NHS: Better Care Fund
Earl Howe Excerpts(10 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I join other noble Lords in thanking the noble Lord, Lord Kennedy of Southwark, for enabling us to consider a topic of considerable significance for patients and service users.
In every area of the country, CCGs and local authorities are now planning together to use the better care fund to transform local health and care, to improve outcomes for people and to secure the best possible value for money by pooling resources. This is one part of a wider picture of change for health and social care. We must move away from traditional models if we are to provide responsive, effective services to a changing population.
Noble Lords will remember that the need for greater integration of health and social care has long been a recognised issue. The NHS and the social care system provide some fantastic care for people when they are already experiencing acute poor health and high care needs. We must, however, get better at providing care for those with long-term, chronic conditions by keeping people as healthy and independent as possible, living in their own homes and communities for longer, and going to hospital only when they really need to for specialist medical treatment. People will be supported to return to their homes, and to independence, as soon as possible.
We are living longer now than ever before, which is obviously good news, but we do not live all our lives in good health. As people live longer, we are seeing a corresponding rise in long-term conditions that require regular treatment. A lot of this treatment currently occurs in hospitals when it does not have to. It happens because the NHS was founded to treat episodic cases of sickness in hospitals, but the needs of the people are changing and we as the Government must work with the health and social care sector to adapt.
The noble Lord, Lord Turnberg, gave us some of the statistics. ONS projections show that between 2010 and 2030 the number of people aged 85 and over will increase by 95%. This increase is equivalent to more than 1.1 million people or a local authority the size of Birmingham. By 2030, there will be more than 3 million more people than today with three or more serious, long-term conditions.
Much long-term care can be undertaken in a way that promotes independence, sometimes with family members and carers, or with the support of professionals in people’s own homes and communities. People have told us this is what they want and, yes, it is a more efficient use of resources. As I said, these truths have been recognised for some time, and this Government are the first to address it head on. There is broad consensus that greater co-ordination of health and social care services to enable this kind of home and community-based care for the majority is the right direction in which to go. The better care fund presents a real opportunity for radical change at scale and pace for people to receive the right care in the right place at the right time. Local authorities and CCGs are working together to plan and deliver this shift to a more integrated system, with resources used to best effect where they are needed most. As the noble Lord, Lord Hunt, pointed out, acute trusts should indeed be part of that work.
As my noble friend Lord Bridgeman mentioned, for the first year of the BCF, it will include £1.9 billion of the real cash increase in the NHS budget. This represents 2% of the 2013-14 NHS budget, and it is being redistributed to help fund care in non-NHS parts of the system, which will in turn help to make acute care more efficient.
The noble Lord, Lord Kennedy, asked about funding for the longer term. I cannot yet commit to a five-year plan because we have said that it is for the incoming Government to look at their priorities next year. The 2013 Autumn Statement, however, made it clear that pooled budgets would be an enduring part of the framework for health and social care past 2015-16. While the structure of the fund and the pay-for-performance elements may change as progress is made, the principle is very much here to stay.
The noble Lord, Lord Turnberg, asked a similar question about funding for health and social care generally. We will set out the funding levels for social care from 2015-16 in the future spending review but the Government have already set out their plans for changes in how social care will be funded in the future through the Dilnot reforms.
On the specific issue of winter funding, which my noble friend Lady Brinton put to me, the Department of Health is constantly looking to the future, as she may well be aware. Possible pressures on the NHS and social care are very much part of that thinking. We have considered what pressures there will be in the coming winter and I can assure her we are planning appropriately.
Leading care professionals—hospital staff, care workers, GPs and researchers—all agree on the need for resource to be put into integrating our health and social care services, so that a better service can be provided at the same cost. This will certainly involve changing the way things are currently done. The NHS model is geared toward treating people as they get ill. We must shift our approach to focus increasingly on keeping people well and providing acute care in hospitals for those who unavoidably get sick. Keeping people well and out of hospital for as long as possible, and reducing their length of stay by co-ordinating with social care, will reduce the strain on NHS acute services. It will also improve people’s experience and improve health and well-being. An integrated service would allow this to happen, and that is what the BCF has been formed to do.
The noble Lord, Lord Kennedy, asked me whether dementia will be prioritised in the BCF. Guidance on the better care fund sets out that dementia services provision can be a part of the better care fund. Many area plans already contain good examples of health and social care working better together to provide dementia services. He also asked me what seven-day social working means. It is imperative to see social care working over seven days. Too often people have to stay in hospital because they are unable to leave at the weekend. Seven-day working, which will see social care operate at the weekend, as it already does in many areas, will see people return home at the earliest opportunity.
The noble Lord, Lord Turnberg suggested that all this was about robbing Peter to pay Paul. With respect, I do not see it like that at all. This is not about taking money from one part of the system and giving it to another. The better care fund will be held jointly by CCGs and local authorities for them to decide between them how best to spend it. They will decide how to make best use of the money available across the whole care system. This provides a real opportunity to join up services and transform people’s lives, particularly vulnerable people.
As I have explained, one of the aims of the BCF is to reduce the burden on acute services caused by avoidable admissions to hospitals. The way that funding for acute services works means that hospitals receive a marginal level of funding for unplanned admissions. Using the available budget to fund better-integrated, more proactive services will help hospitals to balance their budgets by reducing the operational and financial burden created by avoidable admissions. I am sure the noble Lord will be familiar with the 30% tariff for emergency admissions above a certain threshold. All this will allow hospitals to focus on providing specialist and trauma services, for which they receive full funding so it will make them more financially viable than they would be if the current system was retained. I say to the noble Lord, Lord Hunt, that evidence suggests around a fifth of all emergency admissions are avoidable in some way. If we get it right, transforming hospital care could therefore prevent these unnecessary admissions, which can be distressing for patients, quite obviously, and are costly to the NHS.
The noble Lord, Lord Turnberg, asked me whether the Government have plans to recruit more doctors into general practice. I am sure he will know from statistics that the number of GPs has increased since 2010, but our mandate to Health Education England requires them to increase the proportion of trainee doctors going into general practice from 40% to 50%. We have also set out our ambition to increase the primary care workforce as a whole—not just doctors, but nurses and other primary care professionals—by 10,000 by 2020.
Using resources to keep people out of hospital, by improving other methods of care—social care and home care—will lead to better use of NHS services, ensuring that services are focused on people who cannot be treated at home or in the community.
That brings me to the issue raised by the noble Lord, Lord Turnberg, of the impact of the BCF on acute care. All areas need to show that they have assessed the impact of their BCF plans on the acute sector—that is, hospitals. No plan will be approved without this. They will need to show that they have considered both the operational and financial implications and how these will be—
Lord Hunt of Kings Heath
My Lords, I realise that the noble Earl does not have much time but can he just answer this point? Why not give the acute trusts the ability to sign up to it, or not, to prove that it will reduce capacity?
Earl Howe
My Lords, we are looking at ways to assure these plans, and to assure them in a way that is satisfactory to the acute sector. At the moment, I cannot tell the noble Lord precisely how that mechanism will work but his central point is well made. I hope that in due course we will be able to share some of our thinking with him. However, the key point is that acute providers must have been consulted in this process.
This sort of approach is being pursued around the country. We know that it can work. For example, a network of 14 pioneer areas around the country are currently working with central government and health sector and third sector organisations to demonstrate the logic of integration and to disseminate what they have learnt to the rest of the country. That includes data-sharing—a point raised by the noble Lord, Lord Kennedy. Areas that have made significant progress in that respect are Southend, Leeds and South Tyneside.
There are other examples, too. In Greenwich, more than £1 million has been saved from the social care budget. In addition, 64% of people who went through their new integrated care pathway required no further services upon completion of the pathway. That has helped to lead to a 50% reduction in the number of people entering full social care.
My noble friend Lord Bridgeman asked whether admissions had been taken into account in the pilot scheme. Greenwich is a good case in point. More than 2,000 patient admissions were avoided there due to immediate intervention from the joint emergency team.
In Northamptonshire, £3.5 million has been saved through prevented admissions, exceeding the target by 14%. In Leeds, children and families now experience one service supporting their health, social care and early educational needs, championing the importance of early intervention. Since the service has been in operation, the increase in face-to-face antenatal contacts has risen from 46% to 94%.
Those examples, along with many others, should demonstrate to noble Lords that the integration of our health and social services can, and indeed has been, achieved in several areas. Integration will not only preserve our ability to provide services but improve them. The better care fund exists to enable all the local areas in England to do what the pioneers and others are doing to move towards a more responsive, effective and sustainable system that makes much better use of the resources available.
Health: Multiple Sclerosis
Earl Howe Excerpts(10 years, 4 months ago)
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Baroness Gardner of Parkes
To ask Her Majesty’s Government what plans they have to introduce new treatment for relapsing-remitting multiple sclerosis.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, it is important that people are able to access the innovative and effective new treatments they need. Many thousands of people in England with multiple sclerosis have benefited from the medicines recommended by the National Institute for Health and Care Excellence or covered by the MS risk-sharing scheme.
