World Innovation Summit for Health
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Lord Crisp
To ask Her Majesty’s Government what is their response to the recommendation for improving mental health globally made at the World Innovation Summit for Health.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we welcome the recommendations made at the World Innovation Summit for Health and outlined in its report, Transforming Lives and Enhancing Communities. Mental health and well-being is a priority for this Government. Our overarching goal is to ensure that mental health has equal priority with physical health, and that everyone who needs it has timely access to the best available treatment. We hope that other countries will afford it equal priority.
Lord Crisp (CB)
My Lords, I thank the noble Earl for his reply. I should have made it clear when I tabled the Question that I was really looking for a reply from the Department for International Development. I will, however, ask two questions.
I know that the Minister will be as appalled as everyone else by this report and its finding that 700 million people with mental health problems worldwide are not getting treated, as a result of which some find themselves chained up or caged. Does he think the report’s findings and recommendations are relevant in the UK as well as elsewhere, although, obviously, not in relation to being chained up or caged? DfID currently spends, essentially, nothing on mental health. What is it planning to do post-2015 to make sure that nobody is left behind, as the Prime Minister has set out in his report?
Earl Howe
My Lords, the principles espoused at WISH do indeed apply with equal force to mental health services in this country. Those principles are several, but I would draw the noble Lord’s attention to the need to draw on evidence-based practice; to strive for universal mental health coverage; to respect human rights and to take a life-course approach. We try to embody all those things in our mental health services. Regarding DfID, I can tell the noble Lord that there are a number of multilateral and bilateral programmes which are in train and supported by the Government. We are supporting work in the Caribbean and Bermuda and promoting work in a number of countries in sub-Saharan Africa. I would be happy to write to the noble Lord with a complete list of these.
Earl Howe
My Lords, in broad terms, dementia falls outside the scope of mental health but it is, of course, closely allied. Many of the principles that apply to good mental health care apply equally to dementia. We are, again, doing our best, in responding to the Prime Minister’s challenge on dementia, to ensure that those who contract this dreadful condition are looked after with dignity and respect in the appropriate setting.
Baroness Wheeler (Lab)
My Lords, the WISH report, to which the Government are signed up, recommends key improvements to community care for mental health by 2020. Yet the recent FoI survey of 51 NHS mental health trusts by BBC News and Community Care magazine shows overall budgets shrinking by over 2%, including those for community mental health support teams, despite referrals to them rising by 13%. How is this consistent with pledging to achieve the WISH goal by 2020? What leadership and direction will the Government give to preventing this very disturbing situation from getting worse?
Earl Howe
My Lords, we need to hold the NHS to account by reference to the outcomes that it achieves. I do not belittle the need to spend sufficient sums of money. The National Survey of Investment in Adult Mental Health Services has indicated that reported spend on mental health services has continued to hold reasonably steady over time. I reiterate that mental health and well-being is a priority for the Government, as I hope the noble Baroness knows. We have clear indicators in the NHS outcomes framework, which will ensure that NHS England will need to focus on this area very closely.
Lord Alderdice (LD)
My Lords, it is extremely welcome that my noble friend has emphasised again that for the Government, under the Health and Social Care Act, parity of esteem between physical and mental health is to be maintained in this country. Perhaps I might press my noble friend a little further than the noble Lord, Lord Crisp, did. Have there been discussions between the Department of Health and DfID about DfID espousing parity of esteem for physical and mental health in its proposals, and have there been discussions with other government departments, such as the FCO, about the increasing abuse of mental health and psychiatry facilities for political prisoners in various parts of the world, not least in some of those countries with which we have good relations, including Russia?
Earl Howe
I will write to my noble friend on the issue of political prisoners. On his main point of principle about parity of esteem, that principle—which essentially works to ensure that mental health has equal priority with physical health—is central to government-funded mental health programmes overseas; in particular, DfID funds programmes that promote the rights of people with mental health disorders to ensure that their needs are equally met. We recently invested £2 million for an additional three years’ support to the Disability Rights Fund, which makes disability, including mental health issues, a key international development priority.
