Mesothelioma
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Lord Alton of Liverpool
To ask Her Majesty’s Government what funding has been secured for research into the causes of and potential cures of mesothelioma.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government are fully committed to research into the causes of this dreadful disease and into potential treatments. The usual practice of the main public funders of health research is not to ring-fence funds for expenditure on particular diseases, and funding is available for high-quality research proposals. With its partners, the Department of Health is actively pursuing a package of measures that we believe will stimulate an increase in the level of research on mesothelioma.
Lord Alton of Liverpool (CB)
While thanking the noble Earl for his reply, does he recall the assurance he gave to the House, when an all-party amendment—which would have created a small, statutory levy to support mesothelioma funding—was defeated by 199 votes to 192, that insurance companies would voluntarily step up to the plate? Given that there have been 2,400 deaths from mesothelioma this year, with 60,000 anticipated over the next 25 years, and with the imminent ending of even the existing insurance industry funding, would it not be shameful to leave unfunded research that could save lives and prevent vast expenditure on compensation? The Mesothelioma Bill is now before another place, with an amendment supported by both Conservative and Labour Members of the House of Commons. Surely Ministers should be looking again at this practical way of finding a cure for this deadly disease.
Earl Howe
My Lords, I understand that the British Lung Foundation has had discussions with representatives of the insurance industry about extending the funding for research, but that no commitment has been made by the industry so far as to future funding. As I made clear during the debate, the issue holding back progress is not the lack of available funding—there is plenty of that—but the lack of sufficient high-quality research applications. The money previously donated by insurers is supporting valuable research, as the noble Lord, Lord Alton, has said. At the moment, a greater volume of mesothelioma research is supported by the Government, and we believe that the package of measures that I mentioned will stimulate an increase in that volume.
Lord Beecham (Lab)
My Lords, I refer to my interest in the register. Section 48 of the Legal Aid, Sentencing and Punishment of Offenders Act 2012 requires the Government to review the application to mesothelioma claims of the provisions banning conditional fees. The Government have announced that, in the light of a consultation as yet unpublished, they will not treat those cases differently from other claims. They seek to conflate this issue with entirely different provisions in the Mesothelioma Bill.
Is the Minister aware that the Civil Justice Council has been unable to agree whether the current consultation,
“fulfils the conditions set out in Section 48 of LASPO”?
Is this not another example of the Government cravenly caving in to the demands of their friends in the insurance industry and ignoring the strong feelings of this House in support of those suffering from this terrible disease?
Earl Howe
I am sure that the noble Lord wants to take advantage of this opportunity to raise that particular issue, but it is a rather different one from the Question posed by the noble Lord, Lord Alton. However, I will take his question away and ensure that a letter is sent to him in response.
Lord Ribeiro (Con)
My Lords, the Government are to be congratulated on introducing the Cancer Drugs Fund, but how do they anticipate that the vital research which needs to be done into mesothelioma will continue to be funded without legislation to compel those insurance companies which so far have not stepped up to the plate to make a contribution?
Earl Howe
My Lords, as my noble friend will be aware, four insurance companies have stepped up to the plate with funding of £3 million, which admittedly is nearing its end, but I do not think that we can belittle that contribution. My noble friend may be interested to know that the MRC and the NIHR together spent more than £2.2 million on mesothelioma research in 2012-13, which is a larger sum than for many other disease areas. I say again that the issue is not the lack of funding because the research funding in both the MRC and the NIHR has been protected. What is lacking are suitable proposals.
Lord Howarth of Newport (Lab)
My Lords, does the Minister share the disappointment expressed by the noble Lord, Lord Alton, which I certainly do, that following the scandalous mistreatment of mesothelioma sufferers by employer’s liability insurers over decades, there has been no commitment from those four employer’s liability insurers or from the rest of the industry to continue funding beyond next year? Whatever arrangements are made to secure the continuation of research in this vital field, can the Minister be more precise on how the Government will bring their influence to bear to ensure that the research is of suitable quality?
Earl Howe
My Lords, we have committed to doing four things, the first of which will be to set up a partnership to bring together patients, carers and clinicians to identify what the priorities in research are. Secondly, the NIHR will highlight to the research community that it wants to encourage research applications in this area. The NIHR Research Design Service will be able to help prospective applicants develop competitive research proposals, and we will convene a meeting of leading researchers to discuss and develop new proposals for studies. I think that those four measures together will deliver what the noble Lord seeks.
Lord Avebury (LD)
My Lords, does my noble friend acknowledge that the £3 million has run out and that there is a danger that the talented clinicians who have been working on mesothelioma as a result of that fund will move on to other subjects? However, the Association of British Insurers has told me that it would be prepared to consider a new scheme funded jointly by all employer’s liability insurers and the Government, so I wonder if the Government will approach the ABI to see if that scheme could be taken a little further.
Lord Walton of Detchant (CB)
My Lords, what makes mesothelioma such a fatal disease is the length of the incubation period, in that individuals who have been exposed to asbestos may not develop the disease until many years later; indeed, 2,000 new cases have been reported this year. The developments to which the Minister has referred are helpful and encouraging, but have the Government been able to persuade the relevant insurance companies to increase significantly their contribution to the research programme?
Earl Howe
My Lords, I said earlier that the discussions between the British Lung Foundation and the insurance industry have not so far resulted in a pledge for further funding, but as my noble friend Lord Avebury has indicated, that door may be open. However, we should bear in mind that asking insurance companies to fund research is an unusual mechanism in itself. I suggest that we should not push the envelope too far because in the end the cost will fall on the industry.
Health and Social Care Act 2012: Risk Register
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Lord Brooke of Alverthorpe
To ask Her Majesty’s Government whether they will now publish the risk register prepared in advance of the passage through Parliament of the Health and Social Care Act 2012.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, it remains the Government’s position that they will not be publishing the transition risk register. The decision to withhold the risk register was based on the principle that Governments, together with their civil servants, need to be able to consider all aspects of policy formation, including its risks, in private. It remains our view that a full and candid assessment of risk and the mitigating action required to manage it is carried out within a safe space.
Lord Brooke of Alverthorpe (Lab)
My Lords, the House will be grateful to the Minister for reminding us of the Government’s position and of what is in the public domain, but I remind him that the Question is about what the Cabinet and the Secretary of State decided should not be in the public domain. Is there no shame or embarrassment on the part of the Government, who have imposed, quite rightly, a duty of candour on the NHS but who decline to practise that policy themselves by being candid with the public, particularly with those of us who use the NHS? What are the Government hiding? If it is nothing, they should publish the register tomorrow and put it away.
Earl Howe
My Lords, the Government are fully committed to transparency and openness, but they need also to be able to manage large and complex projects and programmes efficiently and effectively. If requests for information are made that threaten to compromise their ability to do that, as is the case here, then the Government have to weigh up whether releasing what is being asked for is, on balance and bearing in mind the consequences, in the public interest. Up to now, we have taken the view that the public interest is not served by publication.
Baroness Brinton (LD)
My Lords, the previous Government refused to release Department of Health strategic risk registers in response to three requests under the Freedom of Information Act. Can my noble friend the Minister tell the House whether there is a discernible difference between this Government and the previous one in their approach to the publishing of risk registers?
Earl Howe
That is a helpful question. I do not believe there is a difference. As the noble Baroness rightly said, on a number of occasions the previous Government refused to disclose the risk registers, and they did so for perfectly good reasons, one of which was to enable the safe space that I referred to earlier.
Lord Mawhinney (Con)
My Lords, will my noble friend accept that many in your Lordships’ House will welcome this reaffirmation of the Government’s policy, particularly those who have had the privilege of being Ministers?
Lord Grocott (Lab)
Will the Minister, who is clearly not going to give the information from the risk register, perhaps give us a clue along the following lines? Given the experience of the reform in operation, have any of the risks that were identified in the private risk register come to pass, or is everything going wonderfully well?
Earl Howe
My Lords, the risk register, as the noble Lord knows, is simply a tool that records the risk assessment process and the actions that need to be taken to mitigate those risks. However, to be effective, the process has to be robust and consider all likely implications—and indeed some that are not so likely—of a proposed course of action. The candid recording of risks enables them to be effectively managed. However, as the noble Lord knows, we have gone as far as we can in publishing the areas of risk that are contained within the risk register. I remind the noble Lord that in 2012 we published an extensive document that set out quite a lot of detail. That document is still available on the department’s website.
Lord Hunt of Kings Heath (Lab)
My Lords, I refer noble Lords to my health interests. To return to the Question asked by my noble friend, is it not a fact that officials warned Ministers that they would be introducing a shambolic reform of the health service? Those officials, much-maligned by the noble Lord’s ministerial colleagues, have been proved to be absolutely right. As we are all looking forward to the new musical by the noble Lord, Lord Lloyd-Webber, can the noble Earl tell me which will be published first: the full Profumo papers or the noble Earl’s risk register?
Earl Howe
My Lords, I do not accept the noble Lord’s description of the transition, which has gone extremely smoothly. By most measures the NHS is performing very well indeed. Waiting times are low and stable, the number of people waiting more than 12 months has plummeted since 2010, hospital-acquired infections are at an all-time recorded low, we have more doctors and healthcare professionals in the system, and mixed-sex accommodation has been reduced to minimal levels. That does not indicate to me that the reforms have had a damaging effect—quite the reverse.
Lord Dobbs (Con)
My Lords, I am not sure whether a risk register was published before the war in Iraq. However, will my noble friend use his best influence on his colleagues in government to make sure that in the interests of candour the Chilcot report is published as soon as possible? We have all waited long enough for answers on that particular affair.
Baroness Armstrong of Hill Top (Lab)
My Lords, if the reforms are going so well, why does the Secretary of State, who now presides over an Act that said that the health service would be at a long arm’s length from Ministers, now see the key people in the health service at least once a week? Why does he take it upon himself personally to interfere in ways that during the passage of the Bill the Minister here told us very clearly Ministers would no longer be doing?