Baroness Gardner of Parkes (Con)
My Lords, I thank the Minister for that reply. People with multiple sclerosis consider that specialist MS nurses are the key health professionals for providing responsive, person-centred, co-ordinated and integrated care. The latest MS Trust report assesses the provision of MS nurses across the UK and considers that there is a shortage of around 200, and that more specialist nurses are required to ensure that everyone has access to a specialist nurse. The new draft NICE guidelines offer only limited support for this specialist role. Given the scarcity of neurologists in the UK, is it not important that this chain of nurses is in place to ensure that emergencies do not develop, which of course costs the National Health Service very much more? Can my noble friend assure me that he will take action to ensure the continuance of MS nurses?
Earl Howe
My Lords, I am pleased to say that the number of specialist nurses for multiple sclerosis in the UK has risen from 80 in 2002 to 245 currently. I hope that my noble friend will agree with our view that local healthcare organisations, given their knowledge of the healthcare needs of their local populations, are the people best placed to determine the workforce needed to deliver safe and effective patient care within the available resources. However, it is of interest that NHS England’s service specification for specialised neurology does specify that nurse specialists should be involved in the care of people with multiple sclerosis.
Lord Turnberg (Lab)
My Lords, 11 drugs are now available for remitting and relapsing multiple sclerosis, three or four of which have been approved only in the past two or three months, which is great news. Is there any chance that these new drugs will be included in the risk-sharing initiative with industry?
Earl Howe
My Lords, I think that the answer is almost certainly no because the risk-sharing scheme initiated under the previous Government is quite complex to administer and we would need to be persuaded that the administrative burdens associated with it were worth while. Now that we have the NICE process, it is probably best that NICE should look at these drugs in the context of its new clinical guideline, which is what the stakeholder groups thought was preferable.
Lord Blencathra (Con)
My Lords, I declare a personal, though not a financial, interest in this Question. My noble friend may be aware that there is a drug called benztropine which has been approved for the past 10 years for use in Parkinson’s patients. We know that it is not carcinogenic, mutagenic, teratogenic or any other genic—it is safe. US researchers have just discovered that it seems to completely restore the myelin sheath on the spinal cord, at least in laboratory animals. This is of enormous interest to MS patients. Will my noble friend add benztropine to the list of medicines for urgent consideration by his early access to medicines scheme?
Earl Howe
My Lords, we are keen to see candidates being proposed for the early access to medicines scheme. If a body of evidence suggests that benztropine could qualify for designation as a promising innovative medicine—a PIM—the Medicines and Healthcare products Regulatory Agency stands ready to consider such evidence. However, it is for the manufacturer of the drug, not the Government, to decide whether it wishes to propose the drug as a candidate for the scheme.
Baroness Barker (LD)
My Lords, three drugs are currently awaiting approval by NICE, some of which have been turned down by the European Medicines Agency because of their side effects. To what extent does NICE take that factor into account in its own decision-making process?
Earl Howe
My noble friend will know that NICE looks at the clinical effectiveness of a drug alongside its cost effectiveness. The cost-effectiveness equation will naturally include consideration of unpleasant side-effects. The advice that it issues will reflect the evidence that it has from clinicians on that matter. It will then be for clinicians to decide whether the risk-benefit ratio is appropriate for particular patients.
Baroness Wheeler (Lab)
My Lords, when considering the Care Act we were very concerned to ensure that care and support plans for social care users included contingency planning for people who have fluctuating conditions such as MS and rheumatoid arthritis, where support needs can vary from week to week and day to day. What mechanisms are being put in place to ensure the provision of the flexible and comprehensive care plans that are needed?
Earl Howe
The noble Baroness is right that care plans have to be tailored to each individual patient. For those with serious neurological conditions, that is as important as for anyone. I do not have up-to-date information about what work NHS England is doing at the moment on this, but I am happy to write to her on the subject.
Lord Roberts of Llandudno (LD)
My Lords, how widely shared are these new medications? For instance, I know that some cancer medications are available to patients in England but not to patients in Wales. How widely is this information shared so that everyone can benefit, even if we are under the devolved Administrations?
Earl Howe
My noble friend will know that I cannot speak for the devolved Administrations, who have complete autonomy in their healthcare policies. I can say that a number of drugs have been recommended for use on the NHS for MS patients, including Tysabri, Gilenya, Aubagio and Lemtrada. However, it is ultimately for the devolved Administrations to decide whether they wish to have the same set of rules in place as we do in England.
Legislative Reform (Clinical Commissioning Groups) Order 2014
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Health Care and Associated Professions (Indemnity Arrangements) Order 2014
Earl Howe Excerpts(10 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, in July 2010 the four UK health departments accepted the recommendations of the Finlay Scott review, which recommended that all regulated healthcare professionals should be required to hold appropriate insurance or indemnity cover as a condition of their registration when carrying out work as a regulated healthcare professional.
The Government are committed to requiring all practising regulated healthcare professionals to hold indemnity or insurance cover, and have been for some time. The Government are also required to implement Article 4(2)(d) of the EU directive on patients’ rights in cross-border healthcare, which reinforces that direction of travel and further commits us to legislation. The purpose of this policy is to ensure that people have access to appropriate redress in the unlikely event that they are negligently harmed during the course of their care. All patients should have that by right. The overwhelming majority of regulated healthcare professionals will be unaffected by the proposals because they already have insurance or indemnity cover. For employees in the NHS or independent sector, cover is already in place because of an employer’s vicarious liability for the negligent acts or omissions of their employees. Personal cover is required in relation only to self-employed practice.
The order makes provision that all practising regulated healthcare professionals must hold an appropriate insurance or indemnity arrangement as a condition of their registration—and, in the case of medical practitioners, a licence to practise—with the relevant regulatory body. It will be for individual healthcare professionals to assure themselves that appropriate cover is in place for all the work that they undertake. Unless healthcare professionals, who are practising or intend to practise, can demonstrate to the satisfaction of the regulatory bodies that such arrangements are or will be in place, they will be unable to be registered as a healthcare professional and will be unable to practise. I commend this order to the Committee, and beg to move.
Baroness Cumberlege (Con)
I declare an interest as a fellow of the Royal College of Obstetricians and Gynaecologists, a vice-president of the Royal College of Midwives and a patron of the National Childbirth Trust and Independent Midwives UK. I have other interests that are in the Lords’ register. I thank my noble friend for introducing this statutory instrument so clearly and for meeting the noble Lord, Lord Hunt, and myself, when we discussed the issue of independent midwives.
Draft statutory instruments are not usually a very gripping subject, but this one is because it affects the livelihood of so many people. It is therefore being introduced as an affirmative resolution. Not many statutory instruments, when enacted, will ensure that a professional is denied the right to practice—denied their livelihood. However, I start from the premise that every practitioner should have professional indemnity insurance. Some independent midwives are possibly the only group reluctantly acting without it but not only do they recognise the need for it, they want it and are prepared to go to great lengths to achieve it. This statutory instrument has concentrated minds and focused on the practicalities to achieve it, and from that point of view I welcome it.
It has been a struggle because insurance bodies draw no distinction between midwifery care and obstetric care, and of course the service given by each profession is very distinct. Obstetric treatment is very often a high risk activity, whereas midwife care is much less so. Successive Governments have adopted a policy that women should have choice—choice in healthcare but particularly choice in maternity services. This policy has been very widely welcomed by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the National Childbirth Trust, which have listened to women and have fought fairly long and hard to achieve this choice. All the evidence that they and others have gathered shows that women and their partners want choice. After all, there is nothing more important in life than giving life and bringing up the next generation.
Over the years, choice has been eroded thanks to the closure of maternity units, but in some places midwife-led units or birth centres have replaced them. They are often under threat as well. I welcome midwife-led units because they are another form of choice but I regret the diminution of home births because that is a choice denied. I ask my noble friend: how many home birth services in the NHS are on temporary hold and how many have closed? I know that they are very detailed questions and I would welcome a written reply if that suits my noble friend better than responding now. I am asking these questions because Independent Midwives UK provides for home births. That is a government policy and one that has been strongly endorsed by NICE. Independent Midwives UK provides continuity by a named midwife throughout antenatal care, birth and postnatal care—another government policy. Throughout the NHS this has proved to be pretty unachievable because community midwives are drawn into the acute services whenever there is a shortage, and because there is frequently a shortage it happens frequently.
The department’s new definition of continuity is co-ordination. A named midwife should co-ordinate the care, as my noble friend said previously. We should ask women what they think. Is co-ordination the same as continuity? Of course it is not, when in extremis women cannot even get their co-ordinator on the telephone 24/7 but they can with an independent midwife. Do they build a relationship with the co-ordinating midwife, assisting at that seminal moment of giving birth? No, because she is not there; she is too busy co-ordinating.
