHS England’s year-end CCG assurance assessment for the year 2013-14 showed that 210 out of 211 CCGs were assured, with 132 receiving some support to improve in particular domains of the assurance framework. An NHS England-commissioned survey of stakeholders, including local health and well-being boards, Healthwatch and patient groups, found that 68% had confidence in CCGs to commission high quality services.
The approach taken in this first year rightly focused on developing the capacity and capability of CCGs, as relatively young organisations, building on the domains which were the foundation of CCG authorisation. This focus on developing the organisational health of CCGs has meant that, as of July 2014, only 13 CCGs still have conditions or directions remaining in relation to their authorisation, compared with 153 CCGs initially authorised with conditions. In one case, a CCG was not assured and NHS England has put legal directions in place to improve its performance. As intervention is the element of the assurance framework which most affects CCG autonomy, careful consideration is, of course, required before NHS England will take this course of action.
Assurance ratings are based on the area team’s assessment of the level of the CCG’s insight of the identified issues and its willingness to take the necessary steps to improve. In cases where serious concerns arise, NHS England has shown that it will take necessary and appropriate intervention action. These legal interventions can take many forms, such as directing the CCG how to perform a certain function or asking another CCG to perform that function. They may even require the removal or replacement of the accountable officer or dissolution of a group.
Noble Lords may have seen recent reports of how NHS England is considering developing the CCG assurance framework to emphasise CCG achievement as well as capability. The detail of the assurance framework is, of course, a matter for NHS England but I am sure that noble Lords will be encouraged that NHS England is reflecting on how the assurance system can be improved. Ultimately, the Secretary of State is accountable to Parliament for the performance of the health system and will hold NHS England to account for how it has fulfilled its responsibilities, including how it has ensured that the health services which both it and CCGs commission are high quality and deliver value for money.
The noble Lord, Lord Hunt, asked about how NHS England is held to account by the department. The Secretary of State has formal accountability meetings with the chair and chief executive of NHS England every two months, which are structured around the mandate objectives and NHS England statutory duties. These are also attended by other NHS England board members, Ministers, the senior departmental sponsor and the Permanent Secretary. These meetings focus on strategic issues and any issues of delivery. Actions for NHS England are agreed in the meetings, recorded in the minutes and followed up in subsequent Secretary of State meetings. This process feeds into an annual assessment of NHS England by the Secretary of State. It is a legal requirement that this is laid before Parliament in response to NHS England’s annual report and covers NHS England’s performance in respect of mandate objectives and fulfilment of its statutory duties.
Meanwhile, NHS England is holding itself to account internally for its commissioning responsibilities. Just as there is a CCG assurance framework, a reciprocal direct commissioning assurance framework has been produced to demonstrate that NHS England is also exposing itself to similar scrutiny of its own commissioning responsibilities. NHS England has made a commitment to CCGs and wider stakeholders that it will apply the same level of scrutiny to its own direct commissioning responsibilities as it does to CCG commissioning. The assurance framework is used to identify concerns where the direct commissioning functions of area teams are particularly challenged. In these circumstances, the issues will be escalated through the line management arrangements in order to ensure that extra scrutiny or support is given as required. Ultimately, NHS England’s board will assure direct commissioning processes.
The noble Lord’s particular concern was around specialised commissioning and the overspend that we saw last year. In quarter 4 last year, NHS England forecast an overspend in specialised services of £172 million, an adverse variation to plan which was in excess of £291 million. Departmental analysis found that last year’s overspend in specialised services was due to a combination of factors, some historical and intrinsic, others unique to 2013-14. In April this year NHS England established a specialised commissioning task force in order to make some immediate improvements to the way in which it commissions specialised services and to put commissioning arrangements on a stronger footing for the longer term. The task force is led by Richard Jeavons, Director of Specialised Commissioning, NHS England. Additional resource from within NHS England has been diverted to the task force to ensure that it has the right mix of skills and expertise to enable it to meet its objectives. The task force comprises seven distinct work streams, which are focusing on financial control during the current year and planning for the 2015-16 commissioning round.
NHS England provides updates on the work of the task force to external and internal stakeholders every three to four weeks. There are also briefings given at key meetings and to key groups—for example, the Patient and Public Voice Assurance Group. Updates can be found on the NHS England website. NHS England describes its specialised commissioning task force work as a way to secure financial control in 2014-15 and to plan for 2015-16; it is not a wholesale review of specialised commissioning. The aim is to improve ways of working and to ensure that specialised commissioning is undertaken in the most efficient and effective way possible. The department is working closely with NHS England as it develops proposals for change. NHS England will continue to be held to account through the regular accountability meetings and the annual assessment that I have referred to.
Although these arrangements for the oversight of commissioning are new, I am confident that they are robust. The CQC’s new approach to inspection and the information that it provides about the quality of care through ratings is itself of use in commissioning, and where there is evidence that commissioning decisions are leading to poor care, it will, as I have said, be possible to escalate this to the CQC. I believe that these arrangements strike the right balance, allowing the CQC’s focus to remain on its core task of inspecting and regulating health and adult social care, but retaining an ability to look at commissioning issues when necessary.
Medical Innovation Bill [HL]
Earl Howe Excerpts(10 years, 8 months ago)
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Lord Turnberg
I accept entirely what my noble friend has said. The surgical aspects of the Bill are quite tricky.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this large group of amendments, all in their own separate ways, seek to ensure that patients are protected against negligent or irresponsible treatment. As we have heard, these amendments take many different approaches in seeking to achieve essentially the same goal. The Government are absolutely committed to safeguarding patients. That is why my right honourable friend the Secretary of State for Health asked Sir Bruce Keogh, the medical director of NHS England, to work with the medical profession to devise a package of amendments that would make this Bill safe for both patients and doctors. Like my noble friends Lord Kirkwood and Lord Cormack, I take this opportunity to commend my noble friend Lord Saatchi for listening to concerns and agreeing to table the amendments recommended by Sir Bruce Keogh in full.
I now address the amendments themselves. On Amendments 1, 7, 17 and 33, the Government do not feel that there is anything to be gained by restricting the scope of the Bill in the way proposed. To set out specific medical treatments or circumstances that would or would not be covered by the Bill would make it complicated for doctors to follow and less flexible to individual patients’ circumstances. That was well exemplified by the exchange that we have just heard. This might limit the Bill’s usefulness to patients and doctors alike. I say to the noble Lord, Lord Turnberg, that there is no question of the Bill applying to unregulated practitioners: it applies to doctors. In answer to the noble Baroness, Lady Wheeler, about what constitutes an appropriately qualified doctor, we believe that to define the required level of experience and expertise would create an overly burdensome requirement on doctors looking to innovate responsibly. A requirement that a doctor is appropriately qualified provides a sufficient safeguard to patients. New Clause 1(3)(b) requires the doctor to take full account of the views of an appropriately qualified doctor in a way in which a responsible doctor would be expected to do.
The provisions in Amendment 7 outlining the process that a doctor must follow to reach a responsible decision are largely addressed by my noble friend Lord Saatchi’s Amendment 12. The provisions in Amendment 7 which require doctors to consult a specified range of other doctors are too restrictive and would make the Bill complicated for doctors to follow. My noble friend’s amendment for doctors to take full account in a responsible way of the views of one or more appropriately qualified doctors in relation to the treatment is less burdensome and is a better equivalent to the existing law.
The noble Lord, Lord Pannick, raised concern that a responsible decision under the Bill is defined as relating to the process rather than the substance of the decision. I listened very carefully to that point. The steps that a doctor has to take under new Clause 1(3) include taking account of substantive factors as well as process. This includes taking full account in a responsible way of the views of one or more other doctors about the proposed treatment. In addition, the doctor must consider the risks and benefits of the proposed treatment as compared to other treatments and to not carrying out any treatments at all. This strays outside the realm of process.
The Government’s view is that it is not necessary in this Bill to require doctors to record their innovation in medical records as set out in Amendments 7 and 15. The General Medical Council’s Good Medical Practice guidance already sets out requirements on doctors to record their work clearly in clinical records, including clinical decisions made and discussions with patients. On Amendment 19 and the related Amendment 34, the Government believe that requiring doctors to record the results of innovative treatments in order to demonstrate that they have not been negligent is not the right approach. This is too bureaucratic and risks deterring doctors from innovating. As regards the idea put forward by the noble Lord, Lord Winston, that there should be some sort of oversight by a clinical or research ethics committee, that would add a very significant level of bureaucracy. Considering the time it would probably take to receive a response, it would act as a barrier to innovation. As the noble Lord knows, research ethics committees are specialists in considering research proposals and would not necessarily be qualified to comment on innovative clinical practice. They do not necessarily have universal coverage and they would not necessarily have the requisite knowledge to advise doctors on very specialised innovative new practices.
However, I have heard the legitimate concerns of noble Lords today, and I commit on behalf of the Government to explore this issue further and constructively with the relevant professional bodies. It will clearly be helpful to understand, should this Bill become law, what might be useful in terms of record keeping and reporting in relation to medical innovation. Furthermore, I commit to ensuring that any guidance that may be appropriate is developed and made available in a timely manner. I hope the intention to issue guidance will be of help to my noble friend Lord Kirkwood.
Amendments 12, 14, 18 and 21 seek to ensure that consent is sought and that proper consideration is given to the views of the patient. My noble friend Lord Saatchi’s Amendment 12 ensures that to fall within the Bill a doctor must obtain any consents required by law. This amendment also ensures sufficient protection for the views of the patient. Furthermore under the existing law of consent patients already have the right to information about the testing and treatment options available to them.
The noble Baroness, Lady Masham, posed questions about drugs. She asked me whether the NHS would pay for unapproved drugs or whether the patient would have to do so. It is worth noting that nothing in the Bill allows doctors to bypass any processes or requirements set by the trust that they are working for. This would include ensuring that the trust would fund any treatment if it were to be provided within the National Health Service. She was fearful that this could result in a two-tier health system in which a patient would be required to pay for innovative treatment. The Bill does nothing to alter funding arrangements for accessing innovative treatments within the NHS, as I have said. That will be governed by whatever rules apply in the trust concerned. However, the Bill also does not change the ability of patients to pay for private medical treatment, as they are able to do now.
Lord Turnberg
I am sorry to interrupt the Minister’s flow. Does he not think that that is confusing for doctors in an emergency situation, wondering which route to take and about the options at that stage, rather than just getting on with the job?
Earl Howe
Personally, no, I do not—although my noble friend may choose to address that point. I believe that what initially motivated my noble friend to introduce the Bill was a perception on his part that there are doctors out there who are afraid to innovate, and perhaps afraid to innovate even on the spur of the moment, for fear of being litigated against. If that situation were to apply, that doctor could regard the Bill as a useful way forward. I do not think that that poses any confusion, because my noble friend is proposing to bring the Bolam test forward, as he has clearly explained, so that the essence of the principle that the courts look at would apply in whichever course the doctor chose to take.
The noble Baroness, Lady Wheeler, made a point about conflict of interest. The Bill makes it clear that the doctor will be protected from a successful claim in negligence only where they have reached a responsible decision. That includes a requirement to consult with one or more appropriately qualified doctors. In choosing which doctors would be most appropriate to consult, a doctor would need to be confident that their views would enable him or her to reach a responsible decision in order to benefit from the protection offered by the Bill. Just to make the point absolutely clear, I say that the Bill does not change the law of consent in relation to children or people who lack capacity, whereby any treatment provided to them by a doctor must be in their best interests.
Amendment 10 would add a requirement on doctors to act in manner that is reasonable and proportionate. My noble friend Lord Saatchi’s Amendment 11 would ensure that a doctor must be acting responsibly in an objective sense when making a decision to depart from the existing range of accepted medical treatments for a condition. Under the law of negligence, “reasonable” and “responsible” have the same meaning. Therefore, the Government’s view is that Amendment 10 is unnecessary.
Amendment 24 would clarify that doctors would not have to follow the steps of the Bill in an emergency. My noble friend Lord Saatchi’s Amendment 29 ensures that it is for the innovating doctor to decide whether to take the steps set out in the Bill or to rely on the existing Bolam test, as I have just explained. There is no requirement to follow the Bill.
My noble friend’s package of amendments ensures that the Bill comes as close as possible to achieving the policy intent of bringing forward the Bolam test to before treatment is carried out. The amendments would do this in a non-bureaucratic way by avoiding the creation of new approval structures or alteration of the remit of existing groups such as multidisciplinary teams. They provide a critical safeguard in ensuring that there is both expert peer review of the doctor’s proposal and that the doctor acts responsibly. The Bill would not provide any protection to a doctor who carried out an operation or procedure negligently. The Government would not support any Bill that sought to prevent patients who receive negligent treatment from seeking compensation or which sought to remove the requirement of doctors to behave responsibility and in the best interests of their patient.