Earl Howe
The noble Baroness would have cause to complain if, in accordance with the debates that we had in this House on accountability, my right honourable friend did not hold the NHS to account on some of the areas of its activities where there were concerns. That is exactly what he does, and he does it quite properly.
Lord Hughes of Woodside (Lab)
Is it not the case, in relation to the Chilcot report, that it is not the Government who are holding it up but something else? Will the Minister not hide behind red herrings like that? It is he and his Government who are refusing to publish the risk register, and they surely must do so.
Earl Howe
My Lords, over the passage of time a view can be taken about the sensitivity of the Department of Health risk register. That is what we have undertaken to do and what we will do. Next spring, we will reach one of the regular review points for the risk register. I can tell the noble Lord that work to review the register has already started in anticipation of that date.
Health: Talking Therapy
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Baroness Royall of Blaisdon
To ask Her Majesty’s Government whether they have plans to create a legal right to talking therapy as part of their commitment to ensure parity of esteem between mental and physical health.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the department has no plans to create a legal right to talking therapies. Mental health and parity of esteem are key priorities for NHS England. The Government’s mandate to NHS England makes it clear that everyone who needs it should have timely access to evidence-based services, which involves extending access to talking therapies. We are working with NHS England to develop standards on access and waiting times across mental health from 2015.
Baroness Royall of Blaisdon (Lab)
My Lords, I am grateful to the noble Earl for his Answer, but I still have serious concerns about the services that mental health patients receive. I do not often quote the noble Lord, Lord Freud, but last month he said that,
“the association between poor mental health and poverty is clear”.—[Official Report, 7/11/13; col. 324.]
However, despite people’s increasing stress due to poverty, the cost of living and zero-hours contracts, the Government have cut mental health spending in real terms in the past two years. Funding for therapies not included in IAPT has been cut by 5%, despite ministerial assurances that this would not happen. Last week, the We Need to Talk coalition released a report that revealed that more than half of mental health patients are waiting at least three months for treatment. Can the Minister commit to reducing those waiting times by March 2015, the date by which time the Government are committed to making progress towards that important parity of esteem?
Earl Howe
My Lords, I agree that waiting times for talking therapies are too long, and we are taking energetic steps to address that within the bounds of affordability. In the context of the noble Baroness’s main Question, what surely matters is the quality of outcomes, rather than just the extent of inputs. We set the outcomes that we expect the NHS to achieve in the NHS outcomes framework. There are a number of outcomes in there specifically for people with mental health problems, and others, about the quality of services. It is up to commissioners to prioritise their resources to meet those outcomes for the population based on assessments of need, and we will hold them to account for that.
Lord Alderdice (LD)
My Lords, I entirely support my noble friend’s commitment to good outcomes, but those also require sufficient inputs. If the noble Baroness’s request for a right to talking therapy were implemented tomorrow, it would completely collapse because there simply are not enough trained therapists to provide the care that is required. What measures are the Government taking to ensure that in future there will be sufficient trained therapists to provide the parity of care for those with mental illness that is available to those with physical illness?
Lord Patel of Bradford (Lab)
My Lords, following on from what the noble Lord, Lord Alderdice, said about having staff who can provide appropriate talking therapies, and what the Minister himself said about someone who needs a service receiving it, we have a long history in the mental health field of mental health practitioners not referring certain minority-ethnic groups such as the south Asian and black African communities for talking therapies. I believe that that is still the case with referrals to the CBT programme. What are the Government doing to address this imbalance?
Earl Howe
I can tell the noble Lord that IAPT is working with a number of BME groups to promote wider access to the service from all sections of the community. A grant scheme will shortly be launched to encourage community-based interventions to increase uptake of talking therapies, including from BME groups.
Lord Elystan-Morgan (CB)
My Lords, will the Minister kindly tell the House roughly what percentage of in-patients and out-patients suffer from mental health problems compared with those who suffer from physical health problems? Can he say, roughly, how the resources of the NHS are divided between the two camps on a revenue basis? I have the clear impression that traditionally mental health has been short-changed for very many years.
Earl Howe
My Lords, the noble Lord’s perception would be shared by many, which is why we have been very clear in our mandate to NHS England that parity of esteem is of the essence, and we will hold the service to account for that. I do not have the specific statistics that the noble Lord seeks but we know that more people are being treated in secondary mental health services now than two or three years ago. However, the proportion who needed to be admitted to in-patient psychiatric care fell over that period, and that reflects increasing emphasis on care in the community.
Baroness McIntosh of Hudnall (Lab)
My Lords, as someone who has benefited from CBT on a number of occasions, may I ask whether the noble Earl agrees that it is not just a question of whether people need the therapy but rather that they receive enough of it? Following the question of the noble Lord, Lord Alderdice, about the number of people who could benefit from this, what is the average number of sessions of talking therapy that a National Health Service mental health patient will receive and is it, generally speaking, enough?
Lord Elton (Con)
Will my noble friend assure the House that this rule of parity will be introduced in the Prison Service as well as the National Health Service generally?
The Earl of Sandwich (CB)
Does the noble Earl share my concern about the overprescription of psychiatric drugs? Can he think of anything to do about this apart from encouraging CBT and talking therapies?
Earl Howe
My Lords, the noble Earl is right. I share his concern, and I think it has been a widespread concern across the mental health community. Nowadays, the guidance given to doctors is much broader than the guidance that was given some years ago. It embraces the talking therapies in particular and it seeks to avoid the overprescription of sometimes very strong pharmaceutical products.
Tobacco: Packaging
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I shall now repeat in the form of a Statement an Answer given earlier today by my honourable friend the Minister for Public Health on the subject of standardised tobacco packaging. The Answer is as follows.
“In accordance with the notice I gave to the House yesterday afternoon, I have this morning made a Written Statement to this House announcing that Sir Cyril Chantler will carry out an independent review of the evidence for the impact of standardised tobacco packaging on health. Tobacco use, especially among children, remains one of our most significant public health challenges. Each year in England more than 300,000 children under the age of 16 try smoking for the first time. Most adults who smoke started before 18 years of age. As a result, we must do all we can to stop young people taking up smoking in the first place if we are to reduce smoking rates.
We have listened to the strong views expressed on all sides of this House, including when we debated standardised packaging in the Back-Bench business debate earlier this month. Many Members have told me that the evidence base for standardised packaging continues to grow and have urged the Government to take action. As a result, I believe that the time is right to seek an independent view on whether the introduction of standardised packaging is likely to have an effect on public health. In particular, I want to know about the likely impact on young people.
I have asked Sir Cyril to undertake a focused review, reporting in March next year. It will be entirely independent, with an independent secretariat. He is free to draw evidence from whatever source he considers necessary and appropriate. It will be up to Sir Cyril to determine how he undertakes the review, and he will set this out in more detail in due course. As this House will know, Sir Cyril has confirmed that he has no links with the tobacco industry. The review is not a public consultation. The Government ran a full public consultation in 2012, and these responses will be available for the review. To maximise transparency, the department will also publish the substantive responses received as soon as possible. The Government will also take advantage of the opportunity offered by the Children and Families Bill and will table a government amendment to provide a regulation-making power. If the Government decide to proceed, this will allow the introduction of standardised tobacco packaging without delay.
This Government have been consistent in their desire to have an evidence-based approach to public health. We will introduce standardised tobacco packaging if, following the review and consideration of the wider issues raised, we are satisfied that there are sufficient grounds to proceed”.
My Lords, that concludes the Answer.
Earl Howe
My Lords, I am grateful to the noble Lord for his welcome for this announcement. I do not accept that this is a U-turn. We said in July that we would keep the policy under active review, which is exactly what we have done. I cannot answer for any cynical attitudes on the Benches opposite, but that is the truth. More crucially, since then, the academics, led by the University of Stirling, who carried out the systematic review of the evidence on standardised packaging that was published alongside the 2012 consultation have updated their work. Their original report covered 37 peer-reviewed studies and the update considers an additional 17. We believe that that evidence merits full scrutiny.
The noble Lord suggested that the evidence is already clear so we should just go ahead and legislate. The views that emerged from the consultation were highly polarised. We have always been clear about the need for as robust an evidence base as is possible. We have reached the decision to commission this rapid review from Sir Cyril Chantler so that we have as robust an evidence base as possible.
On proxy purchasing, I think we can all agree that people buying tobacco on behalf of children and young people is wrong, and I want to acknowledge the role played by retailers in ensuring that legitimate tobacco products are sold in accordance with the law. However, a new offence of proxy purchasing would not necessarily tackle the wider problems of supply. We will obviously consider carefully the arguments put forward, but, at the moment, we are not convinced that creating a new offence is the right way forward.
Lord Patel (CB)
My Lords, I declare an interest as a fellow of several medical royal colleges, the Academy of Medical Sciences and the Royal Society of Edinburgh, which have all previously backed, and continue to back, the argument that legislation should be brought forward to make cigarette packaging plain. I have spoken on many occasions in relevant debates under both this Government and the previous one and have tabled amendments to bring in legislation for the plain packaging of cigarettes. I have done so on the basis that the evidence is conclusive, as shown by both the British Heart Foundation and Cancer Research UK, that glamorised packaging is used by the industry to recruit young, new smokers. Now we have to wait until the evidence is produced by Sir Cyril Chantler. Disappointed though I am that we cannot legislate now, I can afford to wait a few months because I know that Sir Cyril Chantler, who is a friend, is a man of principle and will look at the evidence as it is. However, once that evidence is presented, what is the timeline for the Government to introduce legislation for plain packaging?
Earl Howe
My Lords, I am grateful to the noble Lord, who has indeed been a consistent champion for plain packaging over the years. I also appreciate his endorsement of the choice of Sir Cyril Chantler to lead this review. Noble Lords will know that Sir Cyril has a very distinguished record as an academic and paediatrician. As regards the timeline, I cannot be definite at this stage. All I can say is that, should the Government decide to lay regulations in the light of Sir Cyril’s recommendations, we believe that, taking into account a period of consultation and the statutory provisions surrounding European law, we would be able to introduce the regulations within a reasonable time.
