Defibrillators
Earl Howe Excerpts(11 years, 4 months ago)
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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.
Health: Patient Safety
Earl Howe Excerpts(11 years, 4 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(11 years, 4 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.
Mental Health: Parity of Esteem
Earl Howe Excerpts(11 years, 4 months ago)
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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.
National Health Service
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I am delighted that the noble Lord, Lord Crisp, has raised this important topic for debate this afternoon. I would like to thank him for sharing the report on patient empowerment by the six all-party parliamentary groups to which he referred, which I read with great interest.
Giving patients more power in the NHS involves concerted effort at every level: national, regional and local and, perhaps most importantly of all, in the consulting room itself, in the one-to-one conversations between clinician and patient. As the noble Baroness, Lady Pitkeathley, pointed out, the terrible events at Mid Staffordshire show what can happen when patients have no power at all. The deeply unfortunate experience of the noble Baroness, Lady Wilkins, as recounted by the noble Baroness, Lady Masham, is a further example. As a Government, we are committed to putting patients genuinely at the heart of the NHS, to giving them the information, tools, support and care to help them get well and stay well and to give real life to the commitment in the NHS constitution on that theme.
Involving patients and the public in health matters is something that the Government, my department and our partner organisations are firmly committed to. Indeed, there is a general consensus that patients should be at the heart of the health system and that putting the patient first needs to be made a reality.
Ensuring that patients have more say in how their care is delivered and embedding choice are key themes in the Health and Social Care Act 2012, to ensure that we genuinely put the patient first and drive improvements in quality. As part of that, involving patients and ensuring that there is “no decision about me without me” needs to become the norm, not the exception. The same applies to the very apt question, “What matters to you?”
We are passionate about ensuring that people have every opportunity to have their voices heard; that people have the opportunity to shape the services that affect them and their families; and that they are empowered to make decisions about their own healthcare and management. That is why we want everyone to be able to make informed choices about health and social care.
The noble Lord, Lord Crisp, asked me to endorse the principle of patient empowerment, which I readily do. We know that empowering patients and citizens is key to ensuring that health services meet people’s needs, that people have a better experience of care and are able to take better care of themselves; all of which—as the noble Baroness, Lady Pitkeathley, pointed out—will help to sustain the system itself, a system in which we all place so much value.
My noble friend Lady Brinton referred to the need to measure the patient experience, not just patient outcomes, and of course she is right about that. There are a number of measures for collecting information about different aspects of patients’ experience. One way of doing that, which is supported by various parts of the health system, is a validated measure devised by Warwick University.
To do all this it is vital that we understand what patients want from their care. There are a number of ways in which we do that. One in particular can be mentioned; namely, that we have received over 2.5 million responses to the Friends and Family Test in inpatient and A&E settings. That is proving to be a really useful tool in shining a light in almost real time on patient experience.
Patients must be given the chance to be as involved in their decisions about their care as they wish to be. We know that there is an appetite among many people to be more involved in their care than they currently are. Involved patients are in a far stronger position to manage their own healthcare, resulting in improved patient outcomes, a reduction in unnecessary consultations, improved patient experience and better use of resources. This is not a new agenda, and already a lot of progress has been made.
The noble Lord, Lord Crisp, asked about patient decision aids. NHS England is updating the patient decision aids as part of its work to establish a sustainable model of PDA which is underpinned by clinical leadership and partnership with organisations that can stimulate patient use and clinical buying in. Research shows that the tools need to sit within a wider system amenable to partnership, with patients and shared decision-making with clinicians as the norm. Patient decision aids comprise a shared decision-making website. That allows patients to plan their healthcare pathway. As for NHS England, the NHS Citizen programme seeks to put the patient voice at the heart of the decision-making that NHS England itself undertakes. That is a commitment from NHS England.
I am struck by how much engagement has taken place throughout the healthcare system in the past year, with a diverse range of people and organisations: patients, carers, the public, the voluntary sector, social enterprises and the community sector. It is important that we get this right, and we must engage the support of the public and other stakeholders in doing so.