Baroness Hollins (CB)
My Lords, people with learning disabilities are disproportionately affected by mental health problems, with three times as many people experiencing such issues. In this country we are very well aware of that, and despite our own problems, such as Winterbourne View, we actually lead the world in research and service development. This is not recognised in global initiatives such as the summit just referred to by my noble friend. What will the Government do to try to raise awareness of the mental health needs of this particularly vulnerable group of people?
Earl Howe
Often overseas we are working with very scant resources and the key is to build up the skills at primary care level in countries that are developing and may not have regarded those with learning disabilities as a priority for healthcare. It is a slow process but one that we are trying our best to support. Again, I would be happy to write to the noble Baroness with details.
Olympic Legacy (S&T Report)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, first, I congratulate the noble Lord, Lord Krebs, on securing this debate and on the excellent work of the Select Committee on Science and Technology, which he chairs, in highlighting the important issues associated with sport and exercise science and medicine. The Government have welcomed the Committee’s report and its focus on the quality and application of research in this area.
We agree that the biomedical basis for improving performance of elite athletes needs to be of the highest quality possible and meet international peer review standards. For this reason, UK Sport and the English Institute of Sport have robust processes in place to quality-assure the projects that they support. For example, all projects are reviewed by an independent research advisory group, which includes a number of leading experts in the field of sport science.
Our elite sport programme is the envy of the world. UK athletes continue to perform strongly at the highest levels, thanks to the funding and technical support they receive from UK Sport and the home country sports institutes. Based on Team GB’s performance, there is no reason to doubt the quality or appropriateness of the research.
In the light of this success, it makes sense for this knowledge to be shared so that it might benefit non-elite sports men and women. Indeed, there are a number of ways in which UK Sport disseminates research findings. However, it is important to remember that the end goal of research is to support and maximise athletic performance on the world stage. Although UK Sport and the English Institute of Sport concede that more could be done to disseminate their findings, they need to do so without compromising the UK’s competitive edge.
The committee’s report rightly highlights the societal and economic costs of inactivity—a point well made by the noble Lord, Lord Hunt—and the benefits of exercise in promoting health and treating chronic disease. Indeed, the UK CMOs’ report, Start Active, Stay Active, contains recommendations across the life course on the levels of physical activity needed to achieve these benefits. The noble Lord, Lord Hunt, mentioned the research funded by my department. I can tell him that the department’s National Institute for Health Research funds a wide range of research on the benefits of physical activity.
I completely agree with my noble friend Lord Selborne that it is of crucial importance that breakthroughs in sport and exercise science and medicine are translated into health benefits for patients and the public whenever relevant and applicable. For example, characterising the mechanisms by which heart function improves with exercise in elite athletes and the military can help explain how heart function is impaired in people with diabetes or with high blood pressure. There are numerous examples of where the work of UK Sport and the English Institute of Sport is linked to benefits in the health and wellness domains. These typically involve partnerships with universities and necessitate the sharing of knowledge—for example, vitamin D supplements for bone injury and soft tissue injury recovery. There are a number of other channels, including formal and informal events where knowledge is shared within and outside the elite sport community. I think we can therefore be reassured about one of my noble friend’s central points—that taxpayer funding should lead to benefits to the wider public.
Translational health research is a high priority for the Government. In August 2011 we announced a record £800 million to support this through biomedical research centres and units funded by the National Institute for Health Research. Some of this money has been used to establish a new research unit at Leicester and Loughborough. This unit is helping to expand lifestyle interventions available for the prevention and treatment of chronic diseases. The funding is also enabling the NIHR biomedical research centre at University College London Hospital to study the mechanisms through which exercise promotes health, and how to deliver effective exercise strategies.
An important link in all this, which was mentioned by the noble Lord, Lord Krebs, is the first ever National Centre for Sport and Exercise Medicine, a legacy bid commitment of the 2012 London Games. The £30 million project funded by health is on track, with the London hub now actively functioning and treating patients. Loughborough is anticipated to become operational in 2014, and Sheffield will be the final site to become operational in late 2015. As well as supporting elite athletes, the centre’s influence will extend to local NHS hospitals and primary care facilities to provide a service for anyone who plays sport. Public Health England is overseeing the continuing development of the national centre and is keen to ensure that the centre performs a clear leadership role for sport and exercise science and medicine for the next five years and beyond. Public Health England is supporting the national centre to position it as an international voice on sport and exercise medicine, with strong links with the wider physical activity agenda and a global academic platform. PHE is considering an outline business case for funding in 2014-15 to support co-ordination across the national centre and as pump priming for long-term sustainability. The centre is keen to be seen as an independent organisation which generates income through direct patient care and research funding. It has appointed R&D leads to start that work. We can see the makings of the centre as a sustainable long-term organisation going forward.