Independent midwives in all their forms—as social enterprises, employee-owned organisations, provident industrial societies with “bencom” status and so on—want to provide choice, continuity and care for women both in the independent sector and for the NHS. They are based in their communities and many provide services for vulnerable women, asylum seekers, those with mental health problems and so on, on a pro bono basis, but like the rest of us they cannot live on fresh air. They are seeking commissions with clinical commissioning groups. They are working towards direct referrals from GPs who welcome the continuity of knowing the midwife responsible for a mother who needs advice and support. Can my noble friend suggest ways in which the Government could support independent midwives, who are the professionals who not only support the Government’s policy but are the professionals who actually carry it out?
The NHS mandate, which sets the agenda for NHS England and which my noble friend and his ministerial colleagues shape, is an opportunity to ensure that alternative choices are there for women and their partners. Will he encourage the ministerial team to focus on this issue and enable independent providers of services to thrive, thereby enhancing government policies, giving women choice and providing the continuity that they seek?
In closing, I pay tribute to the Nursing and Midwifery Council, which has taken a very measured view of this statutory instrument, has listened and has tried to meet the needs of all concerned, amending its guidance as necessary. I look forward to my noble friend’s reply, in writing if necessary.
Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the noble Earl for his introduction to the order, following, as he said, the Finlay Scott review. The Opposition have no argument with the principle of the order, but I want to raise with the Minister some of the practical consequences of its implementation. The Government’s consultation states that about 4,200 self-employed nurses and therapists may be required to obtain indemnity cover. For most concerned, the insurance premium is modest. The Department of Health’s consultation estimate was that for nurses the insurance premium would be £195 per annum, and for therapists between £255 and £256 per annum. There should not be a problem with those practitioners being able to pay that premium, but we run into great difficulty when it comes to independent midwives.
I take the point made by the noble Baroness, Lady Emerton, that of course the safety of the mother and baby is paramount, and her point about the issue of professional support for independent midwives. I am sure that she would recognise that for some women, the support of an independent midwife is very important to them. Sometimes the reason why a woman will turn to an independent midwife is that they find that statutory services are either not prepared to help her to have a baby at home or are less than sympathetic. It would be a great pity if, as a result of the order, that very small group of professionals was unable to practise. The RIA accepts that affordable commercial cover is not available to independent midwives working as individuals. The consultation estimates that there would be an annual cost of indemnity cover of about £15,000 per individual independent midwife. There is no way that an independent midwife is likely to be able to pay that sum.
It is fair to ask the Minister whether he considers that independent midwives will be able to practise in future as a result of the order. I take the point that the noble Baroness, Lady Brinton, made, about the benefit of this EU regulation, but what an irony that the Conservative Party, in particular, with its histrionics about Europe and the extraordinary behaviour of our Prime Minister in the past few days, is now bringing in a European order that will put independent midwives out of business. I wonder whether the Government really recognise that. They may find that independent midwives are in fact no longer able to practise, and the Government may come in for considerable criticism as a result.
I was unimpressed by the response given by Dr Dan Poulter in another place. He has been very unsympathetic to the issue of independent midwives. That is a great pity. When this order was debated in the Commons a few days ago, I thought that the government response was weak, unsympathetic and gave very little comfort indeed. It is all very well talking about social enterprises in the Wirral as if that is an answer. Clearly, that will not be an answer for many independent midwives. The impact of agreeing to the order is that independent practitioners will not be able to practise any more. Either they will be forced to come into the NHS or they will simply not be available to women in future. I would like the Minister to give his assessment of what he thinks the impact of the order will be on those independent midwives.
Having read the Commons debate, I am not clear what happens to staff who provide care, sometimes complex care, independently but who are not a member of a regulated body. What about care assistants practising independently? The Minister said that where they are employed they are covered because of the vicarious liability of the employer, but I am not clear about those practitioners in the health and care field who provide services but who are not part of a regulated profession.
As a general principle, the Opposition support the order because it is eminently sensible, but the Government could have found a more sympathetic way to help independent midwives to be able to practise in the future. I for one am fearful that, as a result of the order, they will not be able to do so.
Earl Howe
My Lords, I am grateful to all noble Lords who have spoken. I shall endeavour to answer all questions that have been put to me as fully as I can. To the extent that I cannot, I shall of course write to noble Lords after this debate.
The centre of attention in noble Lords’ contributions has been independent midwives. Independent Midwives UK is the body which has expressed most concern about the regulations. I am the first to say to my noble friend Lady Cumberlege that continuity of care and service in the NHS is important, and that is part of the mandate to NHS England. We fully accept the value of independent midwives. NHS England will refresh the maternity commissioning guidance to CCGs over the summer to support the plurality of providers and to help social enterprises get NHS commissions.
However, as my noble friend is aware, we are dealing here with self-employed, independent midwives. It is therefore important to look at the factors which pertain to that group of people in particular. My noble friend suggested that the order effectively puts certain independent midwives, the self-employed practitioners, out of business. I do not see it in that way at all. We recognise that self-employed independent midwives may be required to change their governance and delivery practices to comply with an indemnity policy, and it is for the individual practitioner to determine a suitable operating model under which they are able to continue to practise. Social enterprises are the obvious route to that.
The suggestion that independent midwives have not received the fullest attention from officials in my department is seriously misplaced.
Baroness Cumberlege
I have never said that. The department has really helped independent midwives keep up to date with what has been going on. Nor am I opposed to the order. I said earlier that I start from the premise that every practitioner should have professional indemnity. Perhaps the noble Baroness, Lady Emerton, did not hear that.
Earl Howe
I fully accept my noble friend’s statement on that score. It has been said that the Government have not been sufficiently supportive of the attempt by IMUK to overcome these obstacles, and I welcome my noble friend’s recognition of those efforts.
Independent Midwives UK made an application, as my noble friend knows, for government funding for its proposal. That was considered, but the conclusion reached after independent expert advice was that the proposed insurance model was not feasible and would not provide long-term protection to pregnant women.
Alongside that, we were mindful that the creation of any government scheme specifically for Independent Midwives UK would effectively position the Government as the underwriter of the independent sector. My noble friend is as aware as anyone of the sensitivity of that. That would have undermined any private sector solution, which in turn would reduce the onus on midwifery service providers to demonstrate financial responsibility in what is undoubtedly a high-risk area of clinical practice—that is, it would reduce the onus on them to be responsible for showing an underwriter the appropriate steps being taken to mitigate risks. So, for a number of reasons, we were not able to take those proposals forward.
However, we explored a number of routes. One was that a corporate body should be formed that would be eligible to join the clinical negligence scheme for trusts, although that would not cover non-NHS work. We made funds available via our Social Enterprise Investment Fund to support the development of social enterprise solutions where the market does not offer affordable indemnity to individuals. That was not seen as a viable route either, although a new social enterprise called Neighbourhood Midwives was set up through that route and is now offering maternity care in the private sector with appropriate indemnity cover in place. Its business model is a 100% employee-owned mutual providing management and support to small, community-based neighbourhood practices.
My noble friend Lady Brinton asked about the insurance sector. From the start of the discussion in 2010, dialogue has been in progress with the Association of British Insurers, individual insurers and insurance brokers, who have indicated that insurance would be available for corporate bodies employing midwives to deliver NHS or non-NHS services. It would be necessary for corporate bodies to demonstrate the robustness of their governance systems to provide adequate assurance to an indemnifier. Where providers can demonstrate safe outcomes as well as good risk management processes, this would affect the price that was quoted, making it more affordable. There are also other factors that can be varied, depending on the appetite for financial risk, and which can reduce the price, such as excess provisions. This concurs with the independent research commissioned by the NMC and the Royal College of Midwives that suggests that independent midwives would be able to obtain insurance as employees within a corporate structure. As I say, some independent midwifery providers have secured insurance by fulfilling the above principles.
I heard my noble friend Lady Cumberlege say that the order effectively deprives certain individuals of the right to work. I do not share that view. The right of an individual to practise their profession is not an absolute right; the state may impose certain conditions provided by law that an individual must satisfy in order to practise their profession. Those conditions should be both proportionate and justifiable.
The bottom line here is that we believe it is unacceptable, as the noble Baroness, Lady Emerton, emphasised, for individuals not to have recourse to compensation where they suffer harm through negligence on the part of a registered healthcare professional. The NHS constitution in England reinforces this by including,
“the right to compensation where you have been harmed by negligent treatment”.
In requiring all practising regulated healthcare professionals to hold an indemnity arrangement as a condition of registration, the order does not make the practice of independent midwifery illegal—far from it. Midwifery outside the NHS will still be accessible in the ways that I have already described. I note that Independent Midwives UK is advertising insurance as a benefit of its membership, so I wonder whether any self-employed midwives will in fact have to stop practising.
My noble friend Lady Brinton hit the nail on the head when she expressed her welcome for the EU directive and the principles that underlie it: that all patients across the EU should be treated by healthcare professionals who have insurance or indemnity cover.
The noble Baroness, Lady Emerton, touched on the issue of compensation. As she knows, compensation for negligence can be very high indeed. It is for this reason that the Royal College of Midwives no longer offers insurance. Its scheme was stopped after an issue involving an independent midwife.