I will turn briefly to the questions put to me by my noble friend Lord Kirkwood. First, he asked me whether the Bill would apply to pharmacists who dispense medicines. The Bill applies to a decision by a doctor to innovate, which would include a decision to prescribe an innovative medicine. The Bill does not impact on the reliability of a pharmacist who provides a patient with a medicine in accordance with a doctor’s prescription.
My noble friend also asked whether the Bill would apply in Scotland. It would apply in England and Wales but not Scotland or Northern Ireland. Medical negligence law is within the legislative competence of Northern Ireland and Scotland, but not Wales. He also asked me whether there is a conflict between the Bill and the common law. Under both the Bill and the common law a doctor will not be negligent if they have acted responsibly. The Bill, so far as possible, brings forward the common-law Bolam test, as I have explained, to before the doctor offers treatment. There is therefore no conflict between the requirements under the Bill and the common law. The Bill simply offers doctors a way to demonstrate and be confident before providing treatment that they have acted responsibly and thus not negligently.
As regards the cost of implementing the Bill, which my noble friend also asked me about, my reply to him at this stage is that there is not sufficient evidence for us to arrive at a cost figure. The impact of the Bill is by its very nature hard to predict.
I hope that noble Lords will accept my noble friend’s package of amendments in this group—that is to say, Amendments 8, 9, 11, 12, 16, 20, 25, 26 and 27. It is the Government’s view, based on medical and legal advice, that together these amendments do all that is necessary to protect patients, while freeing doctors to innovate responsibly without undue bureaucratic burden.
Lord Saatchi
My Lords, I thank all noble Lords who have spoken on this group, which was initiated by the noble Lord, Lord Turnberg. Many interesting points have been made on ethics, law, science and medicine. I am sure that we will all agree that the Minister has dealt with them all admirably. He certainly put the points better than I could have myself, and I hope that he has covered most of what was said.
What can I add to what my noble friend has said? I do not want to descend into anecdotage, but if any noble Lord sensed a reluctance on my part in relation to these amendments, perhaps this will help. I was taught the importance of what the noble and learned Lord, Lord Mackay, and the noble Baroness, Lady O’Neill, said as regards trying to maintain the simplicity of the Bill in an exchange with the noble and learned Baroness, Lady Butler-Sloss. At an early stage Daniel Greenberg, the Parliamentary Counsel, who has been the draftsman of the Bill throughout, showed her the first or second draft and said, in effect, “What do you think?”. She replied, “Make it shorter”.
Over the course of the last two years we have tried very hard to keep the Bill in a state which I think the noble and learned Baroness and the noble and learned Lord, Lord Mackay, would approve of. I learnt from her that the courts want to have an Act of Parliament that is absolutely crystal clear in its intent, so that there is no doubt and confusion at all in the mind of the court about what Parliament intended with this or that clause, phrase or wording. We have tried very hard to do that. I reassure your Lordships that if that has in any way given the appearance of reluctance on my part, I am deeply apologetic.
I would certainly welcome following up the suggestion of the noble Baroness, Lady Wheeler, and those of many other noble Lords. The noble Lord, Lord Kirkwood, had an excellent wish list of following up Committee today—with your Lordships’ approval—with discussion between now and Report to see where we can get to. I am trying only to deliver to the noble and learned Baroness, Lady Butler-Sloss, and her fellow judges in the courts, an Act of Parliament that is simple, completely straightforward and totally clear, and which does what it is supposed to: provide clarity and certainty at the point of treatment both to the doctor and the patient. As noble Lords can see, I am resisting the enormous temptation to revert to a Second Reading speech, so I will now sit down, after a long group of amendments, so that we can go on to the next group.
Baroness Finlay of Llandaff
My Lords, I added my name to the amendment deleting “reckless” because I felt quite strongly that it detracted from the overall intention of the Bill. This is not about reckless innovation; it certainly must deter irresponsible innovation, but it is about encouraging responsible innovation. I also added my name to Amendment 3, on treatment for the “relevant conditions”, because many of these patients who are seriously ill will have multiple co-morbidities and may have many things happening to them. This Bill is aimed, as far as I have understood, at the principal condition—the condition for which patients are often desperate for some innovative treatment. It should not inadvertently allow lots of other strange things to be presented to patients to cope with many of the other co-morbidities that they may have.
My feeling about that comes particularly from my own specialty, which the House knows is palliative medicine, where we see time and again patients who are very emotionally vulnerable, psychologically fragile and potentially in despair, so they are unable to make sense of what is going on. In that state, they are quite vulnerable to people presenting all kinds of strange treatments with false claims. I will give a specific example from my own practice. We came across a group of patients on a ward who all had small crystals by their bed, and we discovered that a member of staff strongly believed that holding on to these crystals would shrink the patients’ cancers. The evidence for it was absolutely zilch; I think that the patients had paid to have the crystals given to them. That type of so-called experimentation is completely outside the scope of the Bill—and must be outside its scope. That is why it struck me that the wording about the relevant medical condition should feature in the Bill, because of the potential for exploitation otherwise.
Earl Howe
My Lords, this group of amendments seeks to alter the purpose clause of the Bill. Under the law of negligence, the words “reasonable” and “responsible” have the same meaning, as the noble Lord, Lord Pannick, reminded us. As such, the addition of “reasonable” is not necessary and risks creating confusion. Existing clinical negligence law commonly refers to a responsible body of professional opinion. The addition of “reasonable” may suggest that the test under this Bill differs from the existing Bolam test.
The noble Lord, Lord Pannick, asked me whether the Bill required a rational judgment of success. Proposed new subsection (3)(d) in Amendment 12 requires the doctor to consider a number of factors in relation to the proposed treatment. This includes a requirement to consider,
“the risks and benefits that are, or can reasonably be expected to be, associated with the proposed treatment”,
other accepted treatments, or,
“not carrying out any of those treatments”.
In weighing this up, the doctor must apply an objective standard as to what could reasonably be expected in relation to those treatments. This provides a further safeguard for patients in ensuring that a doctor may not offer an innovative treatment in accordance with the Bill unless he has acted in an objectively responsible way. I hope that that helps the noble Lord, Lord Pannick.
My noble friend’s Amendment 11 seeks to ensure that a doctor must be acting responsibly in an objective sense when deciding to depart from the existing range of accepted medical treatments.
On Amendment 3, the Government do not feel that there is anything to be gained by restricting the scope of the Bill in this way. To set out specific medical treatments or circumstances that would or would not be covered by the Bill would make the Bill complicated for doctors to follow and less flexible to individual patients’ circumstances. This might limit the Bill’s usefulness to patients and doctors alike.
On Amendments 4 and 5, the Government support the amendment to remove the reference to deterring “reckless irresponsible innovation” from the purpose clause. Recklessness has a very specific meaning in criminal law, and the term is out of place in a Bill about the law of negligence. Furthermore, the substantive provisions of the Bill focus on how a doctor can demonstrate that he has acted responsibly. This amendment therefore ensures that the purpose clause better reflects the focus of the Bill. I hope that noble Lords will accept Amendment 4, which brings clarity to the purpose of the Bill.
Lord Saatchi
My Lords, I thank my noble friend the Minister for what he said. I think that there is a consensus on Amendment 5 in my name, that of the noble Lord, Lord Turnberg, and that of the noble Baroness, Lady Finlay, to remove the word “reckless”. I think that we are agreed on that. My noble friend dealt with the point under Amendment 3 from the noble Baroness and the noble Lord. We understand the wish to exclude certain treatments and types of surgery, and perhaps that is something that we can discuss between now and Report.
I share the Minister’s wish to accept Amendment 4 from the noble Lord, Lord Pannick, which removes the reference to deterring quackery from the purpose clause. We are agreed on the view that, if the noble Lord, Lord Pannick, believes that it is important to confine the purpose clause to the positive, we should not insist on the inclusion of both limbs—positive and negative—since as a matter of law the negative flows naturally from the positive in any event. If the noble Lord, Lord Pannick, presses that amendment, I shall support it.
Baroness Butler-Sloss
It seems to me that if one is going to have Amendment 6, instead of saying that it “means”, it should say that it “includes”. That would then leave open everything else that might come in as medical innovation.
Earl Howe
This group of amendments seeks to define innovation and the scope of the Bill. This is a uniquely difficult task as innovation is, in essence, about constant improvement, change and progression. It is essential that in the act of defining we do not inadvertently limit responsible innovation. I ask the Committee to take on board the point neatly made by my noble and learned friend Lord Mackay.
Amendment 8 to Clause 1(2) in the name of my noble friend Lord Saatchi limits the scope of the Bill to situations where a doctor departs from,
“the existing range of accepted”,
medical treatments for a condition. This will be well understood by doctors, who are best placed to know whether they are following accepted treatments. This amendment also ensures that the Bill applies only to medical treatment.
A further provision, Clause 1(4)(a), ensures that the Bill applies not to research but only to the care of individuals. This exclusion of research is sufficient to achieve the same effect as Amendment 6 in the name of the noble Lord, Lord Winston. I hope that that clarifies that point for the noble Baroness, Lady Wheeler.
The Bill’s definition of innovation allows for situations in which doctors choose to carry out no treatment in the best interests of the patient. The definition of innovation in medical treatment proposed by the noble Lord, Lord Winston, would exclude that. I hope that that point, if no other, will give him pause when he decides what to do with Amendment 6.
There is another basic point to make here. Defining innovation on the face of the Bill would restrict the application of the Bill and could risk uncertainty for doctors as to whether the protection offered by the Bill would extend to the treatment that they are proposing. It is important that the scope of the Bill is clear to the medical profession.
Moving on to Amendment 28, the Government do not believe this to be necessary. The Government are already fully committed to promoting innovation which can save and improve lives. The Committee may be aware that NHS England has a full programme of initiatives to unblock innovation and disseminate the benefits to the NHS and beyond—something that the Government fully support. These include Innovation Connect, a programme to help innovators in the health service and industry to realise their ideas, embed them into clinical practice and exploit new opportunities in international markets, NHS innovation challenge prizes to encourage, recognise and reward front-line innovation and drive the spread and adoption of these innovations across the NHS, and the NICE Implementation Collaborative, which supports work streams by providing essential support to overcome identified barriers to innovation. Those are just some examples.
My noble friend Lord Blencathra asked in particular about off-label treatments. Without repeating the answer that I gave earlier to the noble Baroness, Lady Masham, on a similar issue, the Bill sets out a series of steps which doctors can choose to take when innovating to give them confidence that they have acted responsibly and with the intention of reducing the risk to doctors of successful claims of clinical negligence. With that threat diminished, the intended effect is that doctors will be confident to innovate appropriately and responsibly. That applies in full measure to off-label treatments. I would say as an aside that the cancer drugs fund, which has enabled access to a number of novel medicines, including off-label treatments, has benefited more than 55,000 patients since September 2010. So the decision on whether to prescribe unlicensed or off-label medicines will remain a matter for the doctor or prescriber who has clinical responsibility for the patient’s care, taking into account their individual clinical circumstances.
In response to the noble Baroness, Lady Masham, about funding, I should make the simple point that the Bill does not add any extra funding for drugs. Funding may be a consideration in certain circumstances, but the Bill does not affect the situation one way or the other.
I hope that noble Lords will take into account the Government’s view that innovation is best defined as a departure from the standard range of existing medical treatments, and that on reflection the Committee will not accept Amendments 6 and 28.
Lord Saatchi
My Lords, as we have just heard, Amendment 6 attempts to make a definition of “innovation”. I myself think that that is quite difficult to do, even though the noble Lords, Lord Pannick and Lord Winston, made it clear that they are trying to provide a definition in order to assist the purposes of the Bill. I find it difficult to do for the reasons given by my noble and learned friend Lord Mackay. The word is clear and the Minister has just defined it even more clearly, which is that innovation is a departure from the standard procedure. I am advised that that definition of the concept is sufficiently clear for doctors, patients and the courts to be able to judge in the light of the circumstances of each case. I am told that the proposed definition also refers to some procedures, so that the legislation may become outdated at some point.
The main point in plain English is that the noble Lord, Lord Winston, himself described innovation elsewhere as being serendipitous; in other words, the term has in it the concept that what is about to happen is unheard of and unknown, and therefore it is a true innovation because it has not been conceived of. It is quite difficult to make a definition, but perhaps that is something we can talk about with the noble Baroness, Lady Wheeler, when we meet before the Report stage.
I wish I could say something more encouraging to the noble Baroness, Lady Masham, about funding. Many people have said to me over the course of the long journey of this Bill that, “This is all very well, but what we actually need is more money. If we had more money, we could have more innovation for every disease”. I really do not know whether that is true because there are completely different views about it. However, the one thing that is certain is that this Bill, as my noble friend the Minister said, does not do anything to increase the UK GDP, nor does it increase the percentage of UK GDP that is spent on health, nor does it increase the percentage of UK health spending that is spent on innovation. As my noble friend has just said, it has no impact on what the noble Baroness is interested in hearing, which is on the subject of funding. It is completely neutral.