The noble Lord asked about the centre as a source of a national strategy. Public Health England is, once again, working with the national centre to develop a sport and exercise medicine network of academics to help collaboration in research funding bids across multiple academic units. However, potential for conflict of interests has emerged as a stumbling block in developing a national research strategy.
In the context of public health, the noble Lord, Lord Hunt, asked about the role of health and well-being boards and his view that they should be prioritising investment in exercise. Many noble Lords would identify with that view but we must remember that health and well-being boards have been given, quite explicitly, the freedom to prioritise their own spending in relation to local public health priorities. However, I expect Public Health England to show the way in the area for local health and well-being boards to follow.
We envisage that the national centre will continue to attract grants from the research councils and deliver work of the highest quality, with the support of their world-leading host institutions.
Given the important health benefits of physical activity, the Select Committee was right to focus attention on the training of health professionals at all levels to be able to prescribe exercise for prevention and treatment. Clearly, the content and training curricula for doctors is determined by the medical schools and royal colleges, but the Department of Health will work closely with Public Health England and other interested organisations to make the case for physical activity in healthcare. On a more practical level, I am pleased to announce that Public Health England has commissioned an e-learning module on physical activity for healthcare professionals, to be distributed by BMJ Learning.
The noble Lord, Lord Krebs, mentioned the National Institute for Health and Clinical Excellence. NICE plays an important role in turning research evidence into authoritative and practical guidance for practitioners and commissioners. Where appropriate, both its public health and clinical guidance recognise the contribution that physical activity can play in the prevention, management and treatment of particular conditions, ranging from obesity to osteoarthritis and low back pain. I assure the noble Lord that many of NICE’s clinical guidelines recognise the important role that exercise and physical activity can play in the management of individual conditions. For example, its clinical guidelines on osteoarthritis and low back pain already recommend exercise. I am confident that NICE will continue to consider the role of exercise and physical activity in the management of particular conditions, where the evidence allows.
The noble Lord, Lord Hunt, asked about the scope for disseminating exercise guidance for specific chronic conditions to GPs. We are exploring the options for a national dissemination of this learning, which would need to be underpinned by better training for doctors in the benefits of physical activity. The new e-learning package commissioned by Public Health England represents an important step in that direction.
Exercise professionals also play an important role in supporting the most vulnerable patients to exercise as part of their treatment for a range of conditions—for example, as part of cardiac rehabilitation. Ukactive has been working with the royal colleges and training organisations for the fitness industry to develop new professional and operational standards for exercise referral. That work is awaiting the update by NICE of its existing recommendations on the use of exercise referral schemes, which it plans to publish in September next year.
The noble Lord, Lord Krebs, asked about the possibility of incorporating physical activity into an indicator in the quality and outcomes framework. This year saw the introduction of two new QOF indicators for physical activity. Those measured the percentage of patients with hypertension who had been screened for inactivity and, of those not meeting the guidelines, the percentage offered brief advice on how to be active. I have to tell him that these indicators have been retired from the 2014-15 QOF as part of the exercise to free up space for GPs to provide more personalised care. That agreement saw a reduction of the QOF by more than a third. However, the NHS health check programme continues to recommend that patients should be screened for their physical activity levels and the delivery of brief advice or an exercise referral for those who are shown to be inactive. At the same time, we are actively considering the case for continued monitoring of the retired QOF indicators to help inform NHS England’s developing primary care strategy.
We are committed to the dissemination of the UK Chief Medical Officer’s guidelines for physical activity, to both the public and medical professionals, and we are working with Public Health England and other organisations to help make healthcare professionals aware of those guidelines.