The noble Baroness, Lady Pitkeathley, referred to carers as citizens, and of course I agree fully with her. It is important to gather the views of carers through a number of feedback mechanisms, including the Friends and Family Test and the GP Patient Survey. We have to understand the particular needs of carers to ensure that we can tailor the support that is required. NHS England will be publishing commitment to carers this year.
Of course, if we are serious about putting the patient first, that involves much more than giving patients and the public a chance to shape the services, although that issue should not be overlooked. The noble Lord, Lord Hunt, asked whether Healthwatch England was making a difference. We can now see the role of Healthwatch England making itself felt, ensuring that people’s experiences and views about their care and treatment are listened to and acted on. It is providing worthwhile leadership, support and advice to the local Healthwatch network, which is promoting a local consumer voice.
The noble Baroness, Lady Pitkeathley, referred to the patient leaders concept. The Care Quality Commission aims to involve people who use health and social care services in everything it does. For example, Experts by Experience takes part in inspections of health and social care services and visits to monitor the use of the Mental Health Act. Furthermore, NHS England has invested a significant amount of effort to improve the way in which it supports people to manage their own care. There is a number of core programmes, such as personalised care and support planning, so that people with long-term conditions and disabilities can work together with their health and social care professionals. Personal health budgets will give people more choice and control, and sites have now been chosen for piloting personal health budgets for people with mental health conditions.
The noble Lord, Lord Crisp, referred to the benefit of empowering patients to ask more questions. The key to giving patients more power in the NHS is the provision of high quality and accessible health information. Already, NHS Choices helps to put people in charge of their healthcare. The noble Lord, Lord Hunt, and the noble Baroness, Lady Murphy, referred to technology. NHS Choices also includes a health apps library spanning a whole range of lifestyle and clinical conditions to help people choose apps that are safe to use. As part of NHS England’s work to give patients access to their records, the Patient Online programme’s accelerator sites will be testing how that is impacting on patients and clinicians. That represents a real shift in emphasis and the relationship between patients and professionals, so it is important that we test it out first. It is about doctors trusting patients to use information responsibly. Having said that we need to test it, the principle of giving patients practical ownership of their records is surely right, and I think that that work will provide the foundation for that. Of course, we would like to move faster with this critical agenda, but it is important that we do this at an appropriate pace to bring people with us and to learn lessons from trying out new ideas.
Let me pick up the theme that my noble friend Lady Brinton spoke to so powerfully. We must not forget the importance of supporting the workforce. Some are already doing an excellent job in involving patients in their care. But more widely, the right medical education and clinical training needs to be in place, because by empowering health professionals we can empower patients. The NICE standard on patient experience defines best practice in this area and provides evidence-based statements for commissioners to support a cultural shift towards a truly patient-centred service.
I am pleased that NHS England together with other organisations across the health, social care and voluntary sectors has formed a coalition, the Coalition for Collaborative Care, to make person-centred care a reality for people living with long-term conditions. Furthermore, a key part of increasing the involvement of patients in their own care is being able to measure the skills, knowledge and confidence that people have that predispose them to be able to manage their own conditions better. As the noble Lord, Lord Crisp, said, diabetes is an excellent example but we must also think in terms of more complex conditions, as the noble Lord, Lord Hunt, rightly pointed out. Working in partnership with the Health Foundation and the King’s Fund, NHS England is piloting the patient activation measure in five CCGs and the renal registry. This is an exciting development. It is a score based on patients’ responses to 13 questions that include measures of an individual’s knowledge, beliefs, confidence and self efficacy. It has the potential to drive real improvements in participation.
Finally and importantly, the move to a new health system, including the transfer of the public health function to local government, has created the potential for action on health and health inequalities to be centred on people and places. I am delighted to see how Public Health England and NHS England are working in partnership. With Healthwatch championing the needs of children, young people and adults, the health and care system as a whole is working together to make things better for everyone, especially the most vulnerable in our communities.