I will come to Amendment 28 in a moment. Perhaps at this point I could say that it is wonderful to hear my noble friend Lord Blencathra speak because we are hearing the true voice of the patient, as I understand it. We all say that what we do in this House and in the Department of Health is putting patients first. If that is what we are doing, your Lordships have just heard the true voice of the patient and nobody has ever expressed it better.
Baroness Wheeler
My Lords, we have had a very authoritative and detailed contribution on the issues raised by Amendment 29 from the noble Lord, Lord Saatchi. Opinion among noble Lords and indeed the stakeholder medical and patients’ organisations is still divided on: first, whether a change to the law is required or whether the existing law and professional ethics arrangements will allow responsible innovation; and secondly, whether the potential two options/processes—or three as my noble friend now makes it clear will be available if the Bill becomes law—will improve and speed up the administering of innovative treatments or will cause considerable confusion among doctors about which system they should use, lead to more bureaucracy and deter them from embarking on the course?
As we said earlier, we welcome the attempts of the noble Lord, Lord Saatchi, to ensure that with this amendment the Bill does not affect the common-law Bolam test. On the overall Bill he has led a powerful campaign and is reported to have won the support of patients responding to the consultation and the publicity from Cancer Research UK, Marie Curie Cancer Care and other patient organisations. I was pleased that the noble Baroness, Lady Masham, raised a number of questions from Marie Curie about palliative care and the use of drugs arising from issues in the Bill, and I was grateful for the Minister’s very helpful response.
The General Medical Council has now given its support to the amended Bill and the Medical Defence Union has said that the amendments cover the main objections to the previous Bill. However, we have to acknowledge that some key stakeholders maintain that the Bill is not necessary because the existing law already ensures protection for doctors to innovate, and the current law and ethical guidance from the General Medical Council are clear. The Royal College of Surgeons still has strong reservations about the Bill, particularly about it applying to surgery, as we have heard. The Medical Protection Society still believes that it confuses rather than clarifies the law. The Association of Personal Injury Lawyers says that the amendments make a confusing Bill even vaguer. The BMA still strongly questions the necessity and desirability of clarifying or changing the law. Action Against Medical Accidents, one of the leading patient organisations, still says that the Bill is fraught with unintended and dangerous consequences and will create a more bureaucratic system. Sir Robert Francis QC, while considering that the amendments have produced an improvement in safeguards over what was originally proposed, has said that serious problems remain. In particular, he is concerned, as my noble friend Lord Turnberg pointed out earlier, that the Bolam amendment, while restoring a level of safeguard, also has the disadvantage of restating Bolam in different language, leading to a real risk of confusion. His question is: why not just stick to Bolam? I would be grateful for the noble Lord’s comments on that.
Will the noble Lord, Lord Saatchi, and the Minister tell the Committee whether they consider that the amended Bill now meets Dr Dan Poulter’s key test that I referred to earlier; namely, of not placing an undue bureaucratic burden on the NHS or not exposing doctors to a risk of additional liabilities?
I welcome the response of the noble Lord, Lord Saatchi, on the question of convening a round table, which I think will be a very helpful way of going forward. Obviously, it will never be possible to satisfy everybody’s concerns but, if the Bill is to be further supported, what steps will be taken by the Government to engage with stakeholder concerns?
Earl Howe
My Lords, the Government support these two amendments, which ensure that the Bolam test will remain unaffected by the Bill. In practice, this will mean that it is for the innovating doctor to decide whether to take the steps set out under the Bill or to rely on the existing Bolam test. In other words, there would be no requirement for doctors to follow the Bill when innovating.
The amendments clarify that, separate to the existing Bolam test which is applied by the courts, the Bill provides doctors with an alternative option for showing that they are acting or have acted responsibly. Furthermore, subsection (2)(b) of the proposed new clause provides that doctors are not negligent, and thus will not be judged adversely if their actions are later challenged, merely because they have not followed the Bill.
My noble friend Lord Kirkwood asked how the proposed new clause affects how a regulator approaches a complaint or fitness-to-practise procedures. This Bill addresses clinical negligence law and how the courts will assess these cases, not how the regulators will process fitness-to-practise cases.
The noble Baroness, Lady Wheeler, asked whether the Bill was necessary. The Department of Health’s consultation on the Bill revealed that some doctors find the threat of litigation to be a block to innovation, although this view was not universally held. The Bill is aimed at reassuring those doctors who feel unable to innovate due to concerns about litigation. There will also be many doctors who are not afraid to innovate and for whom litigation is not a material concern. Those doctors can continue to act as they have done previously and rely on the existing law of clinical negligence, or, as I have explained, they may choose to take advantage of the Bill instead.
I hope that noble Lords will accept these two amendments, which give flexibility and choice to doctors who want to innovate.
Lord Winston
There is something troubling me here. Let us say that somebody in an emergency or other situation does not have a chance to go through the required tests stipulated by the Bill, consulting other individuals who may be confident about or more experienced in that position. I still do not understand in the context of what the Minister has just said where that individual stands in innovating without those permissions. Is that still part of the Bill? How does that work? Is there a risk of that person being irresponsible in view of his not fulfilling what is required in the Bill when he is innovating?
Lord Woolf (CB)
My Lords, before the Minister replies, perhaps I could just make a comment. I have resisted getting involved in the various excellent speeches that have been made so far. While I am on my feet, I make it clear that I strongly support the noble and learned Lord, Lord Mackay. There is a danger in looking at these as alternatives. If the matter comes before the court—of course, one hopes that it will not—the court’s approach would be to say that there is nothing in the Bill, because of the amendment we are now considering, which prevents the Bolam test being relied upon as it is today, without the Bill.
On the other hand, if the situation is one that enables the Bill to be relied on, that is another matter that the person can rely on. In some situations, such as a state of emergency, it may not be possible to rely on the Bill, but that does not prejudice the doctor involved in any way, because the Bill leaves the Bolam test intact. It is supplementing the Bolam test, and the importance of the fact that it is supplementing it is apparent in the fact that it states that if the doctor can comply with the Bill, he knows that he is safe and does not have to wait until the Bolam test has been applied to find out whether he is in danger. I think that that is understood. Does the Minister agree with my approach, which is that these are not alternatives?
Earl Howe
I completely agree with the noble and learned Lord’s analysis of the situation. I hope that that has been helpful to the noble Lord, Lord Winston. Earlier, the noble Lord cited an example where a doctor was confronted by an emergency requiring innovative practice. Whether the doctor was acting responsibly or not, and the consequences, will depend on a number of factors. It will depend on the extent to which the doctor is confident in his or her judgment, based on experience in previous clinical practice and can, if necessary, show to a court that what he or she did was responsible and, at least in intent, in the best interests of the patient.
The noble Lord asked whether there was a risk of a doctor being found to be irresponsible in some emergency situations where innovative treatment is practised. Yes, there would be a risk if the process outlined in the Bill were not followed—but that situation obtains today.
Lord Winston
Both the Royal College of Surgeons of Edinburgh, of which I am a fellow, and the Royal College of Surgeons in London, absolutely support the idea that surgery should be excluded from the Bill for this very reason: they consider that there might be situations where the courts become unnecessarily involved. That involves extra expenses to the health service because of our current concern with litigation. As the noble Earl well knows, in obstetrics, for example, litigation already accounts for a huge proportion of the expenses devoted to maternal care. There are considerable knock-on effects where litigation may be started because of lack of clarity. It is possible that I am being stupid—I recognise that I am not nearly as intelligent as the noble and learned Lord, Lord Woolf—and I will have to go away to think about this, but there seems to me to be a misconstruction here which is puzzling and, I think, worrying.
Baroness Gardner of Parkes
Can I seek some clarification? I wonder whether anyone could make clear for the Committee whether, if the doctor says that he does not want to do the innovative treatment, there is a defence in court on the grounds that he thought that it would be unwise or unsatisfactory. I say this because everyone seems concerned about the effect of not doing something innovatory.
Earl Howe
My Lords, the Government’s view is that it is not necessary to include in the Bill a provision for the Secretary of State to issue codes of practice about the Bill, but I hope that I can reassure the noble Lord, Lord Hunt, on the last point that he made. If the Bill is passed, the Government will work closely with the professional bodies, including the General Medical Council, to help doctors to prepare for the changes to the law. This will include producing any guidance that may be helpful.
I listened carefully to the points that the noble Lord made about the adoption of innovative treatments in the National Health Service. He knows from his experience as a Minister that this issue has been with us for quite a long time. We have silos of innovation and forward-thinking practice throughout the health service. The challenge has been to spread that innovative behaviour more widely and for the diffusion of innovative treatments to become second nature to the health service. It is a cultural issue.
The noble Lord is right to say that in many cases the non-adoption of NICE-approved drugs is a particular feature in parts of the NHS. That is exactly why the document Innovation, Health and Wealth was published some time ago. It is why we now have the NICE implementation collaborative, which is designed to bring together the key players in the system to ensure that NICE-approved medicines are adopted. There is the innovation score card, which helps in this regard. The academic health science networks are there to shine a spotlight on promising new innovative devices and medicines and to spread them at pace and scale throughout the health service. The early access to medicines scheme is another example of where we are trying to give patients access to innovative treatments, even before they have been licensed.
There is on occasion a good reason why a NICE-approved medicine may not be adopted by a particular trust. That is quite simply that for a given condition there are many alternative treatments, many of which have been endorsed by NICE. The Government cannot mandate clinical decision-making by individual doctors. Where there is a choice between one and another NICE-approved medicine available to a doctor, it is open to the doctor to make that choice. Nevertheless, the noble Lord’s basic point is well made and I hope that he will accept that the Government are taking a number of measures in conjunction with NHS England to ameliorate the situation.
I hope that, with the remarks that I made earlier about producing guidance, the noble Lord will be reassured and the noble Lord, Lord Turnberg, will not press his amendment.
Lord Saatchi
My Lords, perhaps we could add this point to the discussions that we are going to have before Report. My noble friend the Minister expresses a modest view of what the Government should and should not do and wants to leave it to the regulatory bodies to make this happen.
I refer once again to anecdote. The noble Lord, Lord Turnberg, said to me at an early stage in this process, in which he has been a great inspiration, “What are you going to do after the Bill becomes law?”. I said, “I am going to go on a very long vacation”. He said, “Oh no you’re not”. I said, “Why not?”. He said, “Your work is only just beginning”. His point, and he speaks as an expert, is that a culture change is contained in this Bill. “Culture change” is a phrase that my noble friend just used, and it was used by Dame Sally Davies, the Chief Medical Officer, many months ago. A culture change is being sought, but it will not happen overnight. It will follow, exactly as the noble Lord, Lord Hunt, says, a great deal of education and discussion in the medical profession.
Not to go on, but the noble Lord, Lord Turnberg, said that this will fall largely not just on the regulatory bodies, such as the GMC and NICE, but on the royal colleges. They will have to be involved in the process of educating people about what this means. This is the beginning of the process and I am rather with my noble friend in not wanting to have the Government set out the rules. I hope that that is acceptable to the noble Lord, Lord Hunt.
Lord Turnberg
My Amendment 36 has a similar effect to that of Amendment 35. Mine seems somewhat simpler, but I am quite happy to bow to Amendment 35 in the name of the noble Lord, Lord Saatchi.
Earl Howe
My Lords, this group of amendments addresses how the Bill would come into force. My noble friend Lord Saatchi’s Amendment 35 would ensure that the Bill came into force in accordance with regulations made by the Secretary of State rather than on Royal Assent as under the Bill as introduced. This would allow the Government and the medical profession time to prepare for the changes to the law made by the Bill—for example, to produce any guidance that might be helpful. This amendment also enables transitional and saving provision to be made if necessary. My noble friend’s Amendment 35 achieves the same objective as Amendment 36, which the Government therefore do not consider necessary.
The Government also support minor technical Amendments 37 and 38, which clarify that the section in question comes into force on the day on which the Act is passed. I urge noble Lords to accept Amendments 35, 37 and 38, which would ensure a smooth commencement of the Bill, and I hope that my noble friend Lord Kirkwood will allow me to write to him on the question that he posed a minute ago.
Baroness Finlay of Llandaff
My Lords, I will be brief; this will probably turn out to be a probing amendment. We have an interesting situation in Wales because health and healthcare provision is completely devolved. The experience of patients under the Welsh NHS falls completely within the legislative competence of the Assembly. However, if I am right, this relates to the law of negligence, and the Ministry of Justice does not have any devolved functions. The concern expressed to me within Wales has been about the use of resources and the possibility of practitioners being answerable as regards legislation that covers England and Wales, when the provision of healthcare is something for which they are answerable to the National Assembly. I tabled this amendment with a view to seeking clarification over that.