Baroness Gardner of Parkes (Con)
My Lords, is the noble Earl aware that in Australia plain packaging has been very effective? They say that that is, above all, because it is no longer “cool” for young people to smoke. The noble Earl mentioned age as being effective, and that is very relevant.
Baroness Walmsley (LD)
My Lords, I congratulate those in your Lordships’ House on their persistence in keeping this issue before the Government, including my noble friend Lady Tyler of Enfield. I also congratulate the Government on their determination to base policy on evidence. However, if the Government, in the fullness of time, use their regulatory power to introduce standardised packaging, will they keep a watching brief on the tobacco companies? In the past, whatever procedures we have brought in, they have been extremely clever in finding ways round them to lure young people into starting smoking. Therefore, will the Government watch the situation very carefully and try to make sure that the tobacco companies do not get round standardised packaging, thus continuing to attract young people to a habit that will kill them?
Earl Howe
My noble friend makes a very important point. She is, of course, right that the tobacco companies protect their commercial position with great vigour. We will indeed keep an exceedingly close eye on the actions of the tobacco industry and, should we decide to introduce regulations, we will do all we can to ensure that they are watertight.
Lord Ribeiro (Con)
My noble friend should be congratulated on his leadership in taking forward this proposal on plain packaging. He will be aware that I have introduced a Bill on banning smoking in cars where children are present. I recognise the difficulties that that presents for the Government, but after this three-month period of consultation, if the recommendations of Sir Cyril Chantler, who, I agree, is a very highly respected clinician, are accepted by the Government and legislation is introduced, I hope that that will give an impetus to the Government to think again about the importance of banning smoking in cars where children are present.
Earl Howe
I pay tribute to my noble friend for his championing of this cause. I am sure that the main reason people smoke in cars is that they do not understand how harmful second-hand smoke can be for children. Of course we would like to see smoking in cars carrying children eradicated entirely but, at present, we are not convinced that legislation presents the most effective or proportionate approach. Rather than create new offences, we prefer to promote and encourage positive behaviour change, and there is emerging evidence that we are succeeding on that score.
Lord Turnberg (Lab)
My Lords, is there any evidence that has not been published and examined in great detail that we have to wait for?
Earl Howe
My Lords, it is clear from the debates in the other place and from our debates in Committee on the Children and Families Bill, that there is emerging evidence that needs to be considered. That evidence has emerged since the consultation. I am not in a position to make a judgment on that. I think Sir Cyril Chantler is the best person to do it.
Lord Kakkar (CB)
My Lords, I declare my interest as a member of the board of UCL Partners, currently chaired by Sir Cyril Chantler, and I congratulate Her Majesty’s Government on the excellent choice of Sir Cyril to lead this important review. Can the noble Earl confirm that Sir Cyril will be completely free to define both the methodology that he will apply for the review and the question that he will address?
Earl Howe
My Lords, this will be an independent review with advice from the Secretary of State contained in a report. An independent secretariat will be appointed by the chair, who will set out the method of how he will conduct the review in more detail in due course. The secretariat will be wholly accountable to the chair and it will be for the chair to guide and task the secretariat in its work as he sees fit.
NHS: Clinical Commissioning Groups
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Lord Hunt of Kings Heath (Lab)
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer noble Lords to my health interests in the register.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government have been discussing health funding, including progress on the fundamental review of allocations, at regular accountability meetings with NHS England. This NHS England-led review began in December 2012. The independent Advisory Committee on Resource Allocation, ACRA, is providing advice on changes to the formula. NHS England will consider ACRA’s recommendations. Initial views should be available to inform 2014-15 allocations.
Lord Hunt of Kings Heath
My Lords, my understanding of the formula is that it would move resources from areas where people have worse health outcomes to areas where they have better health outcomes. The noble Earl has said that he and his ministerial colleagues are in discussion with NHS England. Can he confirm that this is a decision for NHS England? If that is so, what is the nature of the discussion that has taken place between Ministers and NHS England? Is it being left to NHS England to decide?
Earl Howe
My Lords, very definitely yes. It is precisely to avoid any perception of political interference that we made NHS England responsible for the allocation of resources to clinical commissioning groups. However, we were very specific in the mandate, as the noble Lord will recall, that the principle on which NHS England has to operate is equal access for equal need, with particular attention being paid to health inequalities while not destabilising the NHS. Those are the things we discuss in our regular meetings with NHS England but the actual nature of the formula that it will decide in its board meeting next month is entirely up to it.
Lord Patel (CB)
My Lords, we know that the single most significant factor associated with poor health outcomes is deprivation, particularly for diseases such as chronic lung diseases, cardiovascular diseases and cancers—and, even more importantly, for chronic diseases in children. Would it not be wrong therefore if the tariff did not include the deprivation in the population when setting it for the community?
Earl Howe
My Lords, the CCG target formula recommended by ACRA this time a year ago was rejected by NHS England for the very reasons that the noble Lord cites: because it did not include an adjustment for deprivation and health inequalities. At a recent Health Select Committee hearing, Paul Baumann, the chief finance officer of NHS England, indicated that the proposed new formula would have an adjustment for a health economy’s unmet need—in other words, an adjustment for deprivation where low life expectancy suggests that people are not accessing health services.
Baroness Manzoor (LD)
My Lords, can my noble friend the Minister clarify that responsibility for the development of primary care is to be shared between CCGs and NHS England area teams, particularly as CCGs now control two-thirds of the NHS budget?
Earl Howe
My Lords, at present primary care is commissioned by NHS England and has three broad ingredients: primary medical care, primary pharmaceutical services and primary dental services. However, we are looking at ways of making the whole process of primary care commissioning more creative. That could well involve a joint process by NHS England and clinical commissioning groups.
Lord Campbell-Savours (Lab)
In light of what the Minister said before, are we being assured therefore that age and gender will not be given priority over gross health inequalities and needs in areas of social deprivation, such as in the north of England? If that is not the case, surely the principles on which the National Health Service was created are being undermined.
Earl Howe
My Lords, age is and has always been, in the formula, the primary driver of an individual’s need for health services. The very young and elderly, whose populations are not evenly distributed throughout the country, tend to make more use of health services than the rest of the population. Having said that, the formula contains elements relating to unavoidable differences in the costs of providing services due to location alone—that is, the market forces factor—and a number of other measures of adjustment. As I say, we are assured by NHS England that deprivation will feature in the formula that is published for next year.
Baroness Masham of Ilton (CB)
My Lords, is the noble Earl aware that in Yorkshire, many of the hospitals which are PFI are very seriously in debt? Is there not a rumour that the poorer north will have its money taken to the richer south?
Baroness Quin (Lab)
My Lords, does the Minister accept that in the north-east of England huge concern has been expressed about the initial proposals? This has been widely and repeatedly trailed in the press in the north-east. While I welcome what the Minister said about tackling health inequalities, can he give us an assurance that the most vulnerable communities and the most vulnerable people will not lose out as a result of this consultation?
Earl Howe
There are two elements to consider here. One is the target allocation, which is what NHS England is currently working on, and the other is the actual allocation—the money given to individual areas. The task for NHS England will be to decide how quickly or slowly to move from current allocations to the target. The key will be not to destabilise any NHS area in that process.
Lord Harris of Haringey (Lab)
I do not think the noble Earl answered my noble friend Lord Hunt’s Question about the discussions that have taken place between the Government and NHS England on this topic. Will he tell us what steer the Government have given on these matters?
Earl Howe
We give no steer. As I said to the noble Lord, Lord Hunt, the principles on which NHS England should operate are clearly of concern to Ministers—namely, equal access for equal need, the need to take account of health inequalities in an area, and not destabilising the NHS. We also believe that NHS England should be transparent in whatever it does. Those are legitimate concerns for Ministers, but we do not seek to steer NHS England in any particular direction.
Baroness Hussein-Ece (LD)
Will the Minister reassure me that child and adolescent mental health services will be given sufficient weight in these discussions?
Earl Howe
My Lords, ACRA has recommended that CCG mental health services allocations should be set using the same overall approach as that for other hospital and community health services. That means that a large part of the allocation is linked to the diagnoses reported for people registered with each GP. That makes the formula very sensitive to need. It has the potential to improve the way we allocate resources for mental health services, in particular.
Lord Hunt of Kings Heath
My Lords, will the noble Earl arrange for NHS England to meet interested parliamentarians before it takes its decision at the meeting next month?
NHS: Accident and Emergency Units
Earl Howe Excerpts(10 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I join other noble Lords in thanking the noble Baroness, Lady McDonagh, for raising this important issue, in which I know that she has a significant interest. I thank other noble Lords who have contributed to this very interesting debate.
I would like to respond initially by explaining the Government’s policy with regard to service change in general, before moving on to the provision of care in A&E specifically. I find it difficult to say much about the noble Baroness’s speech beyond observing that there is such a gulf separating us in our respective understanding of the facts and what is actually happening in the NHS that I shall have to write to her—and I shall do so.
The Government are absolutely clear that the design of front-line health services, including accident and emergency units, is a matter for the local NHS. It is the policy of this Government that services should be tailored to meet the needs of the local population. Reconfiguration is about modernising the delivery of care and facilities to improve patient outcomes, develop services closer to home and, most importantly, to save lives. Therefore, all service changes should be led by clinicians, and be in the best interests of patients, not driven from the top down. That is why we are putting patients, carers and local communities at the heart of the NHS, shifting decision-making as close as possible to individual patients, by devolving power to professionals and providers, and liberating them from top-down control.
Lord Hunt of Kings Heath
My Lords, if that is so, why has NHS England put so much pressure on clinical commissioning groups to close walk-in centres? It is simply not happening that clinicians are deciding. The fact is that NHS England is carrying on a micro- management of what is happening; it is simply not playing out in the way that the noble Earl describes.