There are a number of points that I feel I should pick up, but in view of the time I hope that noble Lords will allow me to write to them on those points. In saying that, I would like to thank all speakers for their contributions to what has been a very fruitful debate.
Health: Rheumatoid Arthritis
Earl Howe Excerpts(11 years, 4 months ago)
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Baroness Brinton
To ask Her Majesty’s Government what steps they are taking to ensure that general practitioners are trained to recognise potential rheumatoid arthritis symptoms, and refer such patients immediately to rheumatologists.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government’s mandate to Health Education England includes a commitment that it will ensure that general practitioner training produces GPs with the required competencies to practice in the NHS. The content and standard of medical training is the responsibility of the General Medical Council. The current GP curriculum requires trainees to successfully complete training on care of people with musculoskeletal problems, which includes rheumatoid arthritis.
Baroness Brinton (LD)
My Lords, I thank my noble friend for his helpful Answer. However, the reality is that too many GPs do not recognise the symptoms. A new report published today by the National Rheumatoid Arthritis Society shows that a shocking 25% of patients have to stop work within the first year of diagnosis, and with the delays their clinical outcomes are poorer and it costs the NHS much more. What will the Government do to raise awareness of symptoms, particularly among GPs?
Earl Howe
My Lords, I pay tribute to the National Rheumatoid Arthritis Society, which is organising Rheumatoid Arthritis Awareness Week this week, between 16 and 22 June. I am aware that Public Health England has run early diagnosis campaigns, which up to now have focused largely on cancer. However, I understand that a broader focus on earlier diagnosis is currently being considered. What might be done to tackle other conditions or symptoms has yet to be decided, but I will keep the noble Baroness informed of developments.
Lord Turnberg (Lab)
My Lords, one of the problems is that there are still far too many single-handed general practices, which have great difficulty providing a full range of services. Are the Government doing anything to try to bring them into bigger groupings?
Earl Howe
My Lords, we are encouraging single-handed practices not to disband but to federate themselves—if that is a good word—with other practices in the area, and certainly to seek the support of their clinical commissioning group. That would ensure that the range of professional training available is utilised and that there is peer support where appropriate. Therefore, while many single-handed practices do a very fine job, there is scope for them to collaborate with their colleagues in the local area.
Baroness Howarth of Breckland (CB)
My Lords, I am sure that the noble Earl will tell me that it is the responsibility of either NHS England or the local health commissions, but is he not alarmed by the number of GP practices being suggested for closure at the moment, and by the long waiting times that patients have to endure in many areas? In some country areas you cannot see your GP for four weeks. Should the Government not have at least some concerns on that?
Earl Howe
My Lords, we are concerned by reports of patients having difficulty accessing their GPs. That is why a whole range of work is currently going on in NHS England to look at the issue, to see how general practices can be helped and to enable them to see more patients. However, more generally, we in the Government have amended the GP contract to free up GPs’ working time. We have abolished well over a third of the QOF indicators precisely to do that. The Prime Minister’s Challenge Fund—£50 million-worth of funding—enables GPs to open up different ways of working; for example, consulting patients on Skype and working hours other than nine to five.
Baroness Gardner of Parkes (Con)
My Lords, although it is very important for GPs and even patients to be aware of early symptoms, does the Minister acknowledge that the real answer as to how to deal with this condition will be in research? Can he tell us whether the Government are supporting such research?
Earl Howe
I am grateful to my noble friend. Expenditure on musculoskeletal disease research by the National Institute for Health Research has increased from £15.5 million in 2009-10 to £23.1 million in 2012-13. The NIHR is investing over £21 million over five years in three biomedical research units in musculoskeletal disease. They are all carrying out vital research on rheumatoid arthritis. The NIHR is currently investing £2 million in a programme of research on treatment intensities and targets in rheumatoid arthritis therapy.
Baroness Wheeler (Lab)
My Lords, can the Minister tell the House what impact the very worrying reported shortage in take-up of family doctor training places is likely to have on the ability of GPs to support patients with potential rheumatoid arthritis symptoms? A recent survey by Pulse found that only 7% of the funding for medical schools goes into teaching general practice. Does this not augur badly for the future of primary care?