Sadly, we have had experience of extremely strange medical practices sometimes being put forward in the past. The Assembly is particularly concerned that, with its move toward prudent healthcare, which is a whole policy direction for NHS Wales, the Bill should not inadvertently cut across the principles of prudent healthcare, the first of which is, of course, to do no harm. I tabled the amendment with that in mind.
Earl Howe
My Lords, this amendment seeks to ensure the Bill would not apply in Wales unless a legislative consent Motion had been passed. The operative provisions of the Bill relate entirely to modifying the law of tort, which is a reserved matter. The Bill can fairly and realistically be classified as relating to a non-devolved subject, and therefore not within the competence of the National Assembly for Wales. The Government cannot accept this amendment, and I urge noble Lords to resist it.
Baroness Finlay of Llandaff
I am grateful to the Minister for the clarification. I expected that answer, but it is important to have it on the record. I beg leave to withdraw the amendment.
NHS: Five Year Forward View
Earl Howe Excerpts(10 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I shall now repeat in the form of a Statement the Answer given by my right honourable friend the Secretary of State for Health to an Urgent Question earlier this morning in another place. The Statement is as follows.
“NHS England, along with other NHS organisations, has today published its independent Five Year Forward View, which sets out its view of how the health service needs to change over the coming years.
It is a report that recognises the real challenges facing the NHS but is essentially positive and optimistic. It says that continuing with a comprehensive tax-funded NHS is intrinsically doable, and that there are,
‘viable options for sustaining and improving the NHS over the next five years’.
The report says that the challenges of an ageing population can be met by a combination of increased real-terms funding, efficiencies and changing the models of care delivered. It also says that,
‘decisions on these options will need to be taken in the context of how the UK economy overall is performing’.
In other words, a strong NHS needs a strong economy.
The report suggests detailed new models of care, putting out-of-hospital services front and centre of the solution, delivered through greater integration between primary, community and specialised tertiary sectors alongside national urgent and emergency networks. These can help reduce demand significantly for hospital services and give older people in particular the personal care that we would all want for our own parents and grandparents. It talks about continued opportunities for efficiency savings driven by innovation and new technology, and suggests that they could be increased above the long-term run rate of efficiency savings in the NHS. It talks about reducing variation in the quality of care in the wake of the tragedy in Mid Staffs and how the new CQC inspection regime is designed to drive up standards across the system. It says that to do this we will need to move to much greater transparency in outcomes across the health and social care system. Finally, it makes important points about better integrating the public health agenda into broader NHS activity, with a particular focus on continued reductions in smoking and obesity rates.
The Government warmly welcome this report as a good blueprint for the direction of travel needed for the NHS. We will be responding to its contents in detail in due course but we think it is an important contribution to the debate. We are proud of how the NHS has coped with the pressures of financial constraint and an ageing population in the last four years, but we also know that to sustain the levels of service people want it needs to face up to change: not structural change, but a change in culture about the way we care for people.
Given that the report has been welcomed by all sides of the House, I also hope that this can be the start of a more measured and intelligent debate about the future of the NHS, where all sides of the House recognise our shared commitment to its future and focus on the best way to achieve the strong and successful NHS the whole country desires”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord for his welcome of the report which I am sure is shared by all noble Lords. It is, as the Statement says, a very useful set of conclusions jointly reached by the leaders of our health service and their partners. The noble Lord is right to say that there are common areas of agreement between the Government’s view of how we should move forward in the NHS and the view of the Official Opposition. I refer in particular to the role of integration, not only integration between health and social care, but also between hospital care and out-of-hospital care and between public health and health services. The report endorses the direction of travel that the Government are already taking in initiatives such as the Better Care Fund.
I turn now to the noble Lord’s specific questions. On GPs, we are not of the same mind as regards making GPs salaried employees of the health service. The independent practitioner model has served the country well and we do not think that there is any appetite in the general practitioner community to move in the direction that the party opposite would like. However, I certainly agree that there is a powerful role for health and well-being boards to play, and in many areas they are already doing so by bringing together the key players in a local area to decide on the health priorities of that area and to work out the right strategies to meet them.
On public health, as the Five Year Forward View emphasises, obesity is one of our major public health challenges and will continue to be so. I do not agree that the responsibility deal has been inadequate. It is only a part of a menu of options which the Government have available. We have seen major advances resulting from the responsibility deal and we should not throw those away. It means bringing business along willingly with us: business with its power and reach which goes far beyond that of the Government to influence consumer behaviour.
On GP services, I agree that many GP practices are under strain, but our vision and, I am pleased to say, the vision in this report, really centres around remodelling primary care in the round so that GPs consider themselves part of a wider primary and community care team. Yes, we need more GPs, and we have undertaken to ensure that the NHS has at least 5,000 more by 2020, but more broadly we should look at the multidisciplinary mix of those teams and expand nurse numbers and allied health professional numbers to supplement the work that GPs do.
On parity of esteem, we shall have a useful Oral Question next week which will give us a short opportunity to debate it. As I am sure the noble Lord is aware, a lot of work is going on to make parity of esteem a reality, including for the very first time defining waiting times for mental health patients and ensuring that mental and physical health are looked at on a par by both commissioners and providers.
Lord Fowler (Con)
My Lords, the strategy seems to be very sensible, but I hope that not only the Government but also all the parties will do what the chief executive of the National Health Service said on the radio this morning and recognise that there is no appetite inside the health service for any further top-down reorganisation. Will they also recognise that we need to put much more emphasis on preventing ill health? Pharmacists, who are highly qualified and well trained, should have a much bigger role to play, which would reduce the present burden on general practitioners.
Earl Howe
My noble friend is absolutely right in what he says. The report lays great emphasis on the prevention agenda, not only through the work done in the public health arena by Public Health England and local authorities, but also through secondary prevention by the NHS itself: preventing the need for people to enter hospital in the first place. I fully agree with my noble friend about the potential role of pharmacists. Actually, that role has been enlarged over the past few years in an encouraging way with such things as medicines use reviews and the Healthy Living Pharmacy agenda. We want to go further and pharmacists are keen that we should do so.
Lord Kakkar (CB)
My Lords, I declare my interest as chairman of University College London Partners. This ambitious programme will require very strong leadership. What arrangements are going to be put in place to develop strong clinical leaders across the different sectors and environments of the health delivery system that will be required to ensure that this become reality?
Earl Howe
One of the great features of the Government’s reforms is to put clinical leaders in charge of designing the way that care is delivered throughout the country. That point is often overlooked. It is, of course, the quality of that leadership that we should focus on. That quality is variable and why NHS England, Health Education England and partners in the system are looking as carefully as they can at how to improve that quality of leadership. I direct the noble Lord’s attention to certain passages in the Forward View, which talk about the need for all the bodies in the system to work together: NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Health Education England, NICE, Public Health England—all working together to achieve greater alignment and greater common purpose in the way that these proposals are implemented.
Baroness Blackstone (Lab)
My Lords, on the subject of the prevention of obesity, can the Minister say what steps the Government are taking to introduce a tougher regulatory environment for food companies whose products are damaging the health of many thousands of people in this country?
Earl Howe
Many food companies—not all, but many of the larger ones—have already taken steps, for example, to reduce the levels of salt and saturated fat in their products. We need to go further. This has been done by the previous Administration and the current Government on a voluntary basis. We think that that has worked well. Nevertheless, we have never excluded the possibility of regulation, where we think that it is justified. At present, we believe that there is sufficient scope to make progress without regulation, but that is a matter we will keep under review.
Baroness Brinton (LD)
My Lords, from the Liberal Democrat Benches, we also welcome the five-year report, particularly because it accepts that the business-as-usual model needs to move on. In particular, we welcome the public health aspects and the fact that strong democratic accountability with councillors and local authorities is providing substantial change in public health. Does the Minister agree with the report that there should be more enhanced powers for local authorities to develop this further? If so, can he guarantee that there will be cross-departmental discussions to make sure that there are more responsibilities, powers and funding?
Earl Howe
My noble friend has alighted on an area to which the whole Government will have to give very careful thought. It is not simply a matter for my department. This will entail cross-departmental scrutiny and agreement. However, on the strength of the performance of local authorities in grasping the public health agenda, as they have very enthusiastically, I am sure that we should look at that particular proposal very constructively.
Baroness Hanham (Con)
My Lords, as chairman of Monitor, which is one of the signatories and contributors to this document, may I ask the Minister to confirm further that the Government will not see any wholesale managerial reorganisation in the health service, which is not what the document is looking for, but that they will see change coming about in the way that services are developed? Will they ensure that services will not all be developed in the same way, but that there will be local elements? Will they also support initiatives to help the organisations make this a realisable objective within five years?
Earl Howe
I agree with my noble friend. We neither want nor need further structural reorganisation; but we do need cultural reorganisation. I also agree that a one-size-fits-all model will not work: indeed, the Forward View expressly states that. We need to allow local areas to work through the solutions that are best for them. That can be done on a collaborative basis, with the benefit of health and well-being boards, which are now working so well in many areas.
NHS: Health and Social Care Act 2012 Reforms
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this Government have taken tough decisions to increase the NHS budget by £12.7 billion between 2010-11 and 2014-15. During this period, the Government’s NHS reforms will enable total administration costs to reduce by one-third in real terms, to release funding to NHS front-line services. Already, savings arising from the reforms released £1.5 billion last year and £1 billion in 2012-13 to front-line services.
Lord Brooke of Alverthorpe (Lab)
My Lords, did the Minister read, as I did, the headline “NHS reforms our worst mistake, Tories admit” in the Times last week? This was part of a devastating series of articles analysing what had happened to the 2012 reforms, along with the costs which had accrued or the savings which had failed to be achieved but could have been if the Government had not been diverted by the reforms. Who will be held responsible for this devastating and monumental failure in policy? It has been very costly to the country, especially at a time of austerity.
Earl Howe
First, let me make it clear that the Government have no regrets whatever about the NHS reforms. These reforms enabled massive savings to be made, all of which have been ploughed into the front line. Without investment in the cost of the reforms—which I concede were considerable—we would not have been able to realise these savings, nor would the NHS have been able to plough those savings back into the front line. This has enabled us to employ more than 7,700 extra doctors, and the NHS is now performing more than 850,000 more operations every year. That is the benefit of the reforms.
Lord Patel of Bradford (Lab)
My Lords, if there is so much investment being put into the NHS, as the Minister said, why are mental health services being cut across the country and especially in the north of England? In my own city of Bradford, our mental health care service has been cut by 23%. How do we expect mental health care to have parity of esteem when it is experiencing these kinds of cuts?
Earl Howe
The noble Lord raises a very important issue, which results from the fact that commissioning decisions are taken not by the Government but by clinical commissioners across the service. We are very concerned by the reports of lower resources being channelled into mental health services. A lot of work is going on, in my department and in NHS England, to make sure that those services—and, crucially, the outcomes from those services—are maintained.
Baroness Masham of Ilton (CB)
My Lords, how much was paid out in redundancy to health service staff who lost their jobs and were then taken on again? Is the Minister aware that emergency medicine and accident and emergency departments are really overstretched?
Earl Howe
The noble Baroness asks two questions. We had to abide by the terms of the contracts of employment which were put in place by the previous Administration. In some cases, people were made redundant and were then re-employed by the health service at a later date. No one can take satisfaction from that, which is why we are completely revisiting the terms of those contracts. As regards accident and emergency departments, we know that the NHS is under pressure, but there are now more accident and emergency doctors than there were in 2010. The work being done by Sir Bruce Keogh to look at the system across the piece will, we trust, address a number of the pressures that the NHS is now experiencing.
Baroness Barker (LD)
The Minister will know that health commentators usually assess the annual increase in health spending at 4%. In view of that, does he agree that the sustainability of the NHS rests largely on its integration with social care? Does the Minister also agree that this issue should be addressed in the forthcoming Autumn Statement?
Earl Howe
I agree with my noble friend that the integration of health and social care services has a major part to play in making the system more efficient across the piece and more effective for the patient. That is why we are introducing the better care fund, which, at a local level, will channel at least £3.8 billion into pooled budgets to deliver that integration.
Lord Harris of Haringey (Lab)
My Lords, if the system is quite as wonderful as the noble Earl suggests, will he explain why so many people are waiting so much longer in accident and emergency departments and why so many young doctors completing their GP training decide to leave the country and practise overseas rather than participate in the grotesque mess that this Government have produced?
Earl Howe
I take issue with the phrase “grotesque mess”. If the noble Lord cares to look at the figures, he will see that waiting times are low and stable, MRSA and C. diff infections are at record lows, mixed-sex wards are down by 98% and the number of people waiting a long time for treatment is massively reduced. Yes, we know that many A&E departments are under pressure but many are coping. The work that we are doing, including channelling more money into the system for this winter, should, we hope, relieve the worst of the problems.
Lord Patel (CB)
Now that general practitioners will have incentives to diagnose dementia, will it lead to a better and more accurate diagnosis? Will it increase the number of people diagnosed with dementia or will it increase the number of people falsely diagnosed with dementia? Let us remember that there is no cure or treatment for any of them.
