NHS: Clinical Commissioning Groups’ Funding of Treatment
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Baroness Wheeler
To ask Her Majesty’s Government how many types of treatment Clinical Commissioning Groups have decided not to offer to patients since April 2013.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, clinical commissioning groups are now responsible for commissioning services and treatments for their local populations, with NHS England providing oversight and support. NHS England has advised that it does not routinely collect data on the number and type of treatments that CCGs have decided not to offer to patients. We have been clear: restricting access to services on the basis of cost alone is wrong and compromises patient care. Commissioning decisions should be made using clinical evidence and best practice guidance.
Baroness Wheeler (Lab)
I thank the Minister for his response. Is he not concerned about the recent British Medical Journal survey, which showed that since CCGs took over, one in seven have introduced new treatment restrictions, including treatment for hip and knee replacements, cataracts, and caesarean births for non-medical reasons? What steps are the Government taking to ensure regional and national monitoring and consistency of treatment policies across the NHS? Moreover, the Royal College of Surgeons is concerned that so few CCGs are meeting their legal obligation to publish guidance on how they will provide medicines, surgery and therapeutic interventions. This was meant to provide transparency in rationing decisions. What will the Government do about it?
Earl Howe
My Lords, the availability of some healthcare services is determined nationally; for example, under NICE technology recommendations. Some services are commissioned directly by NHS England, but in most cases decision-making on whether to fund a service or treatment is left to the local CCG or local authority. That is to enable CCGs and local authorities to commission services that best fit the needs of their local population. For such decision-making it is very important that the process is rational, transparent and fair. The right contained in the NHS constitution ensures that that happens. If a CCG decides that a treatment will not normally be funded, it needs to be able to consider whether to fund that treatment for an individual patient on an exceptional basis.
Lord Walton of Detchant (CB)
My Lords, does the Minister accept that, largely as a result of new developments in molecular biology, a number of highly effective but also very expensive so-called orphan and ultra-orphan drugs are coming on stream for the treatment of patients with rare diseases? If these drugs are approved by the rare disease advisory group of NHS England and by NICE, will it then be incumbent on clinical commissioning groups to agree to their being prescribed for NHS patients?
Baroness Brinton (LD)
My Lords, I declare an interest as a patient with rheumatoid arthritis who is on a biologic. What data are available to show whether CCGs follow NICE guidelines for the use of biologics and how long does it take for permission to be granted? I talked to rheumatologists last week at the National Rheumatoid Arthritis Society awards ceremony and I was told that there is increasing evidence that CCGs delay treatment for those on biologics. Is there a case for moving chronic illnesses such as RA to NHS England rather than relying on the lottery of CCGs?
Earl Howe
My Lords, the list of conditions for which treatment is directly commissioned by NHS England is reviewed regularly. On the particular question my noble friend asked about transparency, as part of Innovation Health and Wealth the innovation scorecard is now showing up the variations in prescribing rates between different clinical commissioning groups. We expect this information to be extremely informative as regards the decisions taken by commissioners.
Lord Warner (Lab)
My Lords, has the Minister seen the recent evidence given by the Nuffield Trust to the Health Select Committee showing that a growing, and increasingly large, number of NHS hospitals are financially unsustainable? In the light of his earlier answer to my noble friend, what arrangements do the Government have for ensuring that CCGs or local health economies are not in breach of the NHS constitution by failing to deliver the mandate that the Secretary of State has given NHS England?
Earl Howe
My Lords, it is for NHS England to oversee the commissioning practices and policies of CCGs. If any deficiencies are brought to the attention of NHS England, they will be followed up. On the specific point made by the noble Lord about the financial sustainability of provider trusts, we would expect commissioners and trusts to engage in regular discussions about how to ameliorate that position, not only for the sake of the NHS but also to ensure that patients are treated in the right setting. As we all know, that imperative needs to be pursued very vigorously over the coming months.
Baroness Masham of Ilton (CB)
My Lords, if patients are turned down by CCGs, can they appeal to NHS England?
Lord Harris of Haringey
My Lords, 55 years ago, I had my tonsils removed on the National Health Service. Had that not taken place and I now needed that procedure as an adult, according to figures from the Royal College of Surgeons I would be extremely unlikely to have them removed in the area in which I live—Haringey—but 22 times more likely to have the same procedure carried out in the Isle of Wight. Can the Minister explain why this Government’s arrangements facilitate that extraordinary postcode lottery, which means that there is no equity of treatment across the National Health Service?