My noble friend Lord Addington asked why there are not more sports injury people in A&E to treat soft tissue injuries. I agree that athletes understand the importance of prevention. Sport and exercise medicine is, as he knows, a young specialism. Part of the work of the National Centre for Sport and Exercise Medicine will be to scale up sports and exercise medicine services and it will be important to ensure that supply is linked to demand.
The noble Lord, Lord Krebs, asked about the quality assurance of research initiated by the DCMS. I have already alluded to that very briefly. There is no specific monitoring or assessment undertaken by the DCMS of the research commissioned by its arm’s-length bodies. However, UK Sport acknowledges that further steps are necessary to provide stringent assessments of standards and has already made progress on this for the next funding cycle from 2013-17. This includes the appointment of an independent, technically structured sub-committee in addition to the research advisory group that has been in existence for a number of years. That will provide a more extensive overview of all investments in science, medicine and engineering.
Sport is a key part of a wider physical activity agenda, with an important role to play in getting and keeping people active and thereby improving their health and well-being. All sport is physical activity but an important part of Sport England’s youth and community strategy is pilot funding to support how sport can best contribute to improving health and, at the same time, grow weekly sports participation. There are important links between elite sport and the health of the public.
Aligned to the ambition of getting more people participating in sport once a week, Sport England has focused its work on tackling inactivity as this is where we can make a significant contribution to reducing health inequalities and produce the greatest potential health benefits.
Returning to elite sport, the fruits of National Lottery funding are there to be seen in Team GB’s recent success in the Olympics. I was reminded today that in 1996 GB won only one gold medal. In 2000, that went up to 11; in 2004 it was 9; in 2008 it was 19; and last year it was 29 gold medals.
However, the lasting impact of sport and healthy living has always been at the centre of the legacy ambitions of the Olympic and Paralympic Games. Our 10-point plan includes: elite sport, world-class facilities, major sports events, community sport, the strategy for youth and community sport, the charity Join In, school games, physical education and disability sport. For example, there will be £150 million a year for primary school sport starting in September 2013 and £1 billion over four years to boost youth and community sport.
In his Autumn Statement, my right honourable friend the Chancellor of the Exchequer announced that the Government will provide £150 million of funding to continue the school sport premium into the academic year 2015-16, meaning that primary schools will be able to put in place longer-term plans to improve their PE and sport provision. This is not just about elite sport. It will help people start to be and stay active, whether through sport or wider physical activities.
My noble friend Lord Moynihan asked about a cross-government push. The Olympic and Paralympic Legacy Cabinet Committee is the focal point for legacy and is well placed to ensure a joined-up approach to sport and physical activity. The Department of Health is obviously the lead department for health in promoting physical activity. We are working with other departments to support active lifestyles. Departments have jointly made available £300 million to raise the game in primary school sport. The Department for Transport awarded £77 million to increase cycling in eight of our major cities, with £1.2 million from the Department of Health to support walking. More than a million more people are playing sport than in 2005. I suggest to noble Lords that that progress is positive. As regards the Government’s effort, all this adds up to a significant investment in health-enhancing physical activity, driven by what we have learnt from sport and exercise science and medicine.
NHS: Walk-in Centres
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Baroness Wheeler
To ask Her Majesty’s Government what plans they have in respect of the closures of NHS walk-in centres over the past three years, in the light of the preliminary report made by Monitor.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, since 2007, the local NHS has been responsible for NHS walk-in centres. It is for local commissioners to decide on the availability of these services. It is also for local commissioners to determine how walk-in centres fit into plans locally, rather than being governed by a top-down imposition of services. They make such decisions by involving patients and by using their clinical expertise to determine the pattern of local services and where walk-in centres fit in with this.
Baroness Wheeler (Lab)
I thank the Minister for his response. However, 76 NHS walk-in centres have been closed over the past three years and the Monitor report makes clear that this is often without proper consultation locally on alternative provision, leading to increased pressure on A&E and urgent care services. In Monitor’s survey, one in five patients using the centres said that they would have visited the nearest A&E department had the centre not been there. Monitor also finds in a number of cases that the closure decision has been made by CCGs, with member GP practices themselves having a financial interest in whether or not the service continues. What action will the Government take to ensure that, if future closures of walk-in centres are considered, the public will be properly consulted and patients will have access to an equivalent level of service?