Lord Hunt of Kings Heath (Lab)
My Lords, let us come back to the Question, which is about funding. If the picture was so rosy, why is it that a record number of NHS trusts and NHS foundation trusts are in deficit? If the picture was so rosy, what does the Minister have to say about the report a couple of weeks ago by the Nuffield Trust? It states:
“Prompt access to services has declined … In mental health services, demand”,
is,
“outstripping capacity for urgent care and for younger people. The wellbeing of frontline staff in both health and social care is”,
deteriorating. When he says that the Government are not ashamed of what they did, who is he speaking for? Is he really speaking for the Prime Minister and the leadership of his party?
Children: Obesity
Earl Howe Excerpts(10 years, 8 months ago)
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Baroness Benjamin (LD)
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare an interest as chair of the All-Party Group on a Fit and Healthy Childhood.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we published our cross-government strategy, A Call to Action on Obesity in England, in 2011. It sets out our approach to tackling obesity and includes a national ambition for a sustained downward trend in the level of excess weight in children by 2020. This requires ongoing collective action across all government, businesses, healthcare professionals and individuals. We are seeing encouraging signs of progress, with obesity rates in children falling to 14% in 2012, the lowest level since 1998.
Baroness Benjamin
I thank my noble friend for that Answer. However, a report by the All-Party Group on a Fit and Healthy Childhood has confirmed that childhood obesity has become an epidemic across the country. In some areas, 40% of children are overweight. Medical and dental experts are raising concerns about obesity and health issues in children and millions are being spent by the NHS because of this. Does my noble friend agree that this epidemic has to be called a national emergency and that someone at Cabinet level should be responsible for co-ordinating strategy across all relevant government departments for the sake of our children’s long-term well-being? Will he please agree to meet the all-party group to discuss this report?
Earl Howe
My Lords, first, I commend the all-party group for its report. Tackling obesity is one of our major priorities, as it is for Public Health England. We have a well developed and wide-ranging programme of actions to tackle obesity. We have set a national ambition for a downward trend in excess weight in children. We are delivering the programme through initiatives such as Change4Life, the National Child Measurement Programme, school sports funding and the School Food Plan, and through voluntary partnerships with industry. As regards co-ordination, Public Health England is a leader of the public health service and numerous government departments are contributing to the anti-obesity agenda. We have a Minister for Children, and we have already established the Obesity Review Group, which brings together a range of experts and delivery partners from across the system to try to co-ordinate efforts to meet our national ambitions.
Lord McColl of Dulwich (Con)
My Lords, will the Minister acknowledge that the Department of Health and NICE misled Parliament and the nation in saying that the obesity epidemic was due to lack of exercise? Will the Minister acknowledge that in fact obese people do not need to increase their activity one iota in order to lose weight? All they have to do is to eat or drink fewer calories.
Earl Howe
My Lords, although physical activity can have a role in maintaining a healthy weight, the Government agree with my noble friend that its health benefits are nevertheless subsidiary in those who are obese to the need to eat and drink less. My noble friend may be interested to know that NICE is currently consulting on its draft public health guideline on maintaining a healthy weight and preventing obesity among children and adults. It currently expects to publish this guideline in February next year.
Lord Elystan-Morgan (CB)
My Lords, does the Minister accept that many of us are obese because we are the proud but inevitable products of heredity? Further, does he accept the splendid words of the Scottish author, Eric Linklater, who, speaking of a person of ample frame, said, “His outline spoke not of greed but of grandeur, not of gluttony but of the magnanimity of the human form”?
Earl Howe
There is, I am sure, no more elegant way of describing the issue under consideration at the moment. The noble Lord makes a very important point about heredity. I do not think that sufficient is understood about the role of our genetic make-up in the way in which we all differ in our weight and size. However, for those who are obese, there are clear, evidence-based actions that they can take to lose weight if they have a mind to do so.
Lord Berkeley (Lab)
Does the Minister agree that the link between cycling and the avoidance of obesity is extremely strong? Will he speak to his colleagues in the Department for Transport as his predecessor, whom I met at a conference a few years ago, said that the Department of Health would not encourage cycling because it was a transport matter?
Earl Howe
We are straying a little towards obesity in general rather than obesity in children. However, I concur with the noble Lord that cycling has an important place in the way in which we can take exercise, which is beneficial for our general health. I will, of course, take back the noble Lord’s message.
Lord Walton of Detchant (CB)
Will the Minister say what success, if any, the Government have had in persuading manufacturers to reduce sharply the sugar content of fizzy drinks? Has consideration been given to the possibility of restricting the sale of high-calorie-content drinks through vending machines?
Earl Howe
My Lords, our current emphasis is on overall calorie reduction, of which sugar forms an important part. The scope for reformulation to reduce sugar levels varies widely depending on the food that one considers and a reduction of sugar levels does not always mean that the overall calorie content is reduced. The issue is not black and white. An example of that is when sugar is replaced by starch or other ingredients. Nevertheless, we are discussing with the food manufacturing industry ways in which it can reformulate its food and the Scientific Advisory Committee on Nutrition is finalising its review on carbohydrates, looking at sugar as a particular component of that.
Baroness Wheeler (Lab)
My Lords, given the difficulty of ensuring effective cross-department co-ordination on childhood obesity, what is the Government’s response to a call by the Royal College of General Practitioners to set up a COBRA-style task force? Would that not be a key way of ensuring a joined-up approach that extended beyond the Department of Health?
Earl Howe
My Lords, as I mentioned earlier, we have set up the Obesity Review Group, which contains a multiplicity of experts to co-ordinate the efforts being conducted not only in government but also in local government and on the part of business and the wider private sector. While I buy into the central point made by the noble Baroness that this needs an overarching scrutiny, we believe that we have that already.
NHS: Cottage Hospitals
Earl Howe Excerpts(10 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I first congratulate my noble friend on securing this debate. I know that the role that mutuals play within our society is a subject close to his heart, as he has indicated tonight, and of course the future of our hospitals is a subject of utmost importance to all noble Lords. Before I respond to the particular points raised by my noble friend, I should like to acknowledge the great benefits that cottage or community hospitals provide to those in their local area. I shall set out how the changes we have made to the NHS have provided protection to community hospitals wherever they are needed. Finally, I will describe the role that mutuals play in the delivery of our health services, including our community hospitals, both now and in the future.
Cottage hospitals, generally referred to as community hospitals, are local hospitals, units or centres providing a range of accessible healthcare facilities and resources. They can be invaluable assets that make it easier for people to get care and treatment in the community, closer to where they live. They allow large hospitals to discharge patients safely into more appropriate care, freeing up beds in major hospitals for people who need them, and they can reduce the need to travel long distances to larger facilities.
There are many excellent reasons why people are often extremely protective of their local community hospital. It may deliver a range of essential services, provide employment for local people and afford space for community groups. It is understandable that community hospitals are fiercely defended and inspire such loyalty. It is right that people think about their future place.
The changes that this Government have made to the NHS have given the power to local clinicians and patients to make improvements to their local NHS. Clinical commissioning groups, led by local clinicians, are now responsible for commissioning services. They are free to work out which services are needed and where they should be located to best meet local needs. I beg to differ from the noble Lord, Lord Hunt, about the accountability of clinical commissioning groups, which is real in the sense that they are accountable to NHS England for the outcomes that they produce and the plans that they put in place; they are accountable to the health and well-being boards on which they sit; and they are accountable to their local Healthwatch, which is the body that represents patients and the public in the local community. So I do not share the view of the noble Lord, Lord Hunt, in that sense.
It may be helpful if I explain the ownership of community hospitals. Ownership of the physical premises of many of our community hospitals changed when primary care trusts were abolished. Some were transferred to local NHS trusts and NHS foundation trusts. Other hospitals went to NHS Property Services, the Department of Health-owned property management company. I recognise that some noble Lords had concerns about these transfers when they occurred. We have been extremely clear that the conditions attached to these transfers mean that these hospitals will be retained unless local commissioners determine that they are no longer appropriate for delivering the local services that the community requires. As with all decisions about local patient services, it is right that these decisions are taken locally, taking account of local views. However, we must acknowledge that sometimes old infrastructure, although much loved, cannot keep up with the community’s needs. Changes in treatments and communities may require new and innovative models of care. Local commissioners should be able to explore a full range of options to ensure that services meet the needs of patients.
I now turn to the potential role that mutuals and staff ownership models could play in the future of our hospitals. However, I need to be clear from the outset that mutualisation is about the services that our hard-working NHS staff and their organisations deliver. It is not about the bricks and mortar where they work. I hope that will not disappoint my noble friend, but we are not considering the transfer of NHS property out of the ultimate ownership of the Secretary of State—unless, as I have said, it becomes surplus to NHS requirements.
Public service mutuals, as we define them, are organisations that originate in the public sector, deliver public services and involve a high degree of employee control. Over the last four years, this Government have worked tirelessly to ensure that citizens have access to effective and high-quality health provision. This is why we have broadened approaches to the delivery of healthcare, including through public service mutuals—a model which is revolutionising front-line provision and bringing benefits to staff, local commissioners and service users.
The Transforming Community Services programme, started under the previous Government, saw the separation of commissioning and provision within primary care trusts. As part of this programme, some organisations spun out of the public sector. We now have over 45 mutuals delivering community healthcare across the country, including in some community hospitals, transforming the quality of patient care through a more engaged and empowered workforce. To build on these successes, last year my right honourable friend Norman Lamb, alongside my right honourable friend Francis Maude, asked the highly esteemed Chris Ham, chief executive of the King’s Fund, to consider the options for strengthening the voice and the stake of employees in NHS provider organisations, always with the aim of empowering them to deliver efficient, high-quality services centred on the needs of patients. When he published his report in July of this year, he presented clear evidence that more engaged staff are linked to lower rates for some hospital-acquired infections and positive patient reports of dignity and respect. One study demonstrated that each increase of one standard deviation in levels of satisfaction was associated with a 2.4% drop in patient mortality.
We also know that mutuals can lead to greater job satisfaction, higher productivity and reduced absenteeism, and social enterprises and mutuals have a proven track record of delivering high-quality, responsive, cost-effective services. While there are significant numbers of mutuals delivering community services in a range of settings, a number of different opportunities and challenges arise when thinking about how these mutual principles can be applied to a wider range of acute hospital services where they do not currently operate. That is why, in response to Chris Ham’s report on staff engagement and empowerment in the NHS, we have established a pathfinder programme to support NHS trusts and foundation trusts in exploring the potential advantages of the mutual model. We have made available a £1 million fund to support a number of pioneering pathfinder organisations in understanding what mutualisation could mean for them and identifying solutions to practical barriers. We will use this pathfinder programme to explore and identify the benefits and risks of the mutual model in new areas of the health sector—which could include, but is not limited to, staff working in community hospitals.
I must be clear, however, that the establishment of a mutual model is not a panacea. Mutuals can succeed or fail, as can any organisation. Participation in our pathfinder programme, and any subsequent decisions by organisations to consider the benefits of the mutual model, must be on a voluntary basis, driven by the views of both staff and their patients and users in the local community. Therefore, while I can be clear that this Government understand the benefits of the mutual model and want to explore its potential across a range of health services, we do not anticipate that we would seek to roll this out across all staff working in community hospitals.
I now turn to some of the questions that have been posed. First, my noble friend queried whether we could look at international examples here. He may know that Sir David Dalton, on behalf of my right honourable friend the Secretary of State, is currently leading a review looking at new provider models. The review includes a detailed look at what we can learn from international examples, perhaps bringing those examples to bear in the NHS.
I was aware of my noble friend’s Private Member’s Bill. I am happy to take away his remarks and to discuss with my colleagues in the Treasury the ideas that he has put forward in relation to health services.
My noble friend Lord Framlingham, in his very powerful speech, signalled his concern about the paucity of facilities in some of our community hospitals and the threat of closure that might ensue from that. I hope that I can give him some words of comfort there. As I have indicated, the majority of NHS services, including those provided in community hospitals, are commissioned by clinical commissioning groups, so how those hospitals are funded is very much a matter for local determination rather than a national decision. However, NHS England expects CCGs’ commissioning decisions to be underpinned by clinical insight and knowledge of local healthcare needs, and that those decisions should have regard to the need to address health inequalities.
As I said, I do not think that mutualisation by itself would provide a panacea to prevent community hospitals closing. Where a community hospital is judged to be no longer viable—for example, because of the age of the fabric or a significantly diminished volume of services being provided—a change of organisational form or ownership alone is unlikely to affect local commissioning decisions. I shall come on in a minute to the issue of funding if I have time—although I suspect that I will not and that I will need to write to my noble friend further on that score.