Earl Howe
My Lords, we of course recognise the very hard work that GPs do. Despite a decrease in headcount, there has in fact been a 1.2% increase in full-time GPs since 2012 and the number of practice nurses and practice staff has also grown. However, we also recognise that the workforce needs to grow to meet rising demand. That is why our mandate to Health Education England requires it to ensure that 50% of trainee doctors enter GP training programmes by 2016. Generally, we will work with NHS England to consider how to improve recruitment, retention and return to practice in primary and community care.
Lord Warner (Lab)
My Lords, is not the current model of general practice in this country bust? Is it not time that the Government started to think about setting out the requirements that all GPs who offer services to NHS patients ought to make available? If that means them working in bigger practices then so be it, because that is in the interest of patients.
Earl Howe
My Lords, the noble Lord is right that there is scope to examine different ways of working in primary care. I would have to think about whether I would go quite as far as he has, but the point of principle he makes is a very sound one. That is why the Prime Minister’s Challenge Fund is encouraging GPs to think out of the box in the way they make themselves accessible to patients.
National Health Service: Nursing Staff
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Baroness Kennedy of Cradley
To ask Her Majesty’s Government why there has been a reduction in the number of senior nurses in the National Health Service since 2010.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, local NHS organisations are best placed to determine the skill mix of their workforce and must have the freedom to deploy staff in ways appropriate for their locality. Some organisations have reviewed their nursing staff structures to ensure that they are delivering quality of care for patients. This has resulted in a decrease of some senior posts. However, there has been an overall increase in nursing numbers, with over 3,300 more nurses, midwives and health visitors since 2010.
Baroness Kennedy of Cradley (Lab)
I thank the Minister for that reply, but since 2010 there has been a decrease of 4,000 senior nursing posts—modern matrons, ward sisters and specialist nurses, which we all recognise, as indeed do the Government, as being universally critical to patient care. Are the Government not worried about the fact that, on the one hand, trusts are saving money by decreasing these senior nursing posts yet, on the other hand, they are spending money by increasing the pay of executive directors by 6%? What are they going to do about reversing this worrying trend, and how are they going to tackle this dangerous loss of experience and skill in our NHS?
Earl Howe
My Lords, the figure that I have is in fact a decrease of just over 3,000 nurses in senior positions at bands 7 and 8, but that is more than made up for by the increase of over 7,500 nurses at bands 5 and 6 on the front line. On the noble Baroness’s second point, the figures that I saw emanating from the Royal College of Nursing should be looked at with some caution; the RCN has included exit packages for executive directors but not for nurses. In fact, the latest independent evidence shows that for the third year running there was no increase in median executive board pay. It is important to compare like with like there, and the figure of 6.1% as a rise for executive directors is not one that we recognise.
Baroness Cumberlege (Con)
My Lords, does my noble friend agree that one of the most encouraging aspects of the nursing profession is the number of senior nurses who have gone on to be chief executives and board members in the NHS, bringing all the skills of nursing to the leadership of hospital trusts and clinical commissioning groups?
Earl Howe
I agree with my noble friend. To ensure that nurses have the leadership skills, styles and behaviours that our healthcare system needs, the NHS Leadership Academy has launched the largest and most comprehensive approach to leadership development ever undertaken. More than £46 million has been invested in core programmes that will map to foundation-level, mid-level and executive-level leadership development, with two programmes specifically for nurses and midwives that started in March last year.
Lord Hunt of Kings Heath (Lab)
My Lords, given the answer that the Minister has just given to his noble friend, surely it is ironic that throughout the NHS the number of senior posts is actually being squeezed. Would he not agree that that runs counter to what Francis said post-Mid Staffordshire about the need for highly effective quality supervisory nurses? Is the reason why this is happening not that the NHS cannot afford to increase its nurse staffing levels with the amount of money that it has been given by the Government? Something has gone, and unfortunately it is these crucial posts that seem to be having to give way.