Earl Howe
My Lords, what the noble Lord calls the postcode lottery is, as he knows, nothing new. That is why Sir Bruce Keogh, the medical director of the NHS, has commissioned a project to engage professional bodies, particularly the Royal College of Surgeons, to develop clinical commissioning guidance, in particular, where there is unwarranted variation in the rates of elective surgical intervention. They are currently looking at 28 common types of surgical intervention with more topics under development, and commissioning guidance will ensue from that work stream.
NHS: Urgent and Emergency Care Review
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, with the leave of the House, I shall now repeat in the form of a Statement the Answer to an Urgent Question tabled earlier today in another place on the subject of urgent and emergency care. The Statement is as follows:
“Mr Speaker, in January this year the board of NHS England launched a review of urgent and emergency care in England. Urgent and emergency care covers a range of areas, including A&E departments, NHS 111 centres and other emergency telephone services, ambulances, minor injury units and urgent care centres. The review is being led by Professor Sir Bruce Keogh, NHS England’s medical director. A report on phase 1 of the review is being published tomorrow and it is embargoed until then.
This is an NHS England report. NHS England is an independent body accountable to me through the mandate. The report being published tomorrow is a preliminary one setting out initial thinking. The final version will be published in the new year. Sir Bruce has said that he will outline initial proposals and recommendations for the future of urgent and emergency care services in England. These have been formed by an engagement exercise that took place between June and August this year. These proposals will be further consulted upon through a number of channels, including commissioning guidance and demonstrator sites. Spring 2014 will see another progress report.
Decisions on changing services are taken at a local level by commissioners and providers in consultation with all interested parties. That is exactly as it should be, as only then can the system be responsive to local needs. It is vital to ensure that both urgent and emergency care and the wider healthcare system remain sustainable and readily understandable for patients.
A&E performance levels largely have been maintained thanks to the expertise and dedication of NHS staff. A&E departments see 95% of patients within four hours and this figure has not dropped below the 95% target since the end of April. However, urgent and emergency care is falling behind the public’s needs and expectations. The number of people going to A&E departments has risen historically, not least because of an ageing population; 1 million more people are coming through the doors than in 2010. Winter inevitably further challenges the system, which is why we are supporting the A&Es that are under most pressure with £250 million. Planning has started earlier than ever before this year, and the NHS has been extremely focused on preparing for additional pressure.
We will look at Sir Bruce’s report extremely carefully. Reform of the urgent and emergency care system may take years to complete but that does not mean that it is not achievable. We are exceptionally fortunate in this country to have in the NHS one of the world’s great institutions. NHS staff are working tirelessly to ensure that the care that people need will continue to be available for them wherever and whenever they need it”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord for his questions. To start where he did, NHS England, as he knows full well, is legally and constitutionally an independent body. It is, however, accountable to the Secretary of State through the mandate, as it is accountable in a number of other ways, including regular meetings. I do not think that there is anything wrong about those meetings; indeed, noble Lords would be surprised if the Secretary of State took a detached view of what NHS England did. There is a balance to be struck. We believe that the direction of travel of NHS England is one for Ministers to set through the mandate and through the outcomes frameworks, in particular, but it is then for NHS England to adopt a clinically led approach to how it configures itself and how it oversees commissioning in the system. That is the balance that we have struck through the legislation that the House is familiar with.
It is not unusual to have an embargoed press conference the day before a major announcement. I see nothing wrong with NHS England having done that. It would not be appropriate for Ministers to come to the House the day before such an announcement when this piece of work has not been led by Ministers or the department.
The noble Lord asked what actions the Government had taken. Because this is not a normal Statement—we have 10 minutes in all—I shall be very brief. The work that is now in train is not just about A&E. We have recognised, as has NHS England, that joining up health and care services is a big factor. We have the 10 pioneer pilot schemes. We have launched the biggest ever commitment to making co-ordinated care a reality by 2018. We are looking at how we improve services for frail older people. We are developing a vulnerable older people’s plan. There is £250 million going into the system over the winter to ease the pressures on the hospitals that are struggling the most. In the longer term, we will have the solutions laid out by Sir Bruce in his report, which is published tomorrow.
Anyone who knows the history of walk-in centres will be aware that this was an initiative begun by the previous Government with the very best of intentions but as a top-down exercise, which in many cases resulted in the duplication of services and not the best use of NHS funds. Even under the previous Government we saw the closure of some of these services. We expect clinical commissioning groups to take a holistic view of the needs of patients in their area and to configure services cost-effectively. Sometimes that does mean closing walk-in centres that do not provide value for money.