My noble friend raised the possibility of external funding from the community, and I was interested in his remarks. Our view is that that kind of local levy should not be necessary. The Department of Health capital budget continues to rise in real terms, and indeed provider trusts are funded through the depreciation element of their income, with funds to cover their capital expenditure. Where trusts can prove their business case, the department will provide them with capital loans through the independent trust financing facility and may choose to provide public dividend capital directly in exceptional circumstances. Therefore, capital funding is available where it can be justified.
The noble Lord, Lord Hunt, suggested that CCGs should be reversing the flow of services away from hospital. To an extent, I agree with him, although I think that largely we are talking about acute settings rather than community settings. Simon Stevens, the chief executive of NHS England, has made it clear that there should be no national blueprint for this: CCGs have to be free to determine the services that they commission based on local needs. Of course, this issue does not bear upon NHS privatisation. Indeed, the pathfinder programme is there to explore the benefits of the mutual model and ways in which staff can be actively engaged. That is a million miles away from privatisation and, as I have said on a number of occasions, the Government have absolutely no agenda on that score.
In conclusion, as I have overshot my time, the Government have taken steps to secure the sites of community hospitals and ensure that they are used for the benefit of the community. Local clinical commissioners are best qualified to take decisions about the services required locally. We are supporting organisations that wish to explore in detail the feasibility and viability of the mutual model for their organisation or significant parts of their services and explore the benefits of mutualisation in a wider range of services within the health sector.
Ebola
Earl Howe Excerpts(10 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, with the leave of the House, I shall now repeat a Statement made earlier this afternoon by my right honourable friend the Secretary of State for Health on the subject of Ebola.
“With permission, Mr Speaker, I would like to update the House on the Government’s response to the Ebola epidemic in West Africa. I shall start with the Chief Medical Officer’s assessment of the current situation in the affected countries. As of today, there have been 4,033 confirmed deaths and 8,399 confirmed, probable and suspected cases of Ebola recorded in seven countries, although widespread transmission is confined to Liberia, Sierra Leone and Guinea. This number is doubling every three to four weeks. The UN has declared the outbreak an international public health emergency.
This Government’s first priority is the safety of the British people. Playing our part in halting the rise of the disease in West Africa is the single most important way of preventing Ebola infecting people in the UK. I would like to start by paying tribute to the courage of all those involved in this effort, including military, public health, development and diplomatic staff. I particularly commend over 650 NHS front-line staff and 130 Public Health England staff who have volunteered to go out to Sierra Leone to help in our efforts on the ground. You are the best of our country and we are deeply proud of your service.
Among the three most affected countries, the UK has taken particular responsibility for Sierra Leone, with the US leading on Liberia and France focusing on Guinea. British military medics and engineers began work in August on a 92-bed Ebola treatment facility in Kerry Town, including 12 beds for international health workers. In total, we will support more than 700 beds across the country, more than tripling Sierra Leone’s capacity. With the World Health Organisation, we are training more than 120 health workers a week and piloting a new community approach to Ebola care to reduce, and hopefully stop, the transmission rate. We are also building and providing laboratory services, and supporting an information campaign in-country. We are now deploying the Royal Navy’s RFA “Argus” and its Merlin helicopters along with highly skilled military personnel, bringing our military deployment to 750. They will support the construction of the Kerry Town Ebola treatment centre and other facilities, provide logistics and planning support, and help establish and staff a World Health Organisation-led Ebola training facility to increase training to over 800 health workers a week.
Taken together, the UK contribution stands at £125 million plus invaluable human expertise and is the second-highest bilateral contribution after the US. But we need other countries to do more to complement the efforts of ourselves, the US and France. On 2 October, the Foreign Secretary held an international conference on defeating Ebola in Sierra Leone, during which over £100 million and hundreds of additional healthcare workers were pledged.
I will now move on to the risks to the general public in the UK. The Chief Medical Officer, who takes advice from Public Health England and the Scientific Advisory Group for Emergencies, this morning confirmed that it is likely that we will see a case of Ebola in the UK, and that this could be a handful of cases over the next three months. She confirmed that the public health risk in the UK remains low and that measures currently in place, including exit screening in all three affected countries, offer the correct level of protection. However, while the response to global health emergencies should always be proportionate, she also advises the Government to make preparations for a possible increase in the risk level.
Therefore I can today announce that the following additional measures will take place. First, on screening and monitoring, rapid access to healthcare services by anyone who may be infected with Ebola is important, not only for their own health but also to reduce the risk of transmission to others. While there are no direct flights from the affected region, there are indirect routes into the UK. Therefore in the next week Public Health England will start screening and monitoring UK-bound air passengers, identified by the Border Force, coming on the main routes from Liberia, Sierra Leone and Guinea. This will allow potential Ebola virus carriers arriving in the UK to be identified, tracked and given rapid access to expert health advice should they develop symptoms.
Those measures will start tomorrow at Heathrow, which receives around 85% of all such arrivals, beginning with terminal 1. They will be expanded by the end of next week to other terminals at Heathrow and Gatwick and on the Eurostar, which connects to Paris and Brussels-bound arrivals from West Africa. Passengers will have their temperature taken and complete a questionnaire asking about their current health, recent travel history and whether they might be at potential risk through contact with Ebola patients. They will also be required to provide contact details. If neither the questionnaire nor the temperature reading raises any concerns, passengers will be told how to make contact with the NHS should they develop Ebola symptoms within the 21-day incubation period, and allowed to continue on their journey. It is important to stress that a person with Ebola is infectious only if they are displaying symptoms.
Any passenger who reports recent exposure to people who may have Ebola, or symptoms, or who has a raised temperature will undergo a clinical assessment and, if necessary, will be transferred to hospital. Passengers identified as having any level of increased risk of Ebola, but without any symptoms, will be given a Public Health England contact number to call should they develop any symptoms consistent with Ebola within the 21-day incubation period. Higher-risk individuals will be contacted on a daily basis by Public Health England. Should they develop symptoms, they will have the reassurance of knowing that this system will get them first-class medical care, as the NHS demonstrated with nurse William Pooley, and the best possible chance of survival.
We expect these measures to reach 89% of travellers we know have come to the UK from the affected region on tickets booked for the UK. However, it is important to note that no screening procedure will be able to identify 100% of the people arriving from Ebola-affected countries, not least because some passengers leaving the countries will not be ticketed directly through to the UK. So today I can announce that the Government will ensure, working with the devolved Administrations, that there is highly visible information displayed at all entry points to the UK asking passengers to identify themselves, in their own best interests, if they have travelled to the affected region in the last 21 days. This information for travellers will be available by the end of this week.
We are also taking other important measures. We have tested operational resilience with a comprehensive exercise that took place on Saturday, modelling cases in London and the north of England. Local emergency services across England are holding their own exercises this week and will share lessons learnt.
It is vital that the right decisions are made on Ebola following any first contact with the NHS. So we have put in place a process for all call handlers on NHS 111 to ask people reporting respiratory symptoms about their recent travel history so that appropriate help can be given to higher-risk patients as quickly as possible. The Chief Medical Officer has also issued a series of alerts over recent months to doctors, nurses and pharmacists setting out what to do when someone presents with relevant symptoms. We will also send out guidance to hospital and GP receptionists.
The international profile of the UK as a favoured destination inevitably increases the risk that someone with Ebola will arrive here, so a great deal of planning has also gone into procedures for dealing with potential Ebola patients in the UK, working closely with the devolved Administrations. All ambulances are equipped with personal protective equipment, PPE. If a patient is suspected of having Ebola, they will be transported to the nearest hospital and put in an isolation room. A blood sample will then be sent to Public Health England’s specialist laboratory for rapid testing. If they test positive for Ebola, they will be transferred to the Royal Free Hospital in North London, which is the UK’s specialist centre for treating the most dangerous infectious diseases. We also have plans in place to surge Ebola bed capacity in Newcastle, Liverpool and Sheffield, making a total of 26 beds available in the UK.
We will always follow medical advice as to whether any measures we adopt are likely to be effective and are a proportionate response to risk. However, I believe that we are among the best and most prepared countries in the world.
Lastly, we are harnessing the UK’s expertise in life sciences to counter the threat from Ebola. The UK Government, alongside the Wellcome Trust and the Medical Research Council, have co-funded clinical trials of a potential vaccine which could be pivotal in the prevention effort. We are actively working with international partners to explore how we might appropriately make further vaccine available.
Finally, we should remember that the international community has shown that if we act decisively, we can defeat serious new infectious disease threats such as SARS and pandemic flu.
The situation will get worse before it gets better, but we should not flinch in our resolve to defeat Ebola both for the safety of the British population and as part of our responsibility to some of the poorest countries on the planet. Our response will continue to develop in the weeks and months to come, guided by advice from the Chief Medical Officer, Public Health England and the Scientific Advisory Group for Emergencies.
I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am very grateful to the noble Lord for his comments and questions. I shall endeavour to cover as many as I can. First, let me turn to the advice that we have received in recent days from the Chief Medical Officer. It is important for me to underline that she has made it clear that we can expect a small number of cases over the next few months but that the degree of risk to the UK remains low. That is the point which noble Lords should keep in mind. It makes sense that we should identify people who have been to the affected areas and give them clear advice, making sure that they know exactly whom to call to get access to the best possible advice and care. The evidence from the Texas case, which the noble Lord cited, is that early identification of cases is absolutely critical and screening will help with that.
The noble Lord mentioned that the position of the Department of Health has changed over recent days. He is right; the Chief Medical Officer has been very clear that we are in uncharted territory so far as Ebola is concerned. We will learn as we go and base our policy on the best possible advice but we took the view that, as a Government, we would be failing in our duty if we did not take proportionate and targeted steps to safeguard the UK. The situation is developing all the time. No system of screening, as the Statement made clear, can offer 100% protection against an imported case of Ebola but our aim is to ensure that as many people as possible arriving from affected countries know the symptoms and how to get access to healthcare services as quickly as possible. We can be entirely confident in our ability to isolate and treat a case in this country, should it emerge, and we believe that the measures which we have announced will help to improve our ability to detect and isolate Ebola cases.
The noble Lord asked what modelling had been done on the number of cases. I am advised that a great deal of work has been done in an endeavour to predict numbers. I cannot give a precise number but the CMO’s advice is based on a risk assessment from Public Health England and she has been clear that, although the risk remains low, we should be prepared for a handful of cases over the coming months.
The noble Lord asked whether we had been planning for a worst-case scenario. As I said, the NHS has capacity available to cope with a number of cases. We are confident that the NHS’s capacity is adequate. We have two specialist beds available using the Trexler system at the Royal Free. There is further capacity at the Royal Free itself and surge capacity at a number of other units around the country. It is important, however, to understand that Trexler beds are not the only type of beds that can be used; other beds are appropriate for treating Ebola patients, given that the staff have appropriate PPE.
Turning to the prospects for treatment of Ebola, we are using our position as a global centre of research to understand Ebola better and help prevent a future outbreak. Working with the Wellcome Trust, we have launched a global call for research which could produce evidence to better manage the current outbreak and any that occurs in the future. The UK, alongside the Wellcome Trust and the Medical Research Council, has also co-funded clinical trials of a potential vaccine, as was mentioned in the Statement, which could be pivotal in preventing outbreaks. At the moment I am not in a position to give further details of that work.
The reassurance to the House is that there is now an expert group, chaired by the Chief Medical Officer, alongside Jeremy Farrar of the Wellcome Trust. The Chief Medical Officer and Sir Mark Walport, the Government’s Chief Scientific Adviser, have agreed that this group should be a SAGE group—that is, a Scientific Advisory Group for Emergencies. This will include the best experts that we have available.
The noble Lord asked me about international support for the effort in Sierra Leone on top of the support that we are providing from this country. As a result of the conference held in London on 2 October, a number of countries and organisations have made pledges. Australia has pledged £6.2 million, Canada £18.6 million and Switzerland £3.25 million. Cuba has pledged a significant number of staff. At the African Development Bank a further £94.9 million package of grants and loans has been approved, of which £31 million will go to Sierra Leone. Save the Children is launching a £44 million appeal, with £25 million for Sierra Leone.
Turning back to the UK, the noble Lord asked me about GPs and whether they know how to identify Ebola and what to do. As the Statement mentioned, the CMO has sent out a number of alerts, including to GPs. We are not at all complacent about this. We are asking the Royal College of General Practitioners and the BMA about how we could get messages out more effectively to their constituent members, as they have very good channels of communication.
Finally, I hope that I have sufficiently conveyed to the House that there is clear responsibility for the efforts that we are making in this country and in Sierra Leone to contain this outbreak. Ultimately, Ministers are accountable but, as I said, we have a SAGE group in operation; we have Public Health England providing advice to that group, along with the advice of other experts. The lines of accountability are clear.
Lord Patel (CB)
My Lords, I thank the noble Earl for his Statement. I have two quick questions. One relates to the staff who have volunteered to go out to Sierra Leone and to all soldiers. If any of them get infected while they are working there, will they be brought back to the United Kingdom for treatment? My second question relates to the treatment. While there are likely to be early trials of the vaccine that is being developed, it may well prove ineffective. But there are other companies developing other treatments. Are there plans to fast-track approval of these drugs if they are found to be effective? We know that the stock of ZMapp is now exhausted; further monoclonal antibodies development is likely to take some time.