Baroness McDonagh
I have another example. If what the Minister said were true, how did the Secretary of State for Health try to shut Lewisham general when all the clinicians called for it not to be shut?
Earl Howe
I shall say more on Lewisham in a moment. This is a time-limited debate, and I hope that I may be allowed to conclude my speech.
The principles that I have just enunciated are further enshrined in the four reconfiguration tests first set down to the NHS in 2010, which all local reconfiguration plans should demonstrate. These are support from GP commissioners, strengthened public and patient engagements, clarity on the clinical evidence base, and support for patient choice.
Our reforms allow strategic decisions to be taken at the appropriate level. We are enabling clinical commissioners to make the changes that will deliver real improvements in health outcomes. That is the purpose of reconfiguration. Furthermore, local commissioners proposing significant service change should engage with NHS England throughout the process to ensure that any changes are well managed strategically and, crucially, that they will meet the four tests that I have just referred to.
Given the scale of change across the health system, it is important that local NHS organisations are now supported when redesigning their health services. We are working with our national partners, NHS England, the Trust Development Authority and Monitor, on the continuing design of the interfaces, roles and responsibilities of organisations in the new system. For example, stroke care in London, which has been centralised into eight hyper-acute stroke units, now provides 24 hours a day, seven days a week acute stroke care to patients regardless of where they live. Stroke mortality is now 20% lower in London than in the rest of the UK, and survivors, with lower levels of long-term disability, are experiencing a better quality of life. That is why we must allow the local NHS to continually challenge the status quo and look for the best way of serving its patients.
I turn specifically to accident and emergency departments and points raised by a number of noble Lords. The NHS is seeing more than 1 million additional patients in A&E compared to three years ago and, despite this additional workload, it is generally coping well. I can say to the noble Lord, Lord Kennedy, that we are meeting our four-hour A&E standard and have done since the end of April. The latest figures show that around 96% of patients were admitted, transferred or discharged within four hours of arrival. There are now 500 more A&E doctors in the NHS than there were under the previous Government. Trusts expect to hire 4,000 more nurses, due to the Francis effect, as a result of the public inquiry that the party opposite decided not to pursue.
I have heard many noble Lords describe the current situation as a crisis. I do not share that perception. The NHS is performing well under pressure. Dealing with an extra 1 million patients in A&E does, however, mean that we must look at the underlying causes. Providing urgent and emergency care for people is not just about A&E. It is about how the NHS works as a whole and how it works with other areas such as social care, and how it faces up to the challenge of an ageing population of more people with long-term conditions. Therefore, the Government are taking action to respond to the immediate winter pressures and, looking longer term, we will tackle the unsustainable increasing demand on the system.
NHS England, Monitor and the Trust Development Authority, working with ADASS, have been working together on the A&E improvement and winter planning since May. Staff across the service have worked extremely hard to prepare this year and are committed to making sure that their plans are robust and that patients will receive the services they should expect and deserve. This process was started earlier and is more comprehensive than in previous years. We are determined to do everything we can for the NHS to continue providing high-quality care to patients throughout the winter, which is why we are backing the system with additional funds in the short term to help local areas prepare for and manage additional pressure during the winter.
We have allocated £250 million of funding to NHS England to help cope with winter pressures, with another £250 million for 2014-15. There will also be an extra £150 million from within the NHS England existing budget this year to ensure that everywhere receives a fair share of the funding.
It is, however, clear that the current situation is unsustainable in the long term. That is why we asked Sir Bruce Keogh to lead a review of urgent and emergency care with the first phase published on 13 November, which was also roundly welcomed by the system, including, as noble Lords will be aware, by the NHS Confederation and the Royal College of Surgeons. There will be a further update in spring 2014.
The review is aimed at delivering system-wide change, not just in A&E but across all health and care services in England by concentrating specialist expertise where appropriate to ensure that patients with the most serious illnesses and injuries get the best possible care and ensuring that other services, such as primary and community care, are more responsive and delivered locally. This will mean that people will understand how to access the most appropriate treatment in the right place as close to home as possible.
The noble Baroness, Lady McDonagh, the noble Lord, Lord Patel, and others referred to NHS 111. The introduction of the NHS 111 service is part of the wider revisions to the urgent care system to deliver a 24/7 urgent care service that ensures people receive the best care from the best person in the right place at the right time. This is not only government policy; it was a policy fully signed up to by the previous Government and initiated by them. Although NHS 111 has had a difficult start, we have backed the service with a £15 million fund to support it over the winter. NHS 111 now deals with more than half a million calls a month, and 97% of them are answered in under a minute. The first phase of the urgent and emergency care review sets out a significant expansion and enhancement of the NHS 111 service so that patients know to use the 111 number first time, every time, for the right advice or treatment.
NHS Direct, which was referred to by the noble Baroness, Lady McDonagh, and the noble Lord, Lord Patel, will continue to provide 111 services to patients until alternative arrangements can be made by commissioners. The transfer of NHS Direct’s 111 services is progressing well.
Together with NHS England, we are putting together a strategy focusing on the people who are the heaviest users of the NHS, vulnerable older people and those with multiple long-term conditions. Here I am addressing particularly the points raised by the noble Lords, Lord Patel and Lord Kakkar, and my noble friend Lord Selsdon. The vulnerable older people’s plan will focus on improving out-of-hospital care services centred on the role of general practice in leading proactive, person-centred care within a broader team and is due to be published later this year. A key element of the plan is the provision of joined-up care for vulnerable older people, spanning GPs, social services, and A&E departments themselves, which is overseen by an accountable GP. The aim of proactive care management is to help keep people healthy and independent longer.
A number of noble Lords referred to the workforce challenge. Health Education England is working with stakeholders on a number of innovations to help alleviate the workforce problems in emergency medicine. Through the Emergency Medicine Workforce Implementation Group, Health Education England will work to develop alternative training routes for emergency medicine and a range of mid-level non-doctor clinician posts. They will work with NHS England on potential workforce and training requirements.
I would like to address the point made by the noble Lord, Lord Kennedy, about Lewisham. Lewisham’s A&E is not closing. The TSA proposals were a response, as he is well aware, to a very difficult, long-standing challenge facing south London. The new Lewisham and Greenwich NHS Trust must now work with its commissioners and community to deliver a clinically and financially sustainable future. As regards north- west London, which the noble Lord, Lord Dubs, referred to, the Secretary of State has endorsed the recommendations of the Independent Review Panel, and it is now for CCGs in north-west London, working with NHS England, to take this forward. The decisions here were supported by all the commissioners in the area and all the medical directors in the trusts and all but one of the relevant local authorities.
My noble friend Lady Manzoor spoke about public awareness and engagement. I agreed with a lot of what she said. Through our reforms we have strengthened local partnership arrangements through health and well-being boards. These will provide a forum where commissioners of services, local authorities and providers can discuss the future shape of health services. As I have said, local cases for clinical change should be driven from a local level. We know that these reconfigurations work best when a partnership approach underlies them.
The NHS is one of the greatest institutions in the world. Ensuring that it is sustainable and that it serves the best interests of patients sometimes means taking tough decisions, including on the provision of urgent and emergency care. However—and this is the thought which I leave with your Lordships—those decisions are made only when the local NHS, working with local people and local authorities, is convinced that what it proposes is absolutely in the best interests of its patients.
Health: Tuberculosis
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Baroness Masham of Ilton (CB)
My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and declare an interest as a member of the All-Party Group on Tuberculosis.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
Public Health England has made TB one of its main priorities, and is leading a coalition of key stakeholders to inform its development of a strategy for tuberculosis. This aims to bring together best practice in clinical care, social support and public health to strengthen TB control, leading to a year on year decrease in incidence and a reduction in health inequalities associated with TB. The strategy will be published by March 2014.
Baroness Masham of Ilton
My Lords, I thank the noble Earl for his Answer, but is he aware that London is now known as the TB capital of Europe? It has some good facilities for prevention and treatment, but are those the same throughout the country? That is why the strategy is so important. There is plenty of tuberculosis—and drug-resistant tuberculosis, which is the big concern—in Birmingham, Bradford, Leicester and many other cities. Will he ensure that the strategy is pushed out as soon as possible? That is vital.
Earl Howe
The noble Baroness is absolutely right about the seriousness of the position, especially in some of our big cities. I can tell her that a TB control board has been set up in London, where about 40% of TB cases occur in the UK. The board is developing a dedicated London TB plan to strengthen measures to prevent, diagnose and treat TB in London. There are similar initiatives in Manchester and Birmingham. However, she is also right to say that we need to focus on the rest of the country, not least some rural areas, and the strategy there will be different to identify cases, diagnose them quickly and intervene early. Work is going on to roll out the plans for that.
Lord Walton of Detchant (CB)
My Lords, does the noble Earl accept that some years ago there was an increased incidence of drug-resistant tuberculosis in the UK, and it was discovered that that was, at least in part, the result of the disease being detected in an increased proportion of immigrants? When I went to the United States in 1953 as a visiting fellow, I had to take an X-ray with me to show that I did not have TB. What is now government policy on the medical screening of potential immigrants?
Earl Howe
My Lords, the policy now is that migrants to the UK from outside the European Union who apply for a visa for more than six months need to be screened in the country of origin. That work is proceeding, although I have to say that implementation has proved patchy, so we cannot be complacent. That is why it is vital to have services in this country capable of identifying people, particularly with multidrug-resistant TB, who may pose a threat to the community in that sense.
Lord Turnberg (Lab)
My Lords, is the Minister aware that the cost of treating multi-drug-resistant TB is £100,000 a year, compared with the cost of £5,000 a year to treat non-resistant TB? We now have a new category of extensively resistant TB, which is even scarier. I hope that Public Health England will treat as a matter of urgency getting a national strategy that brings standards up to those of Homerton Hospital, which is completing treatment of most patients whereas the rest of the country lags behind.