NHS 111 is now available in more than 90% of England. Despite the problems that the noble Lord is familiar with in some sites that launched around Easter, performance has stabilised significantly. NHS 111 is now the principal entry route for access to the urgent care system.
On recruitment to emergency medicine, the point that the noble Lord rightly raised was the reason we set up the Emergency Medicine Taskforce in December 2011 to address workforce issues in emergency medicine. That group published an initial report last year, making a number of recommendations. Those recommendations are being pursued. The £250 million that I referred to is being distributed to 53 trusts, as the noble Lord will be aware. I have a breakdown here of how the money is to be deployed but, in the interests of other noble Lords who may wish to intervene, I shall not read it out.
Earl Howe
We have been clear with Health Education England that this is not just about A&E consultants; it is about the entire workforce in A&E, including all relevant disciplines—nursing and others. We have tasked Health Education England with putting even greater emphasis on the need to recruit A&E consultants from medical students over the coming years.
Baroness Brinton (LD)
I know that my noble friend the Minister cannot comment on Sir Bruce Keogh’s review but I wondered, separately, if there was evidence in areas that have already reorganised their urgent and emergency care—such as the West Hertfordshire Hospitals NHS Trust, which reorganised in 2009—that services are performing well or indeed better than under the old arrangements.
Earl Howe
My Lords, I do not have that evidence in front of me but, where there is a case for change, the local NHS has to agree a number of measures to be effective before any changes to services take place. That will include ensuring additional capacity at neighbouring hospitals, where that is appropriate, or in the community, where that is appropriate. If CCGs can properly satisfy themselves that a case for change can provide safe, effective and sustainable services, that is a legitimate justification for moving forward with local proposals.
Lord Warner (Lab)
My Lords, what light can the Minister throw on the recent report in the Financial Times that the Prime Minister has put the private hospital sector on standby for capacity over this winter? Is that true and is that part of the Government’s preparation for winter pressures? What impact do the Government assess has been made on the capacity of A&E departments by the 12% cut in the tariff paid by NHS England?
Earl Howe
I am aware that the tariff has been the subject of active discussion on the part of NHS England and Monitor; in particular, the 70% of the emergency care tariff that has been withheld under the arrangements put in place a number of years ago, and how that money should be used.
As regards the independent sector, the noble Lord is correct: discussions have been taking place with representatives of the independent sector to see whether and to what extent there is capacity to absorb elective care patients over the winter when needed. I see everything to be gained by that. It was something that the previous Government did and we think it is right that the independent sector, where appropriate, should play its part in relieving the burden from the NHS.
National Health Service (Approval of Licensing Criteria) Order 2013
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Health and Social Care Act 2012 requires that all providers of NHS healthcare services that are not exempt must hold a licence from Monitor. This is in addition to the existing requirement to register with the Care Quality Commission under the Health and Social Care Act 2008. Existing foundation trusts were licensed on 1 April 2013, and NHS trusts acquiring foundation trust status will be granted a licence on acquiring that status. Independent sector providers will be licensed from 1 April 2014, subject to the agreement of Parliament to this draft order.
The 2012 Act also establishes Monitor as the sector regulator of providers of NHS-funded healthcare services. In this role Monitor will grant licences and will regulate providers under the conditions of the licence. This builds on Monitor’s previous role as the regulator of foundation trusts. The provider licence is a key tool that Monitor will use in carrying out its functions of regulating providers to protect patients’ interests.
As is right in establishing a new regulatory framework, the Act requires the approval of the Secretary of State to some key aspects of the new licensing regime in order to provide a check on their appropriateness. Monitor sets the criteria that providers which are not exempt must meet to be granted a licence by Monitor. Monitor’s power to set those criteria is, however, subject to the approval of the Secretary of State for Health. In the case of the first set of criteria, it is also subject to the affirmative parliamentary procedure—hence the draft order which is the subject of today’s debate. The criteria proposed by Monitor, and which have been agreed by the Secretary of State for Health, are set out in the schedule to the draft order.
Monitor has already set the licence conditions, a set of ongoing obligations, with which providers must comply once licensed. Monitor published its first set of standard licence conditions in February this year after approval by the Secretary of State for Health as required by the Act.
As the Committee will remember, not all providers of NHS services are required to hold a licence. The Secretary of State has set the exemptions from this requirement and these were considered by this House on 25 July 2013.