If we distil the arguments to their most basic, the implication behind a number of criticisms of this order is that choice in natal care should trump other considerations. I am afraid that the Government take a different view. Our policy is that patients should have recourse to redress if they are harmed, and the most cost-effective and proportionate way of achieving that is by requiring all practising regulated health professionals to hold appropriate cover.
Having said that, we lay great emphasis on choice, as my noble friend is aware. The policy set out in Maternity Matters: Choice, Access and Continuity of Care in a Safe Service, published in 2007 but endorsed by the current Government, aimed to introduce by the end of 2009 four main areas of choice in maternity. The choices are: how to access maternity care, whether via a GP or directly through a local midwifery service; the type of antenatal care—depending on the circumstances, midwifery care or team care with midwives and obstetricians; the place of birth, depending on the circumstances, supported by a midwife at home or in a free-standing midwife-led unit in a hospital, or supported by a maternity team including obstetricians in a hospital; and where to access postnatal care, at home or in a community setting.
I hope my noble friend will concede that maternity has been a major focus for the current Government. We have invested heavily in training additional midwives. There is a record number in training at the moment. We have invested large sums in improving and refurbishing birthing units, as well as introducing specialist mental health midwife training so that every birthing unit will have a specially trained clinician available by 2017. This is a major part of our agenda.
I think I have said as much as I can in answer to questions. I will, however, respond in writing to the points that I have not adequately covered, including my noble friend Lady Cumberlege’s question about how many home births might be on hold or suspended as a result of this order. I beg to move.
Health: Secondary Care
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Baroness Masham of Ilton
To ask Her Majesty’s Government what steps they will take to help to remove barriers to access to secondary care for symptomatic patients so they are identified and can start treatment earlier.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, GPs act as the gateway to and co-ordinator of patient care. GPs hold patients’ medical records and understand their health history. The GP will be able to work with patients and their carers to make an informed decision about whether a specialist referral is necessary, and to recommend appropriate hospitals or clinics. Early diagnosis can improve outcomes and treatment. We are therefore raising awareness of key symptoms and supporting GPs to assess patients more effectively.
Baroness Masham of Ilton (CB)
My Lords, I thank the Minister for his reply. Is he aware that some GPs are being penalised by CCGs for sending patients on for diagnosis? Is that not totally wrong and does it not cause late diagnosis, which is always more expensive in every way?
Earl Howe
My Lords, I agree with the noble Baroness that early diagnosis is vital for just about every condition one can think of, particularly cancer. I am not aware that GPs are being penalised. I am very concerned to hear that, and if I may I will take the point she has made back with me and write to her about it. I would be very concerned if that practice was taking place. Particularly on cancer, we are keen to see GPs referring more. Indeed, that is what they have been doing, quite markedly, over the past four years: there was a 51% increase in cancer referrals over that period.
Baroness Pitkeathley (Lab)
My Lords, would the Minister agree that one of the essential elements for early diagnosis was time—time to spend with the patient and hear exactly what their symptoms are? How does that tie in with the current reports about pressure on GP surgeries and time?
Earl Howe
The noble Baroness makes a very good point. We know that GPs in many areas of the country are under pressure and we know how hard they are working. It was with that knowledge that we agreed with the profession that we would remove from the GP contract for 2014-15 more than a third of the quality and outcomes framework’s indicators, which GPs told us were taking up too much time and resulting in a bureaucratic burden. The aim of that was to free up more time for GPs. On top of that we have the Prime Minister’s challenge fund of £50 million, which will test out new ways for GPs to give access to patients—for example, through innovative means such as Skype and e-mail.
Lord Sharkey (LD)
My Lords, early treatment is key to improving our low cancer survival rates. Lung cancer remains the biggest cancer killer. It has a 5% 10-year survival rate and 33% of all cases are emergency presentations. What progress has been made on improving early diagnosis?
Earl Howe
My noble friend is right. This is absolutely central to raising our performance as a country in successfully treating cancer. We are doing several things. We have piloted a tool to help GPs to identify patients whom they might not otherwise refer urgently for suspected cancer. The tool covered lung cancer, as well as others. Across England, 502 GP practices took part in the pilot. Initial indications are that the tool is extremely helpful. There is also an e-learning tool that offers accredited professional development for GPs. The Royal College of General Practitioners has also identified cancer as an enduring priority. It is working with Cancer Research UK and other partners in promoting models of best practice.
Lord Kakkar (CB)
My Lords, I declare my interests as professor of surgery at University College, London, and chairman of UCLPartners. Better integrating primary and secondary care is crucial to ensuring patient safety, improved clinical outcomes and the most effective resource utilisation. What progress has been made in defining whole pathway metrics for integrated care to best inform rational commissioning of these services?
Earl Howe
Several things are in train. One of those, as the noble Lord will know, was reflected in the legislative reform order that we debated in the Moses Room two days ago. It will cut down the administrative burden of joint commissioning by NHS England and CCGs, as well as the burden currently being experienced by CCGs in joint commissioning between themselves. More importantly, we need to incentivise the system for integrated care, and that is what the better care fund is designed to do. It will ensure that patients receive joined-up care, whether that is in acute settings, in the community or, indeed, from social care.
Baroness Wall of New Barnet (Lab)
My Lords, the noble Earl will know that a number of trusts like my own, which is Barnet and Chase Farm, are trying to remove the barriers that still exist between providers of secondary care and of primary care. What help can the Government give to make sure that primary care is better funded and reinforced so that people do not have to come into hospital, and so that we have an absolutely seamless pathway of care?
Earl Howe
We have said that preparations for the better care fund in 2015-16 should most definitely include a dialogue between commissioners and providers, and that there should be a whole system approach to incentivising the treatment of patients in the community. Of course, that will involve hospitals such as that of the noble Baroness, which I had the pleasure of visiting this week, informing themselves on how they can assist in the effort to do what we all want to do, which is to see patients treated in the best environment possible.
Baroness Gardner of Parkes (Con)
At a time when GPs seem to be very budget conscious and worried about everything, can the Minister assure me that there are no perverse incentives that would tend to deter them from making these secondary referrals early? That is very important.
Lord Winston (Lab)
My Lords, governance, early diagnosis and visits to the general practitioner are all very well but, as the noble Earl will understand, many cancers such as lung cancer, which has just been mentioned, and pancreatic cancer depend on relatively silent tumours that are not going to be diagnosed on a clinical basis anyway. Surely the need is for markers for these diseases. What are the Government planning to do to increase research in this area, to ensure that we have markers for these diseases?
Earl Howe
Cancer research is a major priority for my department. Investment in cancer research by the National Institute for Health Research has risen from £101 million in 2010-11 to £133 million in 2012-13. However, that is only what my department is doing. As I am sure he is aware, a whole range of work is going on across many different types of cancer, which we regard as a priority.
Health: Patient Safety
Earl Howe Excerpts(10 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I now repeat a Statement made earlier today in another place by my right honourable friend the Secretary of State on the subject of patient safety.
“Mr Speaker, I would like to make a Statement to the House about a package of measures that I have announced today in order to boost safety, transparency and openness in our NHS following my earlier Written Ministerial Statement.
Just last week, the respected Commonwealth Fund ranked the UK in first place for quality of care, including safety. We compare well internationally and it is clear that we have much to be proud of. However, it is also clear that there is more to do. We must not be complacent.
It is estimated that 12,000 deaths a year in hospitals have a 50% chance of being prevented. Figures released by NHS England today tell us that there were 32 ‘never events’ in the last two months, including a throat pack and a hypodermic needle being left inside patients post-surgery. These are shocking statistics.
In the Government’s response to Sir Robert Francis’s landmark public inquiry on the poor standards of care at Mid Staffordshire NHS Foundation Trust, I made clear our determination to make the NHS the safest and most open and transparent healthcare system in the world.
So, today, all hospital trusts around the country will receive an invitation to ‘Sign up to Safety’. This campaign, led by Sir David Dalton, the inspirational chief executive of Salford Royal, will help us achieve our ambition of halving avoidable harm and thereby potentially save 6,000 lives. Trusts will be asked to devise and deliver a safety plan, and may receive a financial incentive from the NHS Litigation Authority to support implementation.
Mr Speaker, we are also fulfilling the pledge we made in our response to Francis to create a hospital safety website for patients. As of today, the NHS Choices website will tell us how all hospital trusts are performing across a range of seven key safety indicators including ‘open and honest reporting’. And, for the first time, the website will let patients and the public see whether a hospital has achieved its planned levels for nursing hours.
Indeed, I am pleased to inform the House that the latest workforce statistics published today show us that we have 5,900 more nurses on our hospital wards since our response to Francis.
Mr Speaker, I am proud that the NHS is blazing a trail on openness and transparency. We are the first country in the world to publish this breadth and depth of safety data.
Finally, I am pleased to announce today that Sir Robert Francis QC will be chairing an independent review on creating an open and honest reporting culture in the NHS. This review will provide advice and recommendations to ensure that NHS workers can speak up without fear of retribution. The review will also look at how we can ensure that where NHS whistleblowers have been mistreated; there are appropriate remedies for staff and accountability for those mistreating them.