Earl Howe
There is a limited amount that I can say to the noble Lord about his second question. A general answer is that we would naturally want to give as fast a passage as possible through the regulatory process to any breakthrough treatment for Ebola. It should be borne in mind, however, that safety is the paramount concern. This is why it is important that the vaccine, which is now in clinical trials, is thoroughly tested for safety as well as efficacy. If there is further news on this that I can impart to the noble Lord, I will be happy to write to him.
The noble Lord asked whether staff who volunteer will be repatriated if they contract the disease. My advice is that decisions on repatriation would be taken on a case-by-case basis, taking into account the clinical condition of the person and the benefit they may gain from repatriation. Repatriation involves a long journey that can potentially be dangerous for the patient. Once there is high-quality treatment available in Sierra Leone, it will not necessarily be in the best interests of the patient to be repatriated. That is why we are building the 12-bed unit specifically for national and international healthcare workers.
Lord Fowler (Con)
My Lords, I totally support the measures set out by the Minister. It is obviously sensible, as it has been in past events, for the Government to follow carefully the guidance of the Chief Medical Officer. Is not the real long-term task permanently to strengthen the inadequate and underfinanced health systems in so many parts of Africa? Would that not be to the benefit of tackling not just Ebola but other life-threatening conditions such as malaria, TB and HIV/AIDS?
Earl Howe
My noble friend has immense experience in this area and I completely agree with him. I attended a conference in Washington a few days ago which was called by the President of the United States at which 44 Health Ministers from around the world were present. I emphasised the very point my noble friend has made: yes, it is important to provide assistance to deal with the current emergency—everybody is agreed about that—but we must not lose sight of the need for the health systems in those poor countries to be bolstered in the way my noble friend mentioned and for there to be adequately trained clinicians and healthcare staff on the ground as well as diagnostic facilities so that in future those countries are capable of some resilience if they are hit by such an emergency again. I can tell my noble friend that DfID funding is going into that effort, as it has been systematically over the past few years.
Lord Boateng (Lab)
My Lords, the President of Ghana and chair of ECOWAS—the affected region—will be visiting the United Kingdom next week. He will be received graciously by Her Majesty the Queen, and he will come to this House on 22 October in order to address Members of this House and the other place. The success of the welcome measures outlined by the noble Earl will depend on the active engagement and involvement of West Africa and the whole of the affected region. Will the Minister ensure that the request that the President has put in to meet the Prime Minister and Cabinet members in order to discuss the appropriate co-operation between West Africa and the United Kingdom on these measures will be granted? The President has already made clear, and will make it clear to Members of this House next week, the appalling shortage of PPE and safety equipment on the ground in West Africa as we speak. There is a vital need for further resources and increased co-operation. The Prime Minister and Cabinet Ministers need to hear that message.
Earl Howe
My Lords, I am grateful to the noble Lord for giving me prior notice of his question. We very much look forward to the visit of the President of Ghana. His wish to discuss the Ebola emergency with the Prime Minister or a member of the Cabinet has been fed through at the highest governmental level. I cannot yet confirm whether or with whom such a meeting might be arranged, but I have asked that a response be forthcoming to the Ghanaian High Commission as soon as possible.
Baroness Hamwee (LD)
My Lords, the noble Earl mentioned information to GPs, pharmacists and so on. Can he tell the House anything about information to be given to the general public about the symptoms that we should be looking out for? Obviously I appreciate that one does not want to cause alarm, although I think the public are likely to be alarmed anyway, nor to overwhelm the services, but I imagine the Minister would agree that information is important.
Secondly, can he say anything about advice to air passengers? I do not mean those coming directly from the countries that we know are affected, but all air passengers. I imagine that all of us after a plane journey have got off thinking, “Hmm, with all that stale air, I think I’m about to go down with something—I can feel it at the back of my throat”. Are there precautions that air passengers generally should be taking? If so, will there be advice about this?
Earl Howe
My Lords, we are reviewing those very questions all the time. Our position at the moment is that it would be disproportionate to alert the general public to the risk of Ebola, because it remains low. As for air passengers generally, it is important to understand that the virus is transmitted only by direct contact with the blood or bodily fluids of an infected person. It is not an airborne infection. So while I do not in the least belittle the importance of a public health campaign should that prove necessary, we do not consider that it is warranted at the current time.
Lord Winston (Lab)
My Lords, I am slightly concerned—I hope the noble Earl will forgive me for not giving him advance notice of this question—about the possible risk of seeming a little complacent about saying that this is low-risk. We know that viruses mutate, for example, and we know that the Ebola virus can mutate. We know perfectly well that it is not airborne at the moment, and we know that the pharyngeal and upper respiratory tract cells are unlikely to harbour the virus. However, can the noble Earl assure us that people are looking at the risk of mutation of this virus so that we can make certain that its mode of transmission does not change and that, therefore, it will continue to be low-risk?
Earl Howe
I can give the noble Lord that assurance. There is very close monitoring of the virus itself and the way in which it mutates. I repeat that the official advice is that risk to the public in this country remains low. That advice is based on the fact that we have robust, well developed and well tested systems for managing infectious diseases when they arise, supported by a wide range of experts. The Chief Medical Officer has estimated that we should expect Ebola in the UK, but not more than a handful of cases, and we would be able to cope with those cases.
Lord Alton of Liverpool (CB)
My Lords, does not the handful of cases to which the noble Earl has just referred contrast very sharply with the prediction that 1 million people may die in West Africa? Given the fetid conditions and grinding poverty in places such as Monrovia and Freetown, does he not agree that this public health epidemic has been brought about because of the conditions that we have allowed to fester for so long?
Would the noble Earl not agree that the WHO was very slow in responding when this was first identified? Does he not also agree that an immediate problem is the disposal of corpses, which carry the risks of contagion? Furthermore, when will the 700 beds in Sierra Leone to which he alluded actually come on line?
Earl Howe
My Lords, I believe that the WHO itself has acknowledged that its response could have been swifter. It is easy to say this in hindsight, but I am sure that the noble Lord’s view on that is shared by others. Nevertheless, the WHO has not been slow in rallying support for efforts in the three countries affected. It is now working energetically with many developed countries to provide support, and I would not wish to criticise the WHO in those respects.
On the disposal of corpses, the noble Lord makes an important point. We know that many cases of Ebola in the three countries have arisen as a result of people being in contact with the corpses of people who have died from the disease. That has been as a consequence of the cultural traditions in those countries, which are very hard to displace or persuade people not to follow. It is nevertheless part of our effort in Sierra Leone that we should inform people there that their burial customs need to be set to one side for the duration of the epidemic. This is a very difficult thing to do, for understandable reasons, but that is the effort we are making and it is bearing fruit.
As to the programme for building 700 beds, I do not have a precise date to give the noble Lord but if I receive advice before the end of this debate, I shall tell him.
Lord Reid of Cardowan (Lab)
My Lords, manifestly, this is a terrible disease, not only in its nature but in its scale. According to the rate of growth indicated by the Minister, within around six months we could be looking at between 150,000 and 500,000 deaths, and between 2 million and 5 million suspected cases. Let us hope that that does not occur. However, in view of that, may I ask him one question about screening and entry? I welcome the fact that there is to be extended screening at Heathrow, Gatwick and the Eurostar terminal—two airports and one train station. Manifestly, this does not cover anything like the potential entrants to this country from those regions. With cheap travel and so on, I understand the difficulties in covering every airport, particularly as people break their journeys and do not come directly. However, is it not possible, given the use of so many biometric passports and the technology introduced to UKBA, somehow to target at least people from that area as potentials for screening, wherever they arrive in this country, rather than limit the coverage to three geographical in-ports? Does the Minister have any information on whether this hypothesis has even been tested?
Earl Howe
My Lords, I am grateful to the noble Lord. Existing technology used by the Border Force can inform it about individual passengers coming to this country and identify those who have recently travelled from Liberia, Sierra Leone and Guinea on routes with onward connections to the UK. Systems are therefore in place. We know that fewer than 1,000 passengers arrived by air from the affected countries in September. We are not therefore dealing with huge numbers. We know that around 85% of such people arrive at Heathrow, which is why we are starting there. However, it is important to look as widely as we can; the noble Lord is right. Again we should be reassured by the fact that there is screening on departure from Liberia, Sierra Leone and Guinea but we are starting the in-country screening in the UK at the three ports I mentioned, with the intention of scaling up screening, based on our experience. Plans are in place for a further rollout to other UK ports, if that should prove necessary.
The Countess of Mar (CB)
My Lords, my noble friend Lady Finlay of Llandaff has asked me to apologise to the House for her absence; she had to go to Wolverhampton. I hear the noble Earl saying that the department will consult the BMA and the RCGP about getting the message across to GPs. My noble friend asked me to ask whether a diagnostic algorithm was going to be posted on all appropriate websites, including those of the royal colleges and the BMA.
Earl Howe
I am not aware that the system being conveyed to GPs, which is not for diagnosis but for the referral of patients, can be called an algorithm, but there is a checklist of questions that we are recommending GPs use. That advice has been adapted for use in all healthcare settings, including NHS 111, as I mentioned in the Statement. Naturally, we shall take advice on whether the questionnaire and the sequence of questions are adequate. If it needs amending, we shall certainly not hesitate to do that.
Baroness Andrews (Lab)
The Minister mentioned SARS in his Statement. We have very few precedents, and he has already described this as being uncharted territory in relation to Ebola. What lessons were learnt after the SARS epidemic, particularly in relation to the organisation of global research? It was a different case because the virus was unknown but the same issues of mutation came up as those to which my noble friend referred. How will the lessons learnt be applied?
Earl Howe
The main lesson learnt from SARS, which in general was a very successful exercise, was that there are two keys to this. The first is informing people what to do if they think that they have symptoms, and the second is making sure that the NHS knows what to do if presented with a possible case of the illness. I hope my comments have conveyed that those two things are the focus of our activity in this country. We also need to make sure that adequate isolation facilities are available for patients with these highly transmittable conditions. That work has been done in the mean time, hence the isolation facilities at the Royal Free and other hospitals to which I have referred.
Baroness Warnock (CB)
With regard to research, could the noble Earl reassure us that the clinical trials will be speeded up by waiving the normal practice of control procedures? It seems unethical to use blind control in a case where the consequences of not being treated are fatal.
Earl Howe
I completely take the point of the noble Baroness, and there are processes on which we can draw to ensure that breakthrough treatments are fast-tracked. There are, however, certain necessary stages in testing any new vaccine or treatment that comes forward to make sure that it is safe. It may be clinically effective in its own way but have unacceptable side-effects, so we need to test that. I can reassure her that regulation will not stand in the way of making a breakthrough treatment available.
To answer the earlier question of the noble Lord, Lord Alton, I shall write to him with further details, but the 700-bed facility is under construction now. The first facility as part of that will be open by the end of October in Kerry Town.
NHS: Cancer Diagnosis and Treatment
Earl Howe Excerpts(10 years, 8 months ago)
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what is their assessment of the report by Cancer UK highlighting gaps in the provision of National Health Service cancer diagnostic and treatment services.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, there has been significant growth in the provision of cancer diagnostic tests and treatment over the course of this Government. For example, urgent GP referrals for suspected cancer have increased by more than 50% since October 2009. NHS England is taking action to support the NHS to improve performance, including establishing a cancer waiting times task force. We are investing an additional £750 million over four years to improve diagnosis and treatment of cancer.
Lord Hunt of Kings Heath (Lab)
My Lords, on the question of waiting times, can the noble Earl confirm that the 62-day target for cancer treatment has been breached in the last two quarters? Can he say why that is and can he confirm that it is really a result of the shambles that Mr Lansley’s changes have brought to the NHS?
Earl Howe
My Lords, the noble Lord is correct that although most waiting time standards are being maintained there has been a dip in the 62-day pathway standard in the last two quarters. However, survival rates are improving and we are treating a record number of NHS patients for cancer. Last year, 450,000 more patients were referred with suspected cancer than in 2009-10. That is an increase of 51%. In addition, campaigns such as Be Clear on Cancer have been exceptionally successful in raising awareness of symptoms. In large part, that is what has accounted for the pressure on the waiting time standards: in a way, the campaigns are a victim of their own success.
Lord Sharkey (LD)
My Lords, it is still true that the chances of surviving cancer can vary dramatically depending on where you live. Can the Minister say what progress has been made in understanding the reasons for those variations and what progress has been made in reducing them?
Earl Howe
My Lords, my noble friend is absolutely right. He will know that medical opinion is clear that a variety of reasons such as lifestyle and others account for regional variations. We want to see a uniformity of speedy diagnosis throughout the country. That depends on early presentation by the patient and speedy diagnosis when the GP first sees the patient. It is with those two things in mind that a lot of work has been going on, particularly to support GPs, but also to inform the public.