Earl Howe
The noble Lord is absolutely right. That is one reason why we are placing a particular focus on research into multidrug-resistant TB and diagnostics in that area. We fund UNITAID, which aims to triple access to rapid testing for MDRTB and to reduce drug prices for treating the condition. We have made a 20-year commitment to UNITAID of €60 million a year, subject to performance.
Baroness Gardner of Parkes (Con)
Following the comments of the noble Lord, Lord Walton, is the Minister aware that point of entry is very important? When I was involved in a health issue as a local councillor, we had a case of someone detected at Heathrow. It took two weeks to track him down, by which time he had infected 40 other people because he had moved into very limited accommodation where many people were all living in one room. This situation is developing again. What facilities are available at the airport now to pick up these cases?
Earl Howe
My Lords, there are regulations covering ports and airports which provide a contingency for when a passenger on a ship or a plane enters the UK, is suspected of having a notifiable disease and perhaps refuses to seek medical attention. The regulations include provisions for notification of such a case to the destination port health authority and for the detention of that person for the purposes of a medical examination. There are also quite flexible powers for local authorities to deal with incidents or emergencies where infection or contamination presents or could present a significant risk to public health.
Lord Hunt of Kings Heath (Lab)
My Lords, I refer noble Lords to my health interests. The Minister referred to a number of strategies in London, Manchester and Birmingham. Will he confirm that the implementation, particularly of some preventive strategies, will depend on the work of TB specialist nurses? Is he aware that some budgets are under pressure and there is a risk that we will not have enough nurses to do the job? Will he guarantee that we will see an increase in the number of TB nurses?
Earl Howe
My Lords, as the noble Lord is aware, NHS England allocates funding to clinical commissioning groups which commission health services on behalf of their local populations. It is for CCGs to decide how best to use the funding that is allocated to them, underpinned by clinical insight and knowledge of local healthcare needs. We expect health and well-being boards to have a major say in those areas where TB is commonplace.
Baroness Brinton (LD)
One of the key strands of the directly observed therapy recommended by the World Health Organisation for TB is standard treatment with supervision and patient support. What steps are being taken to empower patients with TB so that they can support DOT? Is there an expert patients scheme, as there is with many other chronic illnesses?
Children and Families Bill
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Lord McColl of Dulwich (Con)
My Lords, I, too, support these amendments, and my name is attached to Amendment 264. I should declare that I have a history as regards smoking as I used to be a chain smoker but gave it up when I was six. About 15 years ago in your Lordships’ House I introduced an amendment to ban smoking in public places. I put it on the back of a criminal justice Bill, which is a convenient way of moving things. I was amazed that the House was full right up to midnight when my amendment was discussed. I fondly imagined that everyone had come to listen to my wisdom, but little did I know that the House had filled with smoking barons waiting to pounce. However, I got my own back on them because at the end of the debate I thanked everyone for their contributions and, instead of saying, “I beg leave to withdraw my amendment”, for some reason or other I said, “Amendment not moved”. They all looked very puzzled because we had just spent hours discussing it. However, the noble Baroness on the Woolsack quickly said, “Amendment not moved”, passed on and they lost the opportunity to vote. They were furious and I was very pleased. As a professor of surgery, of course, I fully back any move to reduce the amount of smoking and I am convinced that these amendments would do that.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this has been an instructive debate and let me say immediately that I have listened carefully to all the contributions, both today and on Monday. Perhaps I may start by addressing Amendment 263. I should say at the outset that I have enormous sympathy with the aim of this amendment, which is to protect children’s health from the harm that can be caused by second-hand smoke, and I am grateful to the noble Baronesses, Lady Finlay and Lady Massey, and the noble Lord, Lord Faulkner, along with my noble friend Lady Tyler for bringing this important issue to our attention.
We all agree that we do not want to see children exposed to second-hand smoke anywhere. The evidence of the harm caused by second-hand smoke is clear, but many children continue to be exposed to it, both in the family car and in the home. The question posed by this debate is whether legislation is the most proportionate and viable means of addressing the problem. We need to consider that question carefully and I must say that, while supporting the spirit of the amendment—which I certainly do—the Government are not convinced that creating new criminal offences is the right approach.
Of course, in some people’s minds there are civil liberties considerations, which might include what is often perceived as state intrusion into people’s private space. That is a complex area worthy of a debate on its own, but of course I acknowledge that any arguments on that score need to be balanced against the need to protect children. Since 2007, evidence shows that smoke-free legislation has been effective in reducing exposure to second-hand smoke in virtually all enclosed work and public spaces, public transport and work vehicles. Compliance with the law is high and we now benefit from clean air at work, in pubs and restaurants, and on public transport. However, it does not automatically follow from that that it is right to extend the scope of legislation to cover private cars.
There are many practical issues to be considered, particularly around effective enforcement, which is not something that we have heard much about during the course of the debate. Smoke-free legislation in England is enforced by local authority environmental health officers. They do not hold powers to stop vehicles or to detain people in vehicles that are already stationary. Consequently, it would be very difficult for them to take effective enforcement action without the assistance of the police. Since this is a public health issue rather than one of road safety, I expect that such an additional duty on top of their many other responsibilities would be a cause for concern for the police. The Chartered Institute of Environmental Health has identified other practical difficulties around enforcement. These include accurately identifying which vehicles are required to be smoke-free. For example, small children may not easily be visible from outside the vehicle. Further difficulties include obtaining evidence of smoking, identifying the driver and passengers, and proving the age of the child.
I hope that the Committee agrees that there would be real practical difficulties in effectively enforcing such an offence. If we cannot credibly enforce the law, then the credibility of the law itself is called into question. That is why the Government firmly believe that, rather than focus on what would be a complicated and resource-intensive enforcement process, we should continue the non-legislative approach that the evidence shows is working; namely, encouraging positive and lasting behaviour change among adults who place children’s health at risk. My noble friend Lord Storey urged us to do this. Our comprehensive tobacco control plan states:
“Rather than extending smokefree legislation, we want people to recognise the risks of secondhand smoke and decide voluntarily to make their homes and family cars smokefree”.
That is why Public Health England, building on last year’s success, ran another hard-hitting marketing campaign in June and July this year. The campaign aimed to encourage smokers to stop and think before smoking in front of children, whether in the home or in the car. It also encouraged smokers to order an NHS smokefree kit with tips on making the home and car entirely smoke-free spaces, together with support to help quit smoking altogether.
This year’s campaign is currently being evaluated, but emerging findings are encouraging. They show that the campaign has been successful in raising awareness and in changing attitudes and behaviour, with almost three-quarters of those surveyed agreeing that smoking out of an open door or window was not enough to protect children from second-hand smoke. Of those surveyed, 37% reported that they had taken action to reduce their children’s exposure to second-hand smoke, compared with 29% in 2012. In addition, 73% agreed that the adverts made them realise that smoking out of an open window was not enough to protect children, and there were nearly 85,000 orders for smokefree kits. That is an increase of 48% on the 2012 campaign.
The right reverend Prelate the Bishop of Chester rightly suggested that this is a global issue. I agree. We are, however, considered to be a leader in tobacco control internationally. The World Health Organisation has assessed us to be number one in Europe in this area, and through the Framework Convention on Tobacco Control we share this good practice as much as we can.
The noble Lord, Lord Palmer, suggested that the Government ought to introduce an offence of proxy purchasing. I know that shopkeepers and others are interested in making it an offence to buy tobacco for young people under the age of 18. I am sympathetic to that concern, but even were such an offence to be introduced, it would not stop family and friends sharing cigarettes with children. Therefore, we get back to the argument about behaviour change, which I think is more relevant here.
The noble Baroness, Lady Howarth, made an interesting point about this being considered as a road safety issue. I agree that any activity such as smoking—getting out a cigarette, lighting it, disposing of hot ash or stubbing the cigarette out—is likely to distract the driver, particularly if carried out in a moment that is critical for road safety. However, there are a host of things drivers do that have the potential to be equally distracting, be it eating, drinking, adjusting the radio, consulting directions or whatever it may be. First and foremost, it is the driver’s responsibility to drive safely at all times. Section 41D of the Road Traffic Act 1988 already provides a perfectly adequate offence if a driver fails to maintain proper control of a vehicle while driving. While a specific offence has been created for driving while using a hand-held mobile phone, the Government do not believe that there is any need to introduce a new and separate offence of smoking while driving.
I welcome the debate on this important issue and I can assure noble Lords that we shall consider carefully the findings of this year’s marketing campaign and decide what further action may be needed. I can assure the Committee that the Government will continue to work to protect children from second-hand smoke in family cars and in the home. We are not complacent but we remain to be convinced that legislation is the most effective and proportionate way of achieving this.
Baroness Young of Old Scone
My understanding of this is that, because the Government would not come forward with a more general provision, this amendment has been hitched on to the Bill in desperation because it seemed to be a sensible place to try to get it into. The convolutions that the Minister is rightly pointing out would be solved at a stroke if there were to be a ban on differentiated packaging across the board and standardised packaging were introduced for all cigarettes.
Earl Howe
That indeed is my understanding. Noble Lords have taken the opportunity of this Bill to raise the dangers of smoking, particularly of passive smoking for children, and I have no issue with that. I merely point out that there are problems with the amendment as drafted. I am not saying that it would not be possible to draft another amendment which noble Lords might care to consider between now and Report. Being able to enforce these provisions as drafted is also a significant aspect. For example, it may be hard to judge whether a product could reasonably be expected to attract children, as the amendment would require, or to determine what might be aimed at or would attract 18 year-olds but not, let us say, 17 year-olds or 13 year-olds.
I am grateful to noble Lords for raising this important issue and for keeping this debate at the front of our minds. It is a debate that we need to continue. As I have said, the Government have yet to make a decision on this policy, but if we were to bring in such a measure, we would not want it to be circumscribed in the way that is proposed. We would not want to set up a situation in which both branded and standardised packs could be sold legally depending on where they were sold and what other products were sold alongside them. I therefore urge noble Lords not to press their amendments and respectfully suggest that they consider other avenues for bringing this matter before the House on Report.