Mr Speaker, I am confident that this package of measures will shine a light on poor care so that lessons can be learnt, action can be taken and harm to patients prevented”.
That concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord for his welcome of the measures that we have announced today. They must be seen in the context of other measures that we have taken in the light of Robert Francis’s report, many of which have been debated in this House.
The noble Lord spoke about a culture of naming, shaming and blaming. I do not see it in that light. The key message from Robert Francis was surely that we need a change of culture in many of our NHS institutions. That is not something that can be dictated by legislation. On the other hand, it is something that we can assist in promoting by means of transparency. The whole drive towards quality is surely assisted by shining a light on poor practice where it exists, encouraging all staff in hospitals to take ownership of what their organisation is doing and then putting those things right. That culture should extend from the board right down to the lowest level of staff. This is part and parcel of the move that the NHS is trying to make in the direction of creating a better culture—one that exists in many parts of our NHS but not in enough of them.
Do we intend to promote transparency in all those providing services to the NHS? Yes, that is the intention. This would be done by means of the NHS standard contract, which in time will incorporate the necessary provisions.
As regards infection rates in hospitals, the picture nationally is in fact very good. The numbers of MRSA bloodstream and C. diff infections are currently at record lows, but there is no scope for complacency. We believe that the website that I referred to in the answer that I repeated, which will incorporate the indicator relating to infection and cleanliness, will act as a spur to hospitals when they know that their patients can see the degree of infection pertaining over the previous three-month period.
How do we intend to save the lives that we have the ambition to save? As I said at the beginning, much of this depends on openness, on transparency and clarity for the public, and indeed on staff taking ownership of problems where they exist, not shying away from them. We think of measures like the fundamental standards being introduced that will define the level below which standards of care should never fall. We think of the duty of candour that is to be introduced. We think of the new ways in which the Care Quality Commission, with its new chief inspectors, is approaching the task of assessing the quality and safety of institutions. All these things combined should be seen as part and parcel of the picture.
Baroness Brinton (LD)
My Lords, a 2012 report by the American Department of Health showed that 86% of reportable events were not reported, partly because of staff misperceptions about what constitutes patient harm. Will the Minister reassure the House that both the Government and the NHS regard one in five incidents going unreported as unacceptable? What will the Government do to ensure that all staff understand what needs to be reported and do so in a truly open and transparent culture?
Earl Howe
My noble friend makes a series of very important points. Clearly, a balance has to be struck here. It would become self-defeating if every single mistake, even one that had no bearing on patient safety, had to be reported by every single member of staff. The system would be overloaded. We are keen to ensure that those incidents that result in potential harm, real harm or—worse still—death are reported, exposed and dealt with. Of course the National Reporting and Learning System, which was originally part of the National Patient Safety Agency when the previous Government set it up and is now housed at Imperial College Healthcare NHS Trust, has the task of collating safety incidents from trusts and drawing lessons from them. That is every bit as important a process as it ever was. It will be the task of NHS England to draw those lessons together and incorporate them in its commissioning guidance. My noble friend has raised that issue and we have a task ahead of us that will take some time to achieve; but I believe that this is a welcome start.
Lord Pearson of Rannoch (UKIP)
My Lords, looking back on it, was the Nursing 2000 initiative not a bad mistake because it turned nursing into an all-graduate profession, with degrees supplied by the second-rate social science departments of the former polytechnics? Are the Government doing anything with the training of nurses that reflects what the noble Lord’s colleague at education, Mr Gove, is doing with the training of teachers, about which we heard in the first Question today? Is there a new emphasis on practical training and on getting back to matron and the discipline of the ward?
Earl Howe
It was only recently that the Nursing and Midwifery Council revised the curriculum for the training of nurses. I am sure that the noble Lord will be pleased to know that that curriculum is broadly divided 50:50 into practical training and training in the classroom, which was the balance historically. I believe that nurse training is now set fair for the future. The noble Lord is right to raise concerns about Project 2000, which many people felt did not quite address the needs of nurse training. However, that programme is substantially different now from what it was in 2000.
Lord Willis of Knaresborough (LD)
My Lords, I am delighted to follow the arch-moderniser, the noble Lord, Lord Pearson. In the whole of my noble friend’s Statement, and indeed until the noble Lord raised his question, not a word was mentioned about the training of the staff who actually care for our patients. We have a situation in which, unless you are a medic, you are not entitled, even if you are a qualified nurse, to have resources spent on you in order to continually update your professional development. In terms of preceptorship, there are no resources; in terms of mentorship, there are little additional resources; and there is virtually no resource to train healthcare assistants. Will my noble friend agree that although the move to have 9,000 more nurses is incredibly welcome, we need to put training at the very heart of the safety agenda, because unless we train we will not get high-quality staff?
Earl Howe
I agree with my noble friend; it would be difficult to disagree with him. Training is essential if we are to have high-quality staff. That is why we have protected the training budget, which is now hosted by Health Education England, whose job it is to ensure not just that there are adequate numbers of each type of professional in the health service but that the quality of the training is as we would all wish. It is the task of the local education and training boards to assess the position at a local level and, informed by the NHS providers that are under their wing, to respond to the needs of those providers.
Legislative Reform (Clinical Commissioning Groups) Order 2014
Earl Howe Excerpts(10 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this draft legislative reform order would amend the National Health Service Act 2006 in two ways. First, it would allow clinical commissioning groups—CCGs—to form a joint committee when exercising their commissioning functions jointly. The NHS Act already allows two or more CCGs to exercise their commissioning functions jointly, but does not make any provision for them to do so via a joint committee. Secondly, it would allow CCGs to exercise their commissioning functions jointly with NHS England, and to form a joint committee when doing so. The Act already allows NHS England and CCGs jointly to exercise an NHS England function, and to do so by way of a joint committee, but it makes no provision for them jointly to exercise a CCG function.
This draft order has already been scrutinised by the Delegated Powers and Regulatory Reform Committee and I was pleased with its recommendation that it should continue under the affirmative resolution procedure. I hope it will assist the Committee if I set out the need for these proposals.
I emphasise from the outset that the proposed arrangements are voluntary. One party cannot impose the arrangements upon another. This allows CCGs to retain their autonomy and to continue to make decisions that are in the best interests of their local populations. At the moment, the lack of provision for CCGs to form joint committees is placing a burden on CCGs and preventing them from working in the most effective and efficient way. Without the power to form joint committees, CCGs have had to find other means of reaching joint decisions which are binding. As an interim measure, some CCGs are forming “committees in common”, whereby a number of CCGs may each appoint a representative to a committee in common; those representatives then meet, and any decisions that are reached are taken back to their respective CCG for ratification. This leads to costs in people’s time to sit on multiple committees and administrative resource, as well as extra financial costs.
For example, I am aware of the limitations that the current commissioning arrangements are having on the East of England Ambulance Service. NHS Ipswich and East Suffolk CCG is lead commissioner for ambulance services across the east of England, and the remaining 20 CCGs in the region are associates to that commissioning arrangement. The CCGs established a commissioning consortium, which brings together all 21 CCGs to discuss both delivery against the ambulance contract and future strategy for ambulance services. However, due to the restrictions of current legislation, the consortium itself is not delegated any decision-making authority. While most CCGs party to the consortium have delegated a level decision-making authority to the individual officers who attend the consortium, the contract with the ambulance service is large, and decisions may exceed delegated limits. In those instances, decisions must be referred to CCG governing bodies, introducing a delay to the decision-making process.
Clearly arrangements such as these are burdensome, particularly when compared to the simplicity of a joint committee. Primary care trusts, the predecessors of CCGs, were able to form joint committees at which, subject to the terms of reference, all participating PCTs were bound by the decisions reached. We therefore want to allow CCGs a route in which, when they are collaborating with other CCGs, they can take decisions in a properly constituted forum. Furthermore, CCGs when agreeing to form a joint committee will have the freedom to agree terms of reference, including voting arrangements. This will not dilute the emphasis of local decision-making.
Similarly, the lack of any power for CCGs to exercise their functions jointly with NHS England is also causing inflexibility. NHS England and CCGs may wish to act jointly to commission better out-of-hospital services, for example. Making sure that services are integrated around the needs of the patient is the best way of ensuring that care is provided in a safe and compassionate way that most benefits the person. This amendment would allow CCGs and NHS England, as co-commissioners, to develop and agree strategic plans and delivery processes that take into account the effects of services across a whole pathway, facilitating design and continuity of services across primary, secondary and community care.
For example, CCGs and NHS England may wish to review service delivery across specialised services, commissioned by NHS England, and any impact redesign may have on non-specialised acute services, commissioned by CCGs, in order for services to be designed and delivered to achieve the best possible outcome for the population served. The inability of NHS England and CCGs to jointly exercise a CCG function and to form a joint committee when doing so makes it more difficult to make timely decisions, which can delay the ability to improve patient safety. Furthermore, the amendments would encourage the formation of new commissioning partnerships, allowing the most effective approach to be used.