Baroness Finlay of Llandaff (CB)
I declare my interest as president of the BMA. Will the Minister outline what action has been taken? Given the crisis in recruitment in general practice, the increased pressures on GPs now that they are also involved in commissioning services and the pressures in emergency medicine, how will GPs have time to tackle obesity? In the obese patient, early diagnosis is much more difficult than in the less obese patient. Also, the incidence of some cancers such as breast cancer is higher in those who are obese.
Earl Howe
My Lords, the noble Baroness makes a number of important points. In August, my right honourable friend the Secretary of State announced a joint piece of work with Cancer Research UK and Macmillan, which will see GPs offered more support to ensure that cancers are diagnosed as quickly as possible. More generally, NICE is updating its referral guidelines for suspected cancer to ensure that they reflect the latest evidence. GPs already have a guide related specifically to direct referral for diagnostic tests, for which we have provided extra money, and early last year the department part-funded a six-month pilot run by Macmillan of an electronic cancer decision support tool for GPs. That pilot is being evaluated, but Macmillan is working with IT software companies to disseminate an updated version of that tool.
Baroness Pitkeathley (Lab)
My Lords, given the importance of early diagnosis and of the significant role that GPs play in that, is the Minister concerned that some patients facing the problems that many now have of finding a GP quickly will be put off presenting with those early symptoms? That will thus get in the way of the early diagnosis that is so important.
Earl Howe
My Lords, I am aware that in some areas of the country access to GPs is proving problematic and a number of work streams are under way to address that. But we are confident in the light of the statistics that patients are not holding back in presenting to their GPs. As I said, referrals have gone up dramatically over the last few years and the NHS is treating a record number of patients.
Lord Avebury (LD)
My Lords, I declare an interest as a cancer patient. What arrangements are made for determining eligibility for treatment by the CyberKnife at the Royal Marsden and UCLH and does it involve any financial assessment of the likely cost to the NHS of the treatment of a particular patient?
Earl Howe
My Lords, my noble friend mentions a particular type of radiotherapy, the CyberKnife. At present there is only limited research evidence of the clinical and cost effectiveness of stereotactic ablative body radiotherapy—the full name. Therefore, it is available only for certain patients with lung cancer. Having said that, NHS England has agreed to make £6 million available over the next few years for new clinical trials which will involve trials on prostate cancer, lung cancer, pancreatic cancer and biliary tract cancers. It is important that we generate that clinical evidence before encouraging the NHS to apply this form of radiotherapy to those cancers.
Lord Brooke of Alverthorpe (Lab)
Will the noble Earl give the House an indication of when the deteriorating waiting times for cancer treatment will be reversed?
Earl Howe
My Lords, clearly a lot of work is going on in the NHS to ensure that we are back on track with the cancer waiting times. Local area teams of NHS England are looking at the causes of those waits and whether there are diagnostic tests that are responsible for the dip in performance. But I can assure the noble Lord that we place a high priority on this area.
Learning Disabilities: Premature Deaths
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, actions are under way with a range of national delivery partners and at local level in response to the inquiry’s recommendations, including improvements in the identification of people with a learning disability, the auditing of reasonable adjustments, and the provision of health checks. Progress is monitored through the Learning Disability Programme Board.
Baroness Hollins (CB)
My Lords, I welcome the commitment in the NHS business plan and the Department of Health mandate to try to reduce premature mortality in people with learning disabilities, and in particular to establish a national mortality review function, but until the necessary data linkages have been made, the review cannot begin. What action is being taken to ensure that the Health and Social Care Information Centre will prioritise the collection of the data required, such as identifying people with learning disabilities and their causes of death, so that the review can indeed begin?
Earl Howe
My Lords, the specification for the mortality review function is under development, and we all wish to see that work proceeded with rapidly. Data to support the function will be needed from both national and local sources. Work is under way with NHS England, the Health & Social Care Information Centre and Public Health England to derive data to underpin both the mortality review function and the NHS Outcomes Framework. However, it is important that this should take full account of wider developments in the collection and sharing of patient data, and this will inevitably impact on the pace of progress. As I am sure the noble Baroness recognises, it is vital that we get that right.
Lord Addington (LD)
My Lords, my noble friend will undoubtedly remember that we had a discussion in this House on the problems of the deaf in trying to access healthcare, and how that leads to other problems. Will there be a pan-disability look into this problem? It is clear that those who have problems communicating in forms of consultation with the NHS get bad results from it.
Lord Wigley (PC)
Does the Minister accept that a number of the points arising out of the confidential inquiry were touched upon by the earlier DRC report published more than six years ago, Equal Treatment: Closing the Gap, and that progress since then has been patchy? In the light of that, will he give a commitment that there will be an annual review of progress made on the confidential inquiry recommendations and a report to Parliament?
Earl Howe
My Lords, I can assure the noble Lord that there is currently a whole-system response to the recommendations in the review. As I said earlier, this is a response from NHS England, Public Health England, local organisations and, indeed, Ministers overseeing the Learning Disability Programme Board. I shall take away the noble Lord’s question about a formal annual review, consider it carefully, and write to him.
Lord Hunt of Kings Heath (Lab)
My Lords, does the noble Earl recognise that the confidential inquiry showed that there are great failings in the health treatment given to many people with learning disabilities, which probably contributes to their very poor life expectancy? He will be aware that my own former trust, Heart of England, appointed specialist liaison nurses who could help people with learning disabilities find a pathway through their healthcare. Would he advise other NHS trusts to follow that example?
Earl Howe
My Lords, the noble Lord makes a good point. Following the recommendations of the UK review of learning disabilities nursing, we have set up an independent collaborative to address that workforce’s needs. We are also working with Health Education England’s 13 local education training boards to develop greater links with the independent and voluntary sector which will help with workforce planning. This year Health Education England increased its national commissions for student learning disability nurses by 4.5%. We are working on a number of initiatives to raise the profile of learning disabilities nursing and promote the profession as an attractive career choice.
Baroness Browning (Con)
The report identifies 37% of deaths that could have been prevented. People with learning disabilities and those on the autistic spectrum, some of whom are included in the report, experience communication problems at hospital level. Will my noble friend please put government force behind the issuing of hospital passports for people with learning disabilities and those with autism? The autism hospital passport was launched two weeks ago and is on the NAS website. However, these very important documents can help to prevent death only if clinicians and hospital staff read them, take note of them and act on them.
Earl Howe
I take my noble friend’s point. The specific needs of people with learning disabilities are being considered as part of the overall work programme to provide people with online access to their GP practice and GP-held e-record. That is being done in the wider context of the development of a fully comprehensive patient-held record. NHS England plans to hold a meeting later this year to look at developing a national standard for a hospital passport. This will be a patient-held document that will detail key information to be shared with any contact in the NHS.
Baroness Warwick of Undercliffe (Lab)
My Lords, what is the Minister doing to ensure that comprehensive community learning disability teams are available in all areas and that GPs are proactively referring patients with a learning disability to these vital services?
Earl Howe
My Lords, the learning disability teams are of crucial importance in ensuring that those with a learning disability are able to access the services that they need. I have a long list of things that are relevant to that subject and I am happy to write to the noble Baroness with that information.
Mental Health: Beds
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Lord Bradley
To ask Her Majesty’s Government what action they are taking to stop patients being unnecessarily sectioned because of shortages of mental health beds.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we are not aware of any incidents of patients being unnecessarily sectioned. In June 2013, the Care Quality Commission asked for notification of such cases. It is for local clinical commissioning groups to commission the right number of in-patient beds to meet the mental health needs of their local population.
Lord Bradley (Lab)
I am grateful to the Minister for that reply, although I am slightly surprised. Does the Minister agree that it is wholly unacceptable that, according to the Royal College of Psychiatrists, doctors are still being forced to section patients to get them their in-patient care? That follows a warning by the Health Select Committee last July on the need to investigate urgently whether patients are being sectioned for them to access psychiatric units, and report to Parliament on the prevalence of that practice. What action have the Government taken on that committee report? Will the Government, if they look carefully at those findings, consider making emergency funding available, similar to that which they made available to A&E departments in the winter, to immediately ease the mental health crisis in beds for adults and children?
Earl Howe
My Lords, I am certainly aware that a number of concerns have been raised about the lack of mental health beds and that there are occasions when patients do not receive care quickly enough because approved mental health professionals cannot locate an appropriate bed. As I said in my original Answer, that is essentially a failing of local clinical commissioning. However, AMHPs—approved mental health professionals—should not be put in that position. We are consulting at the moment on a revised code of practice for the Mental Health Act. That consultation includes a specific question which asks what additional guidance should be included to ensure that AMHPs are not put in that position.
Lord Laming (CB)
Does the Minister accept that depriving a citizen of their liberty is one of the most serious matters that can be undertaken in our society and that it should be done only for very sound reasons, certainly not because of the absence of provision for their needs? When the Minister kindly replied to a Question for Written Answer from me earlier in the year, he said:
“Local areas are expected to … deliver their own ‘Mental Health Crisis Declaration’”.—[Official Report, 18/6/14; col. WA70.]
Can he tell the House how many local areas have signed up to a declaration, and more particularly, how many have failed to do so?
Earl Howe
My Lords, on the very last point, I do not have up-to-date figures, but I will certainly write to the noble Lord. However, on his main question, detention as a mechanism solely to secure access to hospital treatment would not be lawful. If hospitals or local authority staff think that that is happening or feel pressurised to admit people in that way, they should report it to their trust and, if necessary, to the Care Quality Commission. Sectioning under the Mental Health Act, which denies people their liberty, is a very serious matter. It should be done only when a person is a risk either to themselves or to other people and, as the noble Lord knows, it is a legal process. A patient cannot be sectioned merely to secure a bed.
Baroness Brinton (LD)
My Lords, the survey referred to by the noble Lord, Lord Bradley, was of junior doctors in the Royal College of Psychiatrists. If it was somewhat anecdotal and they felt that they were unable to report it formally, can Ministers ask NHS England to ensure that there is a survey of how many doctors are having to use sectioning, to prevent this continuing?
Earl Howe
It certainly is important that we get to the bottom of what is really happening. We take this issue very seriously. The Care Quality Commission intends to explore the issue of people being detained in order to access psychiatric units in its ongoing review of emergency mental health care. The findings of that review will be published later this year. The CQC’s Mental Health Act commissioner regularly and routinely looks at the lawfulness of detention. In fact, the Care Quality Commission is currently developing a new approach to its responsibilities as a regulator of the 1983 Act.
Baroness Uddin (Non-Afl)
My Lords, as a former social worker I know all too well the real cost of sectioning people, the impact that it has and, of course, the immense cost to the overall economy. How will the Government ensure that communities are equipped to look after those with moderate needs, some of whom will have learning disabilities and conditions such as autism spectrum disorder, before a crisis point is reached?
Earl Howe
The noble Baroness referred to people with moderate health needs, which is departing slightly from the Question on the Order Paper. However, I can tell her that mental health policy and its delivery is now a major focus. We have a mental health system board to ensure that all the elements of the health and care system work as effectively as possible together. There is a ministerial advisory group in operation. Parity of esteem is reflected in the NHS constitution and in the Health and Social Care Act 2012. We have challenged NHS England through the mandate to make measurable progress this year towards achieving parity of esteem between mental and physical health.
Baroness Hollins (CB)
My Lords, in 2013 a census found that three-quarters of people with a learning disability admitted to a specialist in-patient facility were subject to the Mental Health Act. For a third of these, learning disability was the only reason given for their admission, without any of the additional requirements under the Act for detention being met. What action are the Government taking to ensure that the Act is being used correctly in the care and treatment of people with a learning disability?
Earl Howe
My Lords, if people with a learning disability are detained under the Act, this must be for assessment or treatment of mental illness. The person must satisfy the strict criteria laid down in the 1983 Act. When a learning disability is identified as well as a need for assessment or treatment of a mental disorder, the important thing is that alternatives to the use of the Mental Health Act are considered—for example, use of the provisions of the Mental Capacity Act and whether reasonable adjustments would assist the person with learning disabilities fully to access the assessment and treatment. This is an area we have explicitly covered in the draft code of practice, which is currently out for consultation.
Baroness Manzoor (LD)
My Lords, more black and ethnic minority people continue to be detained under the Mental Health Act. Can my noble friend the Minister say what is being done to address that issue?
Earl Howe
Yes, my Lords, we know that BME groups are overrepresented in the detained patient population. The reasons for that are quite complex. Research studies indicate that rates of detention reflect the needs of patients at the time of detention. We know that the rates of psychosis, for example, are higher in some BME communities, and they often access mental health services in a crisis. The reasons for that are not entirely clear. We recognise that more work needs to be done to establish the causes of higher rates of mental illness in some communities.