Lord Hunt of Kings Heath
I always admire the noble Earl’s eloquence when defending the indefensible and he has done that par excellence today, but is not the reality that this is an opportunity for the Committee and the House to express a view in principle on the issue? It would then be up to the Government. As the noble Earl knows, when that happens, the Government simply come back with an amendment at Third Reading to deal with the technical issues. Surely the issue here is whether the House goes forward to a vote in principle, which I hope it might be able to do.
Earl Howe
Well, my Lords, if I could repay the compliment to the noble Lord, Lord Hunt, he has very eloquently presented the case for the Government to go away and think further about this, which indeed we will do. I come back to what I said at the beginning of this debate: the message from this Committee has been delivered loudly and clearly. I am grateful to noble Lords for that. I say again that the Government’s mind is not closed on this issue.
Baroness Howarth of Breckland
As one of those who are not quite so eloquent but are equally committed to the cause, I think that the Government would be in a far better position if we had some timescale. We now know when Report stage is likely. I am much attracted to what the Minister said. I would much prefer that we had a universal position that protected adults as well as children because of, as he said, the influence that adults have on children. Many more noble Lords might, like me, be influenced if they knew that something was likely to happen. The anxiety is that, unless we press this, nothing will happen.
Baroness Finlay of Llandaff
My Lords, it falls to me to respond. I am most grateful to all noble Lords who have spoken. I am grateful that nobody has spoken against the amendment that would prevent people smoking in cars when children were there. The evidence is overwhelming. This must fall squarely within this Bill; it is about protecting children from harm. If I may draw on the analogy of a tin box used by the noble Lord, Lord Storey, that would be classified without doubt as child abuse. It would fall to the police to prosecute in such a case—indeed, with other traffic offences, it falls to the police.
I was intrigued to hear that the Minister places so much faith in the public education campaign and cites cost of enforcement as a problem. How much has the public education campaign cost in total, including its evaluation, and what are the cost estimates for the police?
In Wales there has been a public education campaign since 2012 to try to stop people smoking in cars when children are present, and it is currently being evaluated. I live there and I can tell noble Lords that it is not working. In supermarket car parks you see children being offloaded into the back of the car, the shopping offloaded into the boot and a cigarette offloaded out of a packet into the driver’s mouth before they set off. I would dearly love to tap on the car windows of those people and say, “You can’t do that” because they are endangering the children in the vehicle. I also refute the notion that it would be very difficult to identify who is smoking when there are children in the car. The Government are committed to children’s health and well-being and have shown that commitment in many different ways—for example, through sporting initiatives—yet they allow a practice to continue which permanently damages children’s lungs and physical development and leads to premature death in some cases. Indeed, the instances involving asthma sufferers cannot be ignored.
I remind the Minister that the legislation on smoking in public places has brought about huge behavioural change and been extremely successful. I have been repeatedly thanked for that legislation by smokers and non-smokers, as must have happened to other noble Lords who campaigned prior to that legislation going through. That legislation has made it easier for them to attempt to stop smoking or to cut down. I can honestly say that nobody has been angry with me about the legislation having gone through, although some anger was shown when it was being discussed.
I was intrigued by the Minister’s comment about the complexity of Amendment 264 vis-à-vis producing standardised packaging. He may not wish to comment on the detail of it, although I am happy to give way if he does. However, I hope that he will meet me and other Peers who are interested in this issue to explain what problems may arise in this area. I am grateful to him for his critique of the amendment and see exactly what he means. We certainly need to take it away, redraft it and bring it back on Report. We do not want to make it harder for retailers who sell other things to children, such as comics, by differentiating and having some kind of two-tier system.
As regards the point raised by the noble Lord, Lord Palmer, in relation to illicit products, Margaret Hodge, chair of the Public Accounts Committee, found that the illicit market reduced from 20% to 9% between 2000 and 2012-13. The 9% figure applied also to 2010-11, although it dipped to 7% in one year. Margaret Hodge commented that the tobacco manufacturers are complicit in this illicit trade by,
“supplying more of their products to European countries than the legitimate market in those countries could possibly require. The tobacco then finds its way back into the UK market without tax being paid. The supply of some brands of hand-rolling tobacco to some countries in 2011 exceeded legitimate demand by 240%”.
I understand that oversupply to Ukraine has been identified, which fuels a £2 billion black market that has reached across the EU, and that in 2011 Japan Tobacco International was investigated and is now under official investigation by the European anti-fraud office. So I am afraid that it is not a nice story. I am not certain that the argument about revenue saved can possibly be stacked up against the cost of lives shortened, health damaged, children left orphaned and all the other things that we know go on. I beg leave to withdraw the amendment but we will be coming back to it at the next stage of the Bill.
National Health Service (Approval of Licensing Criteria) Order 2013
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NHS: Mid Staffordshire NHS Foundation Trust
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I shall now repeat a Statement made earlier today in another place by my right honourable friend the Secretary of State for Health on the Government’s response to Robert Francis’s report on Mid Staffordshire Hospital. The Statement is as follows.
“With permission, Mr Speaker, I would like to make a Statement about the Government’s response to the Mid Staffordshire NHS Foundation Trust public inquiry.
Let me start by paying tribute to the men and women of courage without whom this darkest episode in the history of the NHS would never have come to light: people like Julie Bailey and members of Cure the NHS, who stood outside the Department of Health in all weathers because no one would meet them to hear about the inhumane care given to their loved ones; brave whistleblowers like Mid Staffs nurse Helene Donnelly; and campaigners who suffered tragedies elsewhere, like James Titcombe, who never gave up the fight after losing his son, Joshua, at Morecambe Bay. They suffered greatly for their selfless determination to make sure that their personal losses were not in vain. All of us in this House today are humbled to stand in the shadow of their bravery.
Robert Francis and his team also deserve huge credit. Their diligence and thoughtfulness led to an outstanding report which will transform our NHS for the better. Finally, let me pay tribute to all NHS front-line staff, for whom reading about these events in the media has been immensely distressing. We owe it to them to make sure that poor care is never again allowed to take root and survive unchallenged in our NHS.
Since our initial response to the inquiry in March, much has happened. Thirteen hospitals have been put into special measures as part of a tough new failure regime. Those hospitals, where poor care had been allowed to persist, are now being turned around, and I thank the Keogh inquiry team for its painstaking work in this area.
Independent, Ofsted-style ratings of hospitals are under way, led by Professor Sir Mike Richards, the new Chief Inspector of Hospitals. The first 18 trusts are currently being inspected, with quality of care and safety paramount. We have appointed new Chief Inspectors of Adult Social Care and General Practice, whose robust inspections of care homes, domiciliary care and surgeries start next year. Surgical survival rates for 10 major specialties have been published by individual surgeons, making the NHS a world leader in transparency.
Today, the Government are publishing their further response to the inquiry as well as our response to the Health Select Committee’s report on the inquiry. Both these responses have been laid before Parliament.
The NHS is a moral being or it is nothing. It was set up 65 years ago with the noble ideal that no one should ever be prevented by background or finances from accessing the best care. That is why it remains the most loved British institution, and rightly so. But each and every case of poor care betrays those worthy aims. I do not want simply to prevent another Mid Staffs; I want our NHS to be a beacon across the world not just for its equity but its excellence. I want it to offer the safest, most compassionate and most effective care available anywhere, and I believe it can.
But that is only if there is a profound transformation of the culture in the NHS. The inquiry shows the devastating effects of overly defensive responses: hurting families, suppressing the truth and preventing lessons being learnt. Failure cannot be addressed when it is covered up, so today I am announcing new measures to promote a culture of openness and transparency.
From 2014, every organisation registered with the CQC will have a statutory duty of candour. Patients must be told promptly about any avoidable harm, but there will be a statutory requirement to notify any harm that has led to avoidable death or serious injury.
We will consult on whether hospitals that are found not to have been open and transparent with patients or families at the earliest reasonable opportunity should risk having their indemnity from litigation awards reduced or removed by the NHS Litigation Authority. The signal must go out loud and clear to all clinicians: if in doubt, report an incident and tell the patient.
The professional regulators have agreed to place a new, strengthened professional duty of candour on all doctors and nurses. Failing to inform a patient, not reporting avoidable harm, or obstructing someone else seeking to do so will be subject to sanctions, including being struck off.
Inspired by the airline industry, this duty will cover “near misses”—occasions when mistakes were made that could have led to harm and from which we need to learn. Conversely, prompt reporting may be considered as a mitigating factor in a professional conduct hearing. This is not about penalising staff for making mistakes; it is about enabling them to learn from them. The NHS will adopt a culture of learning, as recommended by Don Berwick and his expert committee. I thank them for their seminal report.
A culture of openness also means learning from complaints. In line with the recommendations of the right honourable Member for Cynon Valley and Professor Tricia Hart’s excellent review, all patients will be able to access independent help in making their complaint, with clear signs in every ward explaining how to do so; the Chief Inspector of Hospitals will inspect complaints handling to establish whether trusts are genuinely seeking to understand and learn from them; every quarter, trusts will publish the number of complaints received and the lessons learnt; and the Health Service Ombudsman will dramatically increase the number of cases that she looks at.
It is impossible to deliver safe care without safe staffing levels. All hospitals will be required to monitor their staffing levels on a ward-by-ward basis, analysing precisely how many shifts meet safe staffing guidelines. By the end of next year, this will be done using models independently approved by NICE. No hospital will be able to conceal unsafe staffing from the public because from next June all these data, both at ward and hospital level, will be published alongside other safety data on a new NHS safety website, triggering CQC action if there is cause for concern.