The amendments would build upon them by giving CCGs greater flexibility and control in the way that they work. As CCGs become more established organisations, they need to have more flexibility to work together, and with NHS England. In any commissioning structure you have in place, there are always going to be some decisions that may need to be taken locally and some that span a wider population.
CCGs are still accountable as individual organisations. Joint arrangements mean that each CCG is still liable for the exercise of its commissioning functions, even where they are being exercised jointly with another CCG or NHS England. These proposed arrangements will not lead to reconfiguration by the back door. The purpose of these changes is to support more effective joint working and to allow discussions about service redesign to take place across the health economy. The proposed changes will not affect the existing processes and tests that any significant service redesign needs to follow. I beg to move.
Baroness Brinton (LD)
My Lords, the NHS Act 2006 started us down the route of commissioning; obviously, with the updating and creating of clinical commissioning groups under the Health and Social Care Act 2012, we are still moving into fairly new territory. Inevitably, CCGs are feeling their way in the new structures, including joint working. I am pleased that the order will now legislate more formally for CCGs to work closely with each other and with NHS England, and to jointly commission where appropriate.
One of the many reports that come back to your Lordships’ House from CCGs and NHS trusts is the desire to gold-plate any system with legal advice. For example, we know that the Health and Social Care Act enabled tenders to be taken for quality and efficacy, not just on cost, as under the 2006 Act, yet we hear time and again that lawyers tell commissioners that cost is the most important point. I also welcome the issues around CCGs and National Health Service England overlapping. The Minister referred to some of those; it is also important where there is a pathway in rare diseases, where there may also be some linkages with CCGs perhaps implementing at a lower level. That will smooth the way for that to work well.
To this non-lawyer at least it seems extraordinary that CCGs could not form joint committees to commission over boundaries. This draft order now makes it crystal clear that joint commissioning and the arrangements for ratification by the separate CCGs are not just acceptable but welcome. It is encouraging to see in the accompanying notes that the consultees to this order also see it as a cost-efficient measure; I add to that smoother working systems and, most importantly, joined-up services for users of the NHS.
Lord Hunt of Kings Heath (Lab)
My Lords, on the face of it the order is unexceptional, although I agree with the noble Baroness that CCGs have got themselves into a ludicrous state of getting legal advice on almost everything. It is patently obvious that there are ways in which they can come together to make decisions. We also see that as regards tendering, where, despite the commitments the noble Earl made, we see CCGs absolutely panic-stricken about making a decision not to tender out services. If ever one wanted evidence of the foolishness of the arrangements we now have, it would be the kind of reaction we are seeing from CCGs.
I will ask two or three questions on the order. I noted in paragraph 4.6 of the consultation paper that the department points out that there was opposition to the proposal to enable CCGs and NHS England to form joint committees. I understand that while it is mainly about CCGs forming joint committees, they can also form a joint committee with NHS England. The necessary protection is laid out in paragraph 3.6 of the paper we received, which says that:
“The Minister considers that the proposals maintain the necessary protections. CCGs enjoy a degree of autonomy”.
I thought that they were going to be autonomous, but there we go; it has been qualified in that document. The paragraph goes on:
“To this end, NHS England is under a duty … to promote the autonomy of persons exercising functions in relation to the health service. The wording of the proposed amendment to section 14Z9 is designed to ensure that a CCG function can only be jointly exercised with NHS England where both parties are in agreement, thus preserving a CCG’s autonomy”.
I put the point to the noble Earl that if you talk to CCGs, they do not feel autonomous, because they are used to being beaten up by NHS England—receiving incessant phone calls from the local offices of NHS England—and they and the accountable officer find themselves under huge pressure when there are problems with the system. Therefore the idea that there is an equal partnership between NHS England and the CCG as regards a joint committee is simply not believable. Clearly, local area teams will use that mechanism to force CCGs into joint committees and then force decisions through. I would have thought that that is patently obvious from what is happening in the field in the National Health Service. I would be grateful to hear the noble Earl’s comment on that.
Of course, I have no problem about CCGs working together so that we can get rid of some of the current fragmentation. If we take my own patch of Birmingham, where three and a half CCGs cover the city, there is no chance, it seems, of actually having a strategy for the city which can embrace all the trusts and commissioners unless it is done jointly. I would like to hear from the noble Earl how in fact this mechanism is going to be used to encourage CCGs, which are patently too small in many areas, to come together so that we get some decent strategic planning instead of the fragmented and inadequate contracting process that so many CCGs are undertaking at the moment.
I would also like to ask the noble Earl about consultation when decisions are made by a joint committee. I assume that the consultation rights and responsibilities would apply to a joint committee as much as they do to an individual CCG but, as there is scant evidence of CCGs undertaking proper consultations, I suppose that that is not much comfort. It would be good to hear a little more about how CCGs are going to work this. I must say that after two years of this wonderful new system, I am still waiting for a letter from my CCG saying that it actually feels some form of accountability to me as an individual, but alas that letter has yet to come. From the legal cases which have been brought against some CCGs, it is clear that they do not have any sense of accountability to their local population. That is not surprising because they are membership organisations. They are owned by GP practices, which are the members of the organisation.
This morning I listened to Simon Stevens, appearing before the Public Administration Select Committee, talk about the proposal to hand over some of the contractual responsibilities of NHS England to CCGs. So, in effect, not only are the CCGs membership organisations, they are now going to be given co-power with NHS England to contract with the individual members of the organisations in relation to primary care services. I can well understand why the local area teams do not have the capability to manage the primary care contract. It was patently obvious that they were not going to do so. But what it comes back to is that the governance of CCGs is hopelessly compromised. They ought to be public bodies with much greater lay representation. If they were, we would have much more confidence in the arrangements, but they are not. They are dominated by contractors who have a vested interest in the decisions made by those clinical commissioning groups.
Finally, I turn to page 3 of the impact assessment that provides the evidence base for the supporting paper. It is implied that decisions to deal with specific funding requests might be dealt with by a joint committee. That, of course, is a euphemism for rationing services. Again, we know that some CCGs are making highly dubious decisions about restricting patient services to which NHS patients are entitled. I would like some reassurance that if the joint committee is going to do this, it will be done in public, not behind closed doors, and after full consultation. Recently I have been particularly concerned about evidence which shows that NICE technology appraisals are not being fully implemented in the National Health Service. I remind the noble Earl that it is a legal requirement for a NICE technology appraisal to be fully implemented by the NHS. Again, I would like to hear what the Government are going to do to ensure that CCGs actually play fair by the public and do not unnecessarily restrict treatments.
The order itself is unexceptional and it is supported, but I have to say that the performance of some CCGs leaves a lot to be desired. It is because of the potential of the joint committees to make major decisions that I raise some concerns today.
Earl Howe
My Lords, I am grateful to my noble friend and the noble Lord, Lord Hunt, for their comments and questions. My noble friend was quite right to cite the example of rare diseases and specialised services as one which will be assisted by the order before us, because while we have a mechanism for NHS England and CCGs to get together to discuss these things, we lack the ability for decisions to be taken about the whole patient pathway. This, of course, is vital when we look at the aspiration to join up services for the benefit of patients—not just the specialised care they receive in a centre of excellence, but also the follow-on care that they receive in the community. I therefore share my noble friend’s welcome for this aspect of the order.
I turn to the questions put by the noble Lord, Lord Hunt. A key plank of the Government’s reforms was to increase clinical commissioning. We do not want to depart from that, or from the principle of giving clinical autonomy to those who run clinical commissioning groups. We want to encourage them to enter into arrangements that have the buy-in not just of the local GPs, but of health professionals in their local area and the local authority. We have been clear on the need for a different splitting out of the commissioning functions—for example, to avoid CCGs commissioning individual GP practices and the conflicts of interest that may arise. The arrangements for safeguarding against conflicts of interest are still in place, but what we hear is that as organisations become more established they need a bit more flexibility to work together. In any commissioning structure, there is going to be that need and this order is about allowing those CCGs to work more efficiently. I emphasise that point about allowing them and not requiring them to do so. There is no compulsion about this. The noble Lord indicated that he felt that CCGs do not feel autonomous. I am surprised to hear that, because the arrangements that we have put in place are designed to ensure that local area teams of NHS England are there to support CCGs, not to oppress or breathe down their necks. That is my experience as I go about the health service. This is about joint working and taking decisions together in the best interests of patients.
The noble Lord asked me about transparency. CCGs are under certain duties with respect to patient involvement and transparency when they exercise their functions. Those duties would continue to apply when they exercise their functions jointly with other CCGs. The duty to consult still applies. CCGs will be under the statutory obligations as to patient and public engagements. However, it will be up to committees to agree precisely how they will work in accordance to their obligations. Some consultation responses that we received refer to committees in common that meet in public. Joint working does not have to entail working behind closed doors.