Earl Howe
My Lords, I do not agree with that because nursing numbers are now at a record high, which cannot indicate that hospitals are being starved of resources for their nurses. I do not see it as ironic that some senior posts have been reduced, bearing in mind the effect of Robert Francis’s report which has caused hospitals to increase the number of nurses on the wards. By and large, nurses at grades 7, 8 and 9 are in managerial positions and not in front-line posts.
Baroness Manzoor (LD)
My Lords, can the Minister say if an impact assessment has been undertaken on losing senior nurses from the NHS and the impact it has on service standards? The noble Lord, Lord Hunt, has already made the connection with the Francis report. Can the Minister also say whether an exit strategy has been undertaken to see why senior nurses are leaving?
Earl Howe
My general answer to my noble friend is that it is not for the Government to decide how many nurses hospitals should employ. We have not done an impact assessment. That is a matter for local hospitals to judge. They are in the best position to do that, based on the needs of their patients and local communities. What the Government should do, and are doing, is to ensure that staffing levels are available for public scrutiny and comparison on a patient safety website. That work is currently in train. It will now be much more evident to patients and the public what their local hospital is doing in terms of safe staffing ratios.
Baroness Finlay of Llandaff (CB)
My Lords, before seven-day working comes in, are the Government ensuring that senior nurses are also taking part in the seven-day rota to ensure that their expertise is available both in hospitals and in the community to support other nurses at more junior grades?
Earl Howe
My Lords, the work going on on seven-day working certainly includes the nursing workforce. However, I repeat that it is not for the Government to mandate what each and every hospital should be doing in terms of deploying their senior nursing staff. It is a judgment for the board of that hospital.
Lord Warner (Lab)
My Lords, the Minister is very proud of the increase in the number of nurses on the front line. Can he confirm that all these nurses are actually in hospitals? What is the comparable figure for nurses working in the community? I believe the Government’s policy is supposed to be to have more care in the community.
Earl Howe
The noble Lord is right. The Government recognise the very important contribution that community nurses make in providing high-quality care to people within community settings. I think we have seen a reaction, as I have said, to the Francis report. Lots of hospitals say that they are going to employ more nurses on the wards. We now need to ensure that staffing levels are safe across the NHS and the community, and the Chief Nursing Officer has set up a working group which is looking specifically at what we can do to increase the number of community nurses, which we certainly need to do.
Baroness Masham of Ilton (CB)
My Lords, does the Minister agree that specialist nurses are not being replaced when they retire and that there is great concern about this as they do such valuable work for many specialties?
Earl Howe
I acknowledge the valuable role played by specialist nurses in a number of disciplines but, once again, it is up to employers to exercise their responsibility to manage turnover, retention, recruitment and skill mix to ensure that they have sufficient workforce supply to meet the levels of staffing that the hospital or organisation needs. Here again, patient safety is paramount.
People with Learning Disabilities
Earl Howe Excerpts(11 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by expressing my gratitude to the noble Baroness, Lady Hollins, for her huge contribution in the fields of learning disability and mental health, her tireless efforts in championing the rights of individuals and families, and for the very real difference the breadth of her work has made to the life chances of so many people.
It is nearly a year since the noble Baroness convened a debate on action to address the health inequalities identified by the government-commissioned Confidential Inquiry into Premature Deaths of People with Learning Disabilities, and I welcome the opportunity to bring those issues to the fore again. Since the government response was published in July last year, we have published our call to action, setting the aspiration to make the UK among the best nation states in Europe at reducing premature and avoidable deaths.
In April, working with partners and stakeholders, we published Living Well for Longer: National Support for Local Action to Reduce Premature Avoidable Mortality, which recognised the need for a targeted approach for people with learning disability. This national partnership, and the focus and momentum it has engendered, creates a vital opportunity to make a difference in our collective fight to reduce avoidable mortality. At the same time, by creating both the evidence base and a system-wide work programme, the confidential inquiry and the Government’s response have provided a powerful tool to turn that opportunity into action.