Things are already changing for the better and I am pleased to report that trusts are planning to recruit an additional 3,700 nurses compared to a year ago. However, we need to go further to train and motivate staff, particularly healthcare assistants and social care support workers who perform so much vital care. Healthcare assistants and social care support workers will be required to have a new care certificate to ensure that no one is ever asked to perform personal care without adequate training, whether in hospitals or care homes. The title “nursing assistant” will be used widely in hospitals and paths to nursing careers will be improved. I thank Camilla Cavendish for her excellent work in this area. We also need to broaden the talent pool going into NHS management positions, in particular attracting more clinicians and those with good external experience. We have introduced a fast-track leadership programme, sending 50 people a year to a world-leading business school, followed by time shadowing top NHS chief executives.
Robert Francis correctly highlighted the failure of regulatory systems to identify quickly what happened at Mid Staffs. Subsequently it has become clear that Ministers put pressure on regulators which may have led them to tone down news about poor care. This is totally unacceptable, so we will strengthen the statutory independence surrounding reports into care quality. The chief inspector will be the nation’s whistleblower-in-chief and nothing must ever be allowed to stand in his way. The CQC can prosecute when fundamental standards are breached. Trusts put into special measures will have a strictly limited time to get their house in order before administration is considered. Foundation trusts in special measures will have their autonomy suspended and action will be taken to ensure that they quickly improve. No trust will be able to progress to foundation status unless they are rated good or outstanding.
Proper accountability must be at the heart of the NHS. I have therefore accepted Professor Don Berwick’s recommendation of legal sanctions for those found guilty of wilful neglect or ill treatment. There will be a new criminal offence for care providers that supply or publish false or misleading information. A new “fit and proper persons” test will enable the CQC to bar unfit directors from boards. Every hospital patient should have the names of a responsible consultant and nurse above their bed. Starting with over-75s from next April, there will be a named accountable clinician for out-of-hospital care for all vulnerable older people.
One of the most chilling accounts in the Francis report came from Mid Staffs employees who considered such care to be “normal”. Cruelty became normal in our NHS and no one noticed. The Francis report made 290 recommendations. I accept the principles behind all of them and, wherever possible, have adopted the practical solutions suggested by the inquiry.
Robert Francis himself has welcomed today’s announcement as a carefully considered and thorough response to his recommendations, which he says will contribute greatly towards a new culture of caring and making our hospitals safer places for their patients.
Today’s measures are a blueprint for restoring trust in the NHS, reinforcing professional pride in NHS front-line staff and, above all, giving confidence to patients that after Mid Staffs the NHS has listened and learnt and will not rest until it is delivering the safest, most effective and most compassionate care anywhere in the world. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, first, I welcome the noble Lord’s very positive comments about the various reviews that have been commissioned in recent months. I am glad that he agrees that, in broad terms, the Government are on the right lines in accepting the recommendations that have come forward.
The noble Lord asked a number of questions, the first of which was about why we have not implemented all the recommendations of Robert Francis in full. Most of the recommendations have been accepted in principle, in part or—in the main—in their entirety. In some cases, we are taking an alternative approach to that suggested in the inquiry if we believe it is likely to be more effective in reaching the intended outcome. In total, we have rejected just nine of the 290 recommendations and where recommendations have been rejected, a full response outlining the reasons for doing so and the alternative action that organisations are taking is provided in our system-wide response.
The noble Lord asked about the regulation of healthcare assistants, a matter to which we return at regular intervals in this House. I assure him that the Government keep this issue under regular review but, for the time being, our view is to tackle the key issue at its root, focusing on making sure that healthcare support workers have the right training, values, support and leadership to provide the high-quality care that we all want patients to receive. We are committed to ensuring that this part of the workforce receives high-quality and consistent training. We have commissioned Skills for Care and Skills for Health, as the noble Lord knows, to develop a code of conduct and minimum training standards. We have also announced the development of a care certificate, which I am sure will be particularly welcome to a number of my noble friends.
The noble Lord asked me about a situation in which employers might find that a healthcare assistant or social care support worker no longer met the standards required by the care certificate. In that event, Health Education England and the sector skills council will set out in guidance the requirements for ensuring that appropriate retraining is given or other disciplinary action is taken. The guidance will be that the worker in question should not work unsupervised until the problem has been resolved and the employer is confident that their care certificate remains valid. Of course, if a healthcare assistant is found to have harmed patients or have been a serious risk to patients, the Disclosure and Barring Service needs to be considered as the ultimate remedy to make sure that that person does not put patients at risk in future. However, that is an extreme situation, which I believe will not be the norm.
The noble Lord referred to the nurse numbers. In the last spending review, the NHS budget was protected in real terms, with cash funding rising by £12.7 billion by 2014-15. Alongside that, Health Education England has been working with NHS trusts to develop the overall workforce plan for England for next year, reflecting the strategic commissioning intentions. That work indicates that a number of trusts have already increased their nurse staffing levels during the current year and others are planning to do so, as I mentioned in the Statement. Initial plans indicate that trusts intend to employ an increase of more than 3,700 nurses this year.
Moving to staff ratios, nursing leaders have been clear—indeed, there is a letter in today’s Times about this—that hospitals should publish staffing details and the evidence to show that staff numbers are right. However, we do not think that prescribing a rigid set of rules from the centre is the right way forward. The National Quality Board and the Chief Nursing Officer are publishing a guidance document that sets out current evidence on safe staffing. By next summer, NICE will produce independent, authoritative, evidence-based guidance on safe staffing and review and endorse associated tools for setting safe staffing levels in acute settings. From next April, by June at the latest, NHS trusts will publish ward-level information on whether they are meeting their staffing requirements. A review every six months will allow for those staffing levels to be quality assured.
On the issue of candour, we have had a number of debates on this subject, both during the passage of the Health and Social Care Act and, more recently, in the Care Bill, and I believe that we have reached a place for which this House can take some credit because the Government have moved a considerable distance from their original position. We agree with Don Berwick’s intention that professional regulators are in the best position to strengthen the duty of candour for individual professionals working in a hospital. Of course, the duty of candour applies to the corporate entity but the GMC and the NMC will be working with the other regulators to agree consistent approaches to candour and the reporting of errors, including a common responsibility to be candid with patients when mistakes occur, whether serious or not, and clear guidance that professionals who seek to obstruct others in raising concerns or in being candid would be in breach of their professional responsibilities. The professional regulators will issue new guidance to make it clear that it is the responsibility of professionals to report near misses for errors that could have led to death or serious injury as well as actual harm, and they must do so at the earliest opportunity. We will seek advice from experts on how to improve the reporting of patient safety incidents, including whether the threshold for the statutory duty of candour should include moderate harm.
The noble Lord referred to the NPSA. He is right that the NPSA’s function of reporting safety incidents has transferred to NHS England, into which the National Reporting and Learning System has been absorbed. I do not see that transfer as, in any way, inhibiting staff confidence in reporting safety incidents. The essence of the system remains as it always has been.
The noble Lord asked about the responsibility for patient safety being transferred back to the CQC. I am sure that, on reflection, he will agree that patient safety is everybody’s business. In part, it is the business of the CQC but, above all, it is the business of those who work in the NHS. It is the business of trust boards and of commissioners. It is also very much the business of those whose job it is to look at the performance of the NHS on behalf of patients—chiefly Healthwatch, but also patient organisations. Therefore one cannot single out an individual organisation as taking sole responsibility for this.
I will write to the noble Lord about the Freedom of Information Act. However, he should not forget that the standard contract that the NHS operates binds anyone who provides services to the NHS into certain contractual terms, and the disclosure of relevant information is a part of that.
On death certification, the noble Lord asked me about medical examiners. We agree that they must be independent of the deceased person and their medical practitioner. That is because medical examiners need to carry out independent scrutiny of the medical circumstances and cause of apparently natural deaths to make sure that the right deaths are notified or referred to a coroner. However, we need to ensure that there are sufficient numbers of medical examiners to carry out this work, particularly in rural areas, so appointees are likely to have some sort of professional relationship with local care providers. Therefore the draft death certification regulations for medical examiners do not require that medical examiners are independent of the organisation whose patients’ deaths are being scrutinised. However, we are mindful of the need for a greater level of independence within the spirit of this recommendation and the Government will review how they can include further safeguards on this front.
The noble Lord suggested that the NHS constitution was not the right means of changing the culture of the NHS, and I agree with him. However, declaratory statements in the constitution are an important part of signalling to the NHS its vision and values in the broadest terms, and the duties that people should feel they are under. The values, rights and pledges set out in the NHS constitution form the basis of everything the NHS does. NHS England, Health Education England, the department and CCGs are developing a joint strategy to embed the constitution further, as we promised they would during the passage of the Health and Social Care Act.
On the system that we have put in place and the complexity that the noble Lord sees in that system, I say, simply, that the system we now have is more transparent than the one we had before. Accountabilities are clear, responsibility is clearly placed where it should be and it is backed by robust lines of accountability, including to Ministers and Parliament.
I hope that that answers most of the noble Lord’s questions, but I will of course write to him if I have omitted anything.
Baroness Brinton (LD)
My Lords, we on these Benches welcome both the Francis report and the Government’s Statement. In particular, we welcome the importance of openness, transparency and access to information to ensure that there is a change in culture. Can the Minister confirm that the new care certificate will be an NVQ qualification so that the public can be confident that staff have the right skills and training? We would also welcome registration and regulation for those staff in the way that the noble Lord, Lord Hunt, referred to earlier. Can the Minister also confirm that when complaints and other items have to be published, it will not be as a few lines in an annual report but on the web, and that it will easily accessible by patients and the public?
Earl Howe
My Lords, I very much agree with the spirit of my noble friend’s questions. Certainly as regards complaints, the public should have a clear view of the nature of the complaints that have been registered with a particular organisation. They should be able to have a sense of what those complaints relate to and what action the organisation has taken to address the matter in question.
On my noble friend’s first point, we are currently working through the question of the care certificate and will seek advice. It is important to arrive at an agreed formula that gives the maximum assurance, both to care assistants and to those they look after, that basic standards of training have been learnt and are being adhered to. It is important to define as closely as we can what we mean by that, and as soon as we have further details we will announce them.