The noble Lord asked about NICE technology appraisals. He is right that some CCGs are slower than they should be under the legal provisions that pertain to adopting and commissioning approved technologies flowing from NICE. To shine a light on that, as he may know, under the Innovation Health and Wealth provisions, we have the NICE implementation collaborative, which is the mechanism designed to measure the extent to which local commissioners adopt approved technologies. The innovation scorecard is also designed to show how innovation in various forms is being rolled out and diffused across the NHS. I believe that mechanisms such as these will be enormously helpful in exposing the laggards in the system.
I hope that I have answered the noble Lord’s questions. I shall write to him if I have failed to cover any substantive point.
Defibrillators
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank my noble friend Lord Storey for giving us the opportunity to debate what is undoubtedly an important issue. I know that many people feel that better provision of defibrillators could help save more lives of people who have a cardiac arrest outside a hospital setting—known as out-of-hospital cardiac arrest. I acknowledge in particular the work of the Oliver King Foundation in this area.
First, I emphasise that responsibility for the provision of defibrillators rests with ambulance trusts, which are undoubtedly best placed to know what is needed in their local area. Notwithstanding that, last year’s Cardiovascular Disease Outcomes Strategy set out some recommendations around defibrillators. NHS England is implementing the strategy’s recommendations, which includes working with stakeholders to promote the site-mapping and registration of defibrillators and to look at ways of increasing the numbers trained in using defibrillators. The strategy also acknowledged that, although defibrillators are important, more lives could be saved if more people had life-saving skills. As I shall indicate shortly, NHS England is also working with stakeholders to help achieve just that.
Schools are of course at the centre of their communities and are often used for other purposes outside school hours. They are also frequently the location for sports events and other types of physical activity. There have been tragic incidents in which young children have had a sudden cardiac arrest and were not subsequently able to be resuscitated. The number of such incidents is thankfully very low, but of course every child who dies in this way is one child too many. The use of a defibrillator may have made a difference in these cases, which is why we are encouraging schools to acquire defibrillators in a broader package of measures designed to ensure that the medical needs of children in our schools are supported. It might be helpful if I explain a little more about these measures, particularly in answer to my noble friend’s questions.
We have introduced a new duty on school governing bodies which requires them to make arrangements to support pupils with medical conditions and to have regard to new guidance on Supporting Pupils at School with Medical Conditions, which will come into force from this September. We will also inform schools via the “need to know” e-mail and the “myths and facts” documents, which are sent out to schools each term. I absolutely agree with the noble Baroness, Lady Grey-Thompson, and the noble Lord, Lord Aberdare, that emergency life-saving skills are very important. Those skills can be taught as part of personal, social, health and economic—PSHE—education. However, it is also right that teachers should be free to exercise their professional judgment in designing curricula that meet the needs of their pupils. Giving teachers greater flexibility and freedom than ever before will help to raise standards and expectations for all pupils. However, one must put that in the context of the role of governors of schools, who undoubtedly have an influence. The Government do not believe that the teaching of emergency life-saving skills should be a statutory requirement, but we encourage schools to teach PSHE, which may well include emergency life-saving skills, and have outlined that expectation in the introduction to the new national curriculum.
On defibrillators, we believe that head teachers are best-placed to make decisions about installing them in schools. They may, for example, wish to have multiple AEDs, or to share a machine between two schools located on the same site. By strengthening guidance and working to secure the devices at a reduced price, we are encouraging schools to install defibrillators.
The noble Baroness, Lady Grey-Thompson, asked me to give some statistics in so far as I have them about the scale of the issue in schools. The Office for National Statistics says that the total number of cardiac deaths of patients of school age—that is aged five to 19—is 88, although we do not know how many of those deaths occur in schools. However, I have some very interesting statistics from the London Ambulance Service. In London, between 1 April 2012 and 31 March 2013, there were 3,848 patients with a presumed cardiac origin to their arrest and in whom resuscitation was attempted. The breakdown of location for these shows that 79.2% were in the home or in a care home. Of the 800 cases which happened in public, 1.1% were in a sports centre and 0.3% were in a school. I shall make a further comment about that in a moment.
The Department for Education intends to produce a protocol on the use and purchase of AEDs in schools. The guidance to which I referred asks schools to consider purchasing a defibrillator as part of their first-aid equipment and, if they do so, encourages them to promote knowledge of cardiopulmonary techniques more widely in the school, among both teachers and pupils alike; I have already referred to that point. To help schools, we will be working with the Department for Education to identify a supplier that will provide suitable defibrillators to schools at a competitive price. We will provide schools with additional advice on the installation and use of these potentially life-saving devices so that staff will feel confident in using them should the need arise.
Safety in all sports is a matter for the national governing bodies—NGBs—as the designated authorities with responsibility to regulate their sport. The Football Association is working alongside the British Heart Foundation to oversee a £1.2 million investment towards state-of-the-art automated external defibrillators at football clubs in England. This initiative, which started in 2013, will see almost 1,300 defibrillators distributed to those clubs in which they will have the greatest potential use. Through bulk purchase, the FA has secured the defibrillators at a reduced cost and eligible clubs may apply for a defibrillator at a further reduced cost. The FA’s partnership with the BHF has ensured that this investment in defibrillators has the greatest possible impact. In addition, all FA-licensed coaches are required to undertake a first aid course and should be able to administer CPR while awaiting the arrival of emergency medical services.
In answer to the noble Baroness, Lady Grey-Thompson, on who is responsible for the safety of people participating in sports in local venues, the national governing body for the particular sport is responsible for the safety of athletes and/or their training. In practical terms, the responsibility would fall to the coaches and/or any other support staff at the facility. We would expect the owner or manager of the building to be subject to any other relevant health and safety regulation or legislation, such as that on fire safety.
There is frequent discussion about screening for the causes of sudden cardiac death. Screening may have the potential to save lives but it is not a fool-proof process. For example, I understand that the footballer mentioned by the right reverend Prelate, Fabrice Muamba, who suffered a cardiac arrest during a match, had received several screening tests. However, it is important that we keep the issue of screening under review. That is why the UK National Screening Committee, which advises Ministers about all aspects of screening, is reviewing the evidence for screening for causes of sudden cardiac death in people between the ages of 12 and 39. The review is looking at the most up-to-date international evidence, including evidence from Italy, where all competitive athletes are offered screening. There will be a public consultation on the review this autumn.
Noble Lords raised with me separately the need to make sure that, when a person dies of sudden cardiac death, potentially affected family members are identified and are offered counselling and testing to see whether they are also at risk. We know that this does not always happen. That is why in last year’s CVD strategy we said that work would begin to improve the necessary processes. I can tell the Committee today that, since the strategy was published, NHS England has met the chief coroner to discuss what can be done. At the beginning of the year, the chief coroner wrote to local coroners asking them to make the families of those who had died of the condition aware that it may be inherited and encouraging them to contact either the British Heart Foundation, Cardiac Risk in the Young, or their GP.
On the general question asked by my noble friend Lord Storey about why the Government should not be providing more funding for defibrillators, I am sure he will agree that we must direct NHS resources responsibly, particularly now. As I indicated earlier, the statistics show that most out-of-hospital cardiac arrests occur in the home, which means that in our view more lives could be saved if more people had life-saving skills. NHS England is continuing to work with the British Heart Foundation, the Resuscitation Council (UK) and other organisations on how best to increase the number of people trained in basic life-saving techniques. The BHF and the Resuscitation Council (UK) have both produced a variety of free publications to help members of the public understand the importance of basic life-saving techniques, as well as offering training through the Heartstart scheme in various mediums that enable more individuals to learn the basics of helping to save someone’s life in the event of an emergency.
But I come back to the point I made earlier: since February 2007, ambulance trusts have been responsible for sustaining the legacy of the National Defibrillator Programme. To address a question asked by the noble Lord, Lord Hunt, we undoubtedly expect the commissioners of urgent and emergency care who take part in discussions at health and well-being boards to engage with ambulance trusts in an appropriate way and, if necessary, to feed in their views to the priority-setting process that the boards engage in.
The noble Lord, Lord Aberdare, asked whether I have numbers for the people who are trained in life-saving skills. I understand that 3.5 million people have received emergency life support training through the Heartstart scheme. The right reverend Prelate the Bishop of St Albans correctly referred to the important role played by community first responders. I have with me an extensive note which unfortunately I do not have time to read out, but suffice it to say that CFRs carry automated external defibrillators and are trained and equipped to provide oxygen therapy. Finally, my noble friend Lord Storey asked me about a universal logo. I am very happy to take that point away and ask Huon Gray in NHS England to consider the matter. I will then feed back to my noble friend as appropriate.
In closing, I would like briefly to take this opportunity to pay tribute to charities such as the British Heart Foundation and the Oliver King Foundation for their tireless work in placing defibrillators locally and raising awareness of sudden cardiac death. I would also like to take a moment to acknowledge and thank the wide range of stakeholders we have collaborated with to develop the new statutory guidance for schools that I mentioned earlier. I know that they include my noble friend, with the Health Conditions in Schools Alliance, along with a range of other cardiac organisations such as the Oliver King Foundation and the British Heart Foundation. Their advice played an instrumental part in shaping the arrangements that we are now introducing.