We have the policy framework in place and have reflected health inequalities across the NHS, public health and adult social care outcomes frameworks. There are specific measures on preventing people with learning disabilities dying prematurely and greater focus on empowering people to have greater choice and control. The mandate to NHS England for 2014-15 allows us to hold the system to account and gives us the basis for measuring progress. Reducing differences in life expectancy and health expectancy are key measures across the system.
NHS England is committed to establishing a learning disability mortality review function by March 2015, as set out in its business plan, Putting Patients First. A project group is overseeing this development, with representation from Mencap, PHE and the Department of Health. I am delighted that the noble Baroness has also been invited to lend her expertise.
The Government’s response to the confidential inquiry included a commitment from NHS England to an assessment of costs and benefits by March 2014. NHS England, together with the inquiry team and other partners, undertook a robust assessment, and resources have been allocated through the priority-setting processes. This is now a commitment in its business plan and strategic objectives, and we all wish to see this work proceeded with rapidly. As regards funding, I am sure that NHS England, in establishing the review function and beyond, will be giving full consideration to funding issues through its business planning and resource allocation processes.
The noble Baroness, Lady Hollins, highlighted the issue of data linkage. Work is under way with NHS England, the Health and Social Care Information Centre and Public Health England to provide standardised mortality data for people with learning disabilities to underpin the NHS outcomes framework and the mortality review function. However, I hope she will appreciate that in taking that work forward, we must also take account of wider cross-system discussions about the collection and sharing of patient data, which will inevitably have implications for this work. Nevertheless we are working closely with partners and will certainly act to secure the prioritisation of this work through all appropriate mechanisms.
The noble Baronesses, Lady Hollins and Lady Andrews, both emphasised the importance of integrated care for those with learning disabilities and getting the whole system engaged. NHS England is looking at ways to establish care co-ordination and risk stratification for people with learning disabilities as normal practice. We will underline the importance of prioritising this with NHS England.
Following the passing of the Children and Families Act, new arrangements will be introduced from September 2014 for joint assessment, planning and commissioning of health, social care and education services for children and young people with special educational needs up to 25 years old. A single education, health and care plan will set out meaningful objectives which will make a difference to the life of the young person, including supporting their transition to adulthood and independent living. The right reverend Prelate stressed the importance of advocacy for people with learning disability. He is right. Several actions arising from the Winterbourne View programme are intended to improve the quality and availability of good advocacy, working with a range of key stakeholders.
As the noble Baroness, Lady Hollins, emphasised, as did the right reverend Prelate, we need a system for identifying those with learning disabilities. The GP register of people with a learning disability from this year onwards is an all-age register, so will include children and young people with a learning disability. GPs are incentivised to construct this register as part of the quality and outcomes framework.
I can tell the noble Lords, Lord Wigley and Lord Hunt, that the NHS standard contract for 2014-15 now includes a requirement for providers to undertake an annual audit of reasonable adjustments. There is already a system within all NHS foundation trusts to provide board-approved risk assessments to Monitor about six specific areas of good-quality care for people with learning disabilities. On the back of this already-established standard, Professor Sir Mike Richards has agreed that four additional questions will be trialled in the inspection of acute hospitals, concerning numbers of people with learning disabilities in hospital, reasonable adjustments, specialist learning disability nurses and care audits. In addition, Professor Steve Field is exploring the data that can be used for intelligent monitoring purposes, in preparation for inspection of primary care providers and how they meet the needs of people with learning disabilities in a primary care setting.
The CQC will, from the autumn, be inspecting services around its preparedness and plans for children and young people with learning disabilities transitioning into adult services. To answer a point raised by the noble Baronesses, Lady Andrews and Lady Warwick, that better transition planning also feeds into the new enhanced services for learning disability annual health checks, which are starting from the age of 14 from this year onwards. They include a requirement for health action plans, and I can tell both noble Baronesses that NHS England is looking at the variation in uptake and the quality of health checks, with the aim of improving both.