Lord Patel (CB)
My Lords, I thank the Minister for repeating the Statement, and I welcome the Government’s comments on the Francis report. I apologise on behalf of my noble friend Lady Emerton, the matron, who is not here today as she is unwell, and also my noble friend—he is a friend, although he sits on the wrong Benches—Lord Willis. He cannot be here because he has been asked to undertake the duties of my noble friend Lady Emerton. They asked me to represent their views—which I will not do, because I would get them wrong, but perhaps I may make my own comments. I realise I am not allowed the same time as the noble Lord, Lord Hunt, had. That is a pity, because I have much to say about the Statement.
I welcome the statutory requirement to give notification of any harm or serious misses that have happened. During my time as chairman of the National Patient Safety Agency I tried to get that into statute and failed; it was not under the current Government, but that does not matter. I am therefore delighted that this will be a statutory requirement. The important thing is that, as Don Berwick said, this is about learning; reporting by itself is not enough. The Minister referred to the airline industry, which learns from what has happened by doing root-cause analysis. We need that system established in the NHS if we are to learn from avoidable harm and near misses. Whose responsibility will it be to do that, and how will that expertise be gained?
On staffing ratios, the Minister knows that if my noble friend Lady Emerton had been here she would have asked about ratios of trained to untrained staff. Now that there will be a new care certificate to ensure training for all care assistants and nursing assistants, which I welcome, she would have asked for regulation. However, we have passed that stage, and I welcome the fact that there will be a new care certificate following the training. Why, however, is all this to be only for hospitals? What about care homes? Why were care homes excluded from reporting on staffing ratios?
Lord Patel
The Statement refers particularly to hospitals. They will have to report on staffing ratios, but it did not say that care homes will have to do that.
Earl Howe
I am grateful to the noble Lord. I am in complete agreement with him on his first point. The best thing might be for me to read out a very short passage from Professor Don Berwick, who said:
“The best keys to health care safety do not lie in blame, or regulation, or punishment, but rather in learning, support, and encouragement to the health care staff, the vast majority of whom are dedicated to excellence in care.
Leaders who aim for safe and effective care have a duty to supply the workforce with the tools, knowledge and encouragement to do the work that adds meaning to their lives”.
We have attempted, as far as we can, to make that philosophy the guiding principle of our response on patient safety. We do not want to create a blame culture; we want to create a culture that encourages everybody to feel ownership of the work that they do, and to feel well led. That is the other side of the coin to the culture that we have spoken about in other debates about innovation—about making innovation everybody’s business in an organisation. It comes down, in the end, to good leadership.
We are not insisting that every organisation should carry out root-cause analysis. On the other hand, we are saying that it is the business of trust boards to make complaints, mistakes, and lapses in patient safety central to their work and to the scrutiny that they undertake of their organisations, and for those matters to be discussed openly and resolved openly.
As regards care homes, as I said, we have commissioned NICE to work through the guidance that will underpin safe staffing. It is not yet apparent whether that will cover care homes and it is difficult to see how it could do so because care homes are clearly very different organisations from acute trusts. On the other hand, we expect the CQC to have some way of judging whether a care home can call itself safe. We will certainly look at the noble Lord’s points as we carry that work stream forward.
Baroness Pitkeathley (Lab)
My Lords, I am sure it will be welcome to patients and their families that the name of a responsible consultant will now be above the patient’s bed, but will the noble Earl say a bit more about the new attention to 75 year-olds that has been promised? In the extensive leaks of the Government’s response over the weekend, GPs were definitely named as the people who would be responsible for the over-75s. The Statement refers to “a named accountable clinician”. Is there a difference between the two?
Earl Howe
Yes. There were no leaks. The report that the noble Baroness saw was a report on the new GP contract that we announced at the end of last week. That was legitimate reporting by the press of an element of the new contract for next year, when we want all NHS patients over the age of 75 to have a named, accountable GP. However, we are saying in this response that every patient in a hospital setting should know who their consultant is, and therefore that there should be a named responsible consultant for every hospital patient. The two issues are, therefore, related but different.
Lord Mawhinney (Con)
My Lords, the Statement said that the NHS has to be a moral organisation or it is nothing. I am sure that my noble friend carried the whole House with him when he said that. Therefore, the raft of changes and the new legal accountability that will come in next year are very welcome in their own right as they will bolster that concept. However, how is it that no individual or individuals have been held accountable for the tragedy and disaster at Mid Staffordshire? I know that my noble friend keeps saying, on behalf of the Government, that they do not want to encourage a blame culture, but will he explain to your Lordships’ House how we can have an accountability structure without any blame attached?
Earl Howe
My Lords, the trust board at Mid Staffs was ultimately responsible, and individuals on it have been replaced. That was the first step in holding the system to account. We are introducing strengthened accountability for the future, including a fit and proper persons test for directors, as well as a single-failure regime triggered by failures in care. We have also appointed a Chief Inspector of Hospitals with power to ensure that the system acts quickly to tackle unacceptable care. In a range of ways I hope that we have addressed the central point in my noble friend’s question, which is very well placed.
Baroness Masham of Ilton (CB)
My Lords, I am pleased to hear about the transparency and the duty of candour, but will the noble Earl give the House an assurance that patients will be listened to? I am thinking about the young man who implored staff for a drink, and even telephoned the police on his mobile, but was ignored by staff. This was not Mid Staffordshire but a London teaching hospital. Further, will staff be protected when they blow the whistle? Will the noble Earl give an assurance that they will not lose their jobs?
Earl Howe
My Lords, I completely agree with the noble Baroness that the voice of the patient is an essential part of maintaining a culture of safety in the NHS. Improving the way in which the NHS manages and responds to complaints will be critical in shaping a culture that listens to patients and learns from them and ending a culture of defensiveness or, at worst, a culture of denial about poor care. That is why we welcome and accept the spirit of the review of the NHS hospital complaints system by Ann Clwyd MP and Professor Tricia Hart and the principles behind their recommendations.
On whistleblowers, the amendments to the NHS constitution have enhanced the protection for whistleblowers, but we are not complacent and we are already considering whether there is a need for more developments both to protect whistleblowers and to ensure that action is taken, where necessary, in response to concerns. We are looking, with the national regulators, at how whistleblowing concerns are dealt with at the moment and, where appropriate, we will introduce improvements to systems in the future.
Baroness Knight of Collingtree (Con)
My Lords, much of what my noble friend has said has given us satisfaction, but it is perfectly true, as we have already been reminded, that troubles were going on not only in the Mid Staffordshire area but all over the place. It is also true that it is not just the whistleblowers who warned time and time again about what was going on and who should have been listened to. I spent four or five years raising cases of people who had written to me. On one occasion I presented the then Minister, the noble Lord, Lord Hunt of Kings Heath, with a dossier of some 25 cases, all of which had been checked very carefully. All the details were correct, all the patients, or their relatives, had given permission for these cases to be raised and they were raised in this House. I am not blaming the noble Lord for failing to take these cases forward, or failing to listen to the arguments put out clearly in this House, because I think that he passed them on, but they were never properly investigated.
It is upsetting that for such a long period warnings were being given and were allowed somehow to filter into the ground and away, or into the past. I particularly warned about the practice, which was fairly unknown at that time, of failing to feed patients because food was put too far away from them and other examples. I worry about the people who suffered for those long years when something could have been done if those responsible at the grass roots had taken care of what was being said in this House. I beg the Minister not to leave aside the really serious point that cases raised with great sincerity and truth in this House should be regarded and not just pushed aside in the future.
Earl Howe
My Lords, my noble friend should be listened to with great care. Of course, I remember those cases. I was not the Minister in charge at the time she submitted those cases to the Department of Health, but she shared them with me, and I share her concerns, which are, of course, directly relevant to the matters we are discussing today. We have the new duty of candour and in April the Enterprise and Regulatory Reform Act strengthened the main whistleblowing legislation introduced by the Public Interest Disclosure Act so that an individual who suffers harm from a co-worker as a result of blowing the whistle now has the right to expect their employer to take reasonable steps to stop this. The idea is to ensure that people do not feel intimidated from speaking up. The Care Quality Commission is using staff surveys and the whistleblowing concerns it receives as part of the data in its new intelligent monitoring system. That data will guide the CQC about which hospitals to inspect. Since September, the commission’s new inspection system includes discussions with hospitals about how they deal with whistleblowers and handle them.
Baroness Hayman (CB)
My Lords, I declare an interest as a member of the General Medical Council. In no way do I speak on its behalf today, but it is obvious from the remarks that the Minister has made that the GMC has been working with the Government and other regulators and is committed to underlining professional responsibilities, particularly in relation to the duty of candour. That work will, of course, continue. On a personal level, I welcome the return to naming the consultant and the nurse responsible for an individual patient. It is emblematic of that personal sense of responsibility and accountability for patient welfare.
In respect of the new complaints procedure, as the Minister said, the care of patients and their safety are the responsibility of not only the named consultant and nurse but everybody in that institution. Does he agree that there is also a particular responsibility on the trust’s non-executive directors in that respect and that the new system should ensure that they are taking their responsibilities seriously? I know from decades ago, when I chaired the complaints panel at a London teaching hospital, that that resource, in terms not only of the ability to protect patients but of improving efficiency and the quality of care by understanding complaints, was a treasure trove that should not be abandoned.
Earl Howe
I entirely agree with the noble Baroness, who of course has immense experience in these fields. I agree with her in particular about the role of the non-executive director. If an organisation has what may look like quite a high number of complaints, it should be regarded as a sign of openness, transparency and the right kind of culture in that organisation. It is only where suspiciously low numbers of complaints have been recorded that alarm bells should start ringing. I agree that boards of directors, led and encouraged in this area by the non-executives, should make it a central part of their business to analyse complaints and make sure that they have been followed through, not just that the matters have individually been remedied but that any systemic issue has been properly addressed.