Mental Health: Parity of Esteem
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Lord Patel of Bradford
To ask Her Majesty’s Government what assessment they have made to measure the success of their policy No Health Without Mental Health, which undertook to give mental health “parity of esteem” with physical health within the National Health Service.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, our commitment to parity of esteem is explicit in the Health and Social Care Act 2012. As stewards of the system, we hold the NHS to account for the quality of services and outcomes for patients through our mandate to NHS England and the NHS outcomes framework.
Lord Patel of Bradford (Lab)
My Lords, I think that the picture is fairly gloomy. There has been a real-terms 1% drop in investment in mental health services for adults of working age, and mental health trusts have reported a real-terms reduction of 2.36% over the past two years. Investment across the three priority areas—crisis resolution, early intervention and assertive outreach—has seen a £30 million drop for the first time. Funding for older people in mental health services has seen a 1% real cash-terms drop, and 67% of councils have stopped child and adolescent mental health services funding. These cuts have come in at a time when more people—almost 8 million—are experiencing mental health problems. In addition, 30% are suffering from a long-term physical health problem, the number of deaths by suicide is increasing and mental health ward occupancy levels are at over 100%. This Government promised parity of esteem and we were assured that that would be in the Health and Social Care Act. Does the Minister agree that we are far from meeting our obligations on this simply because of the cuts and what has happened to these vulnerable people?
Earl Howe
My Lords, mental health and mental well-being are priorities for the Government; I want to make that clear to the noble Lord. We have legislated for parity of esteem between mental and physical health, and we mean business on this. Our new mental health action plan, which has been well received, sets out our priorities for essential change. We have the Crisis Care Concordat, which guarantees that no one experiencing a mental health crisis should ever be turned away. We are rolling out choice in mental health, which is an extremely important step forward, and a whole range of other measures, including IAPT and the children’s mental health measures that I outlined a moment ago. I hear what the noble Lord says about funding. We have debated that matter in the House before. We are currently scrutinising local CCG spending plans to make sure that mental health gets the priority that it needs.
Baroness Howe of Idlicote (CB)
My Lords, I am sure that everyone welcomes the fact that mental health has emerged at last to receive the attention that it should be getting. However, will the Minister confirm that the Government are paying particular attention to the number of women in prison with a mental health problem? In previous decades, that was not addressed at all.
Earl Howe
My Lords, yes, we are doing so. We are paying attention not just to women in prison but to women and men in prison and in the criminal justice system more generally. We have committed £25 million to introduce a new liaison and diversion scheme in England to identify and assess the health issues and vulnerabilities of all offenders when they first enter the criminal justice system, which I think is the crucial moment. We are building on liaison and diversion services to improve the quality of those services and their coverage across England, and we are trialling a core model in more than 20 areas over the next two years with the aim of moving towards comprehensive rollout by 2017.
Baroness Brinton (LD)
My Lords, is the Minister aware that one in 10 children between the ages of five and 16 has a mental health problem and may continue to have problems into adulthood? What are the Government doing to ensure that child and adolescent mental health services are properly funded by NHS England and CCGs?
Earl Howe
My Lords, we are investing £54 million over the four-year period from 2011 to 2015 in the Children and Young People’s Improving Access to Psychological Therapies, CYP IAPT, programme. That, along with the measures that I referred to earlier, will, I hope, give a sense of the priority that we attach to children and young people’s mental health services.
Lord Winston (Lab)
My Lords, the Minister gave us a long list of things that the Government are doing. However, he does not mention research into mental health. Is not one of the key problems that clinicians are never able to identify the disease phenotype, and that makes further and better treatments impossible? Should there not be much more emphasis on the need to research mental ill health throughout the country?
Lord Rooker (Lab)
My Lords, will the Minister do what he can in government to lock in the policy of the programme that he has announced today? I remind him that—I think it was in 2004—the former Social Exclusion Unit published a seminal report on mental health and social exclusion, with 27 action programme recommendations. As Ministers come and go and as civil servants get recycled, things go off the boil and we have to start doing it all over again. That does not serve the citizens of the country on an issue such as this, which transcends all our other divisions. We need to concentrate on it so that we do not lose it as people come and go.
Earl Howe
The noble Lord is right and I can say to him that the coalition Government have tried as far as possible to continue the good work on mental health of the previous Administration. One has to keep renewing the momentum on this. Situations do not stand still, and that is why our new mental health action plan Closing the Gap reminds everyone in the system of the most important gains to be made in 25 areas where people can expect to see and experience the fastest changes. I am glad to say that that document has been well received by all stakeholders.
Mental Health: Social Work
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Baroness Tyler of Enfield
To ask Her Majesty’s Government what plans they have to improve the provision of mental health social work, given the incidence of mental health problems among the population.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government recognise that improving mental health services remains a significant challenge. Social workers play a vital role in delivering high-quality mental health services, and the Chief Social Worker for Adults is taking forward a number of initiatives with the sector to help address these challenges. Along with the College of Social Work, we recently launched The Role of the Social Worker in Adult Mental Health Services.
Baroness Tyler of Enfield (LD)
I thank my noble friend for his Answer. Does he share my concern about the shortage of good social workers who are able to work effectively in mental health settings in many places in the country? What further steps are the Government taking to address this? What specific plans do they have to ensure that social workers working in integrated health and social care teams feel valued by their medical colleagues and that their professionalism is indeed recognised?
Earl Howe
My noble friend makes some excellent points, and I acknowledge her role as a member of the programme board for the Think Ahead programme, which is designed to attract, in particular, new graduates into social work, and specifically into mental health social work. Good-quality social work can transform the lives of people with mental health conditions. It is an essential part of multidisciplinary and multiagency working. As we move forward into new ways of working, particularly in the context of integrating care, my noble friend’s point about other professionals understanding and appreciating the value that mental health social workers can give will be key, not just in terms of earlier intervention but by building resilience, reducing and delaying dependency and ensuring that people have all the information and enabling support that they need to look after themselves better.
Lord Bradley (Lab)
My Lords, I note my health interests. What is the Government’s assessment of the scale of shortages of mental health social workers? In particular, what assessment has been made of the capacity to respond to requirements under the Mental Health Act, particularly Section 135, for approved social workers?
Earl Howe
My Lords, we need more social workers, particularly in mental health. The Think Ahead programme is certainly one way in which we hope to improve the numbers. Social work is not always seen as an attractive career option. We know that there is a growing appetite among graduates to work in mental health; unfortunately that enthusiasm has not filtered through to the social work profession. We need to focus on that. Much will depend also on finding a greater number of placements in social work, particularly relevant to mental health, so that there is on-the-job training for those trainees.
Lord Laming (CB)
My Lords, does the noble Earl agree that the very least we must do for social workers operating in this very complex area of work is to ensure that they all have the appropriate training, which is not just about classic mental health problems but about the abuse of drugs and alcohol, and indeed now extends into the great impact that dementia has on patients and their relatives?
Earl Howe
The noble Lord is quite right. The importance of mental health knowledge across social work in its entirety—adults, children, adolescents and families—is vital. Mental health is a key factor for people with substance abuse problems and other complex social and health needs that defy neat categorisation. The Chief Social Worker for Adults, Lyn Romeo, is working with the Chief Social Worker for Children and Families, Isabelle Trowler, to produce a statement of the knowledge and skills required across children’s and adult services and the need for students and qualified social workers to be able to work with mental health issues in all contexts.
Baroness Trumpington (Con)
My Lords, what is the Minister’s solution to the situation that arises when a social worker moves from one district to another without necessarily taking their portfolio of work with them? I speak having been a Minister when a social worker was murdered when the person who killed her had changed district but the social worker had not been informed of the move.
Earl Howe
My noble friend makes an extremely important point about continuity of care. Not only is this important in terms of sheer administration; it is vital for the health of the service user or patient, as the social worker is very often the key point of contact for vulnerable people living at home and maybe on the brink of being admitted to NHS in-patient care. My noble friend makes a very good point. If I can amplify those remarks in any way I will write to her.
Baroness Farrington of Ribbleton (Lab)
My Lords, will the noble Earl join me in saying that, important though they are, it is not only patients with mental health issues who need help and support? Many young people in particular live at home with people who previously may have been inside a hospital and now quite rightly are being treated in the community. Those children and young people are in many cases coping with circumstances where adults would find it impossible to work. Will the noble Earl ensure that, in looking at this, the needs of those young people are borne in mind, not least because many of them fail in school because of the pressure they are under at home?
Earl Howe
The noble Baroness makes a series of extremely well put points. That is why we are looking at a number of ways to bolster the services that children receive from mental health services and professionals. We have the Children and Young People’s Improving Access to Psychological Therapies programme, as she knows. We are taking forward options for a new survey on how many children and young people have mental health problems, which is of course important for planning. New guidance published last week by the Government will help teachers to better identify underlying mental health problems in young people, and NHS England is currently reviewing children and young people’s in-patient mental health services so that we can see where there are pressures in the system and how money is being spent.