Earl Howe
My Lords, when any service change is proposed, we expect that the four tests which the Government laid down early on in their term of office should be followed. One of those is a patient and public consultation or involvement in the decision. Another is clinical buy-in. I can give the noble Baroness the assurance that this is what local area teams of NHS England would expect to see in any proposals involving the closure of a walk-in centre.
Baroness Brinton (LD)
My Lords, does my noble friend share my concern that the NHS is paying twice for patients who regularly use walk-in centres due to the capitation payment to GPs and activity payment to other care systems? Could part of the alternative provision to closed walk-in centres be that all GP practices follow the good practice of those who already extend opening hours for early and late sessions and Saturdays?
Earl Howe
The noble Baroness makes an extremely good point. One of the findings of the Monitor review was that, when responsibility for walk-in centres was handed down to local commissioners in 2007, many of them were decommissioned because they were duplicating services locally and GPs felt that they were paying twice for the same thing. I am sure that the ideas the noble Baroness has put forward will have a resonance in many areas.
Baroness Masham of Ilton (CB)
My Lords, is it true that doctors are being paid not to send patients to hospital? Does the Minister agree that when patients are ill they have no alternative but to go to A&E departments?
Earl Howe
I agree with the noble Baroness that A&E often presents the easiest and most convenient route into the NHS. That is why Sir Bruce Keogh is currently conducting his system-wide review and looking at pressures on the system. I am not aware of any doctors who are being paid not to refer patients to hospital. Indeed, as the noble Baroness may be aware, the BMA has been steadfast in its opposition to any such scheme.
Baroness Wall of New Barnet (Lab)
My Lords, the noble Earl suggested in his response earlier that part of the problem might be that the commissioners felt that they were paying twice. Obviously, GPs are paid for the people on their lists; those same people could use the call centre and they would have to be paid again. How does this fit with the view—certainly the view on the policy—that you can belong to any GP throughout the country, which is exactly what should happen and, if it did, we would not have this dilemma? Walk-in centres are hugely important. I assure the House that, from the point of view of the provider trust, they are absolutely vital to stop people coming into A&E and possibly being admitted.
Earl Howe
My Lords, I would not deny for a second that walk-in centres had a role in many places, and indeed the fact that so many are still open is proof of that. However, it is a mixed picture. Those centres that have closed are in many cases ones where doctors locally have perceived that, in one form or another, there is adequate provision for patients, whether through pharmacies, GP surgeries or community services of a different kind.
Lord Mawhinney (Con)
My Lords, how many proposals for walk-in centre closures have been advanced to public consultation over the past three years and then have not been proceeded with as a consequence of the consultation?
Earl Howe
My Lords, I cannot give my noble friend the answer because that is not information that we collect in the department but, as I said earlier to the noble Baroness, Lady Wheeler, we expect consultation to take place in local areas so that patients and the public at least have a chance to voice their views.
Lord Turnberg (Lab)
My Lords, when these centres were introduced, most people believed that they were a very good thing; I think they still think that. They help to take the load off A&E departments and GPs. Does the noble Earl agree that one of the problems is that there is no overarching co-ordination between A&E departments, GPs and these centres? Furthermore, there are no overarching similar funding arrangements. Should we not do something about that?
Earl Howe
Yes, my Lords, and that is exactly why Sir Bruce Keogh has been tasked to look system-wide not simply at walk-in centres but at the entire community and urgent and emergency care network to make sure that patients go where is most appropriate for them, that there is not undue pressure on any single part of the system, and that tariffs reflect the right balance of patient flows.
Lord Brooke of Alverthorpe (Lab)
My Lords, if there is an expectation that there should be consultation with patients and it does not take place, who is accountable for that failure?
Earl Howe
In some cases, a change of services will be so minor that formal consultation with patients is not required under the existing rules if, for example, a service moves a few yards down the road or something of that kind. However, it is the responsibility of the commissioner—either NHS England or a clinical commissioning group—to make sure that consultation where appropriate does take place.
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
Earl Howe Excerpts(11 years, 7 months ago)
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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
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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
Earl Howe Excerpts(11 years, 7 months ago)
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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?