I return to the issue of patient identification. In the last year, Public Health England has been involved with the Health and Social Care Information Centre in the development of information standards to improve the identification of people with learning disabilities in healthcare records. Public Health England’s Learning Disabilities Observatory maintains a national register of examples of reasonable adjustments made by hospital and other health service providers to help ensure that people with learning disabilities can benefit as much from available care as other people.
On health checks, as my noble friend Lord Ribeiro mentioned, Public Health England has produced leaflets specifically designed with and for people with learning difficulties, which explain the invitation and screening process for cancer and cervical screening programmes. It also has guidance for professionals on access to screening, and on informed consent and best interests decision-making. NHS England is also looking very carefully at that. In recognition of the very poor uptake of flu immunisation by people with learning disability, this year’s annual flu immunisation letter asks GP practices to prioritise vaccine uptake in people with learning disabilities.
Education and training in this field is vital. My noble friend Lord Ribeiro stressed the importance of compassion and good clinical practice. The noble Baroness, Lady Andrews, referred rightly to a need for cultural change, as did the noble Lord, Lord Rix. Health Education England’s mandate includes an objective to improve the skills and capability of the workforce to respond to the needs of people with learning disabilities and behaviour that challenges. The Department of Health has commissioned a consortium, led by the Royal College of Paediatrics and Child Health, to develop Disability Matters, an e-learning portal for those who work with children, young people and adults with a disability. The Care Quality Commission is raising awareness among its inspectors.
On the issue of the Mental Capacity Act, raised by the noble Lord, Lord Patel of Bradford, the Government’s response to the House of Lords report on the Mental Capacity Act was published this week. It sets out a system-wide programme of action to address low levels of awareness of the Act among professionals. Health Education England is reviewing all education and training programmes to determine compliance with the principles of the Act. It will also look at including MCA compliance in the standard contract with education providers.
The noble Lord, Lord Rix, and the noble Baronesses, Lady Hollins and Lady Andrews, expressed disappointment that the department had not published a one-year-on report. We undertook to keep the Learning Disability Programme Board informed of progress. At a conference organised by the department on 28 March, the confidential inquiry team was able to share information and best practice on national, regional and local work to address the recommendations. That was followed by a meeting with members of the Learning Disability Programme Board in April.
We now need to step up the pace and make a concerted national effort to see more equitable access and outcomes for people with learning disabilities. A report setting out progress to date will be presented to the Learning Disability Programme Board in July, a year on from the Government’s response to the confidential inquiry. That will be published online.
The noble Baroness, Lady Hollins, asked whether we would embed the learning from the confidential inquiry into other policies. Most certainly yes: we have already committed to link the learning recommendations from the inquiry to other policies and programmes—for example, the Winterbourne View programme, the Mental Capacity Act and, indeed, end of life care.
The noble Baroness, Lady Warwick, expressed her concern over what she saw as the Government’s lack of action. I hope I have demonstrated that there has been extensive action, but of course there is more to do. I believe that collaboration nationally and locally on this challenging issue will give us the best chance of delivering equitable health outcomes across our nation. I would say to the noble Lords, Lord Adebowale and Lord Hunt, that the Government, as steward of the health and care system, are taking responsibility for delivering their commitments in response to the confidential inquiry’s recommendations. In doing so, we are ensuring that all key delivery partners across the health and care system play their rightful part as well.
Health: Transition to Adult Health Services
Earl Howe Excerpts(11 years, 4 months ago)
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what action they are taking to ensure the continuity of standards of care for teenagers with long-term health conditions who transfer to adult NHS services, as recommended in the Care Quality Commission report From the Pond into the Sea.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, our 2013 pledge to improve health outcomes for children and young people included the ambition to co-ordinate care around the individual young person with complex needs to deliver the best experience of transition to adult services. The partners to the pledge—including NHS England and Health Education England—are working to deliver this. Our mandate to NHS England calls for improvements in the way that care supports smooth transitions between children’s and adult services.
Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the noble Earl. He will know that this is a worrying report and that it would appear that young people with long-term health conditions often fall through the net when they transfer to adult services. He said that the mandate to NHS England requires it to do something about this, but can we be confident that NHS England actually will take note of what Ministers ask for? I would just refer him to the inability of NHS England to implement the Winterbourne recommendations and its failure to fund mental health services in accordance with parity of esteem. Does the mandate amount to anything at all? Too often Ministers have come to this House and said that something would be done, but nothing has actually happened.
Earl Howe
I think that I can reassure the noble Lord on this point. NHS England is currently developing service specifications across the range of commissioning models: specialised commissioning, CCG secondary and primary care commissioning, adolescent mental health and special educational needs, and learning disability. Those will translate examples of best practice and published outcomes into specifications for commissioning to hold providers to account for the delivery of robust transition services with measurable quality standards attached to them.
Baroness Butler-Sloss (CB)
My Lords, there is a particular problem with young people who have not only physical problems but very considerable mental health problems. Is a priority being given to help that group of children?
Earl Howe
The noble and learned Baroness is quite right, and as she well knows, this has been a long-standing issue. Our document, Closing the Gap: Priorities for Essential Change in Mental Health, which we published recently, identifies the transition from child and adolescent mental health services into adult services as a priority for action. We are supporting the work of NHS England to develop the service specification which I have just referred to. CCGs and local authorities will be able to use that specification to build excellent person-centred services that take into account the developmental needs of the young person, as well as the need for age-appropriate services.
Baroness Pitkeathley (Lab)
My Lords, problems arising at the transition stage are often reported by the parents of these young people because they are their carers. Does the Minister agree that standards of care must include support for those much-needed parent carers?
Earl Howe
I fully agree. I think that much of this will succeed only if services work together around the needs of young people as well as their families and carers, and if the families and the young people themselves feel involved in the way in which their care is being organised and planned.
Baroness Howarth of Breckland (CB)
My Lords, in terms of developing the specification, can the noble Earl tell us how stakeholders are to be involved? In particular, will the young people themselves now have a voice? I declare an interest as the president of Little Hearts Matter, which deals with children with single-ventricle problems.
Earl Howe
I think that we can pay considerable tribute to the Children and Young People’s Health Outcomes Forum. It is one of the bodies that have highlighted the need for more effective transitions and for new outcomes indicators to measure them. Its framework for this year includes a proposal that, where possible, all data should be presented in single-year or five-year age bands up to the age of 25 to support better monitoring. Moreover, the forum asked the National Network of Parent Carer Forums to develop a narrative of what good integrated care looks like in transition. The CQC report has drawn quite heavily on that report in its conclusions.
Baroness Barker (LD)
My Lords, the Teenage Cancer Trust had to battle for years to get NHS commissioners to understand that age-specific rather than gender-specific wards are better for young people. It is a good organisation, but it has been a hard job to change the mindset of the NHS. Can he help organisations such as the Teenage Cancer Trust to find ways in which to influence commissioners far more quickly than they have been able to do in the past?
Earl Howe
My noble friend raises another extremely important point which applies not only to cancer, but also particularly to mental health settings. We have had many debates in this Chamber about age-appropriate settings. I will take her point back with me and find out where we are in our dialogue with stakeholder groups.
Baroness Uddin (Non-Afl)
My Lords, can the noble Earl tell the House whether the commissioning will specify autism in the service specifications? Further, will the NHS England staff who are responsible for implementing these measures be trained to deal with the issue of autism?
Earl Howe
The noble Baroness raises an important point and I can reassure her that we are addressing the full range of complex needs in children and young people. She may also be interested to know that Health Education England will be working with the Royal College of General Practitioners and the Royal College of Paediatrics and Child Health to develop a training course that will allow GPs to develop a specialist interest in the care of young people with long-term conditions. The aim is to introduce the course in September 2015. It will include a particular emphasis on the transition from childhood.
Baroness Finlay of Llandaff (CB)
Do the Government recognise the need for a champion, such as we have had with Dr Lidstone in Wales, who has completely transformed the transition for children with life-limiting illness?