This order is concerned with the licensing criteria. These criteria set the requirements which providers of NHS healthcare services must meet in order to be granted a licence. The licensing process is the entry point into the regulatory regime and provides Monitor with the tool to regulate providers. The licence conditions, the exemptions and the licensing criteria will give Monitor the tools to operate a regulatory framework on a large but defined pool of providers. It will enable Monitor to fulfil its main duty to protect and promote the interests of people who use healthcare services by promoting healthcare provision which is economic, efficient and effective and maintains or improves the quality of services.
In this context, Monitor has taken a proportionate and balanced approach to proposing the licence criteria and setting the licence conditions. Monitor undertook extensive engagement and consultation on its approach in order to arrive at a framework which protects patients’ interests by ensuring that providers are subject to proportionate regulation.
Monitor has proposed two criteria, which correspond broadly to two of the ongoing standard licence conditions. The first criterion requires providers to be registered with the Care Quality Commission, if required by law, in order to provide NHS services, and acts as an objective measure to assess compliance with standards of quality and safety. In order to meet this criterion, applicants for a licence must be registered with the Care Quality Commission, if required by law to do so, when the licence is granted.
The second criterion focuses on providers’ fitness. The purpose of this criterion is to ensure that people involved in overseeing the organisation and influencing the provision of healthcare services meet certain fitness requirements. In particular, no person who is a director or governor of a provider, or is performing an equivalent or similar function, may fall within the specified description of an unfit person. The description of an unfit person is designed to ensure that individuals performing these functions must comply with the statutory fitness requirements which are equivalent to those set out for directors and governors of NHS foundation trusts, and certain requirements on directors of companies. Examples of these requirements are that an individual must not be an undischarged bankrupt; have undischarged arrangements with creditors; be subject to a moratorium period under a debt relief order; have received a prison sentence of three months or longer during the previous five years; or be subject to a disqualification order or undertaking.
The criterion also requires that any corporate body which holds the position of director or governor of a provider must not be subject to the insolvency proceedings or arrangements listed in the order. Such proceedings might indicate that the company is not effective in governing the applicant and managing the applicant’s financial affairs. Providers must be able to meet these criteria in order to be granted a licence, but they must also continue to meet them to keep their licence, along with other licence conditions designed by Monitor to protect and promote patients’ interests. The department agrees that these are robust, appropriate criteria for Monitor to assess providers against, and I therefore commend this order to the Committee.
Lord Hunt of Kings Heath (Lab)
My Lords, first, I thank the noble Earl for that very full explanation of this order. In the context of the order, I should declare my chairmanship of an NHS foundation trust, which is subject both to Monitor and the Care Quality Commission.
I thought that the noble Earl’s full explanation of the order really reinforced concerns about the complexity of Monitor’s role and potentially the conflict between its licensing responsibilities, its independent regulation of pricing of NHS services and the general support that it gives for NHS foundation trusts. Now that Monitor has had time to consider these matters, since the passage of the 2012 Act, can he explain how it avoids conflicts of interest between these three separate roles? He will be aware that we discussed that issue when we debated the Bill.
Clearly, a lot of responsibility in Monitor rests on the leadership of Dr David Bennett. The noble Earl will be aware that in the pre-scrutiny hearing in the other place, the Health Select Committee—after examining Dominic Dodd, who had been proposed as chairman of Monitor—said of David Bennett that he,
“was appointed as interim Chief Executive in April 2010, and appointed as substantive Chair in March 2011. Since then he has filled the roles of both Chair and Chief Executive—effectively Executive Chair—and has led Monitor through the whole process of change brought about by the Health and Social Care Act 2012. This has been a period of great uncertainty for Monitor, with the nature of its role in the new system being unclear for most of the 18 months between the introduction of the Bill in January 2011 and its passing in 2012. Dr Bennett has both shaped and interpreted the role that Monitor now plays in the system which makes the transition to another individual taking on the Chair an especially difficult one. We do not think Mr Dodd is the right person to undertake that difficult transition”.
I understand that, following that, Mr Dodd withdrew his nomination, or at least his nomination was withdrawn.
In the context of this order, which sets the framework in which licensing will be undertaken by Monitor in future, can the Minister say a little more about the Government’s intention with regard to leadership, particularly the continuing role of Dr Bennett as both chairman and chief executive? As the Minister will know, in normal corporate governance terms that is not normally encouraged.
My third question relates to the Explanatory Memorandum, rather than the order itself. I was interested to see that, under “Policy Background”, paragraph 7.2 sets out three key functions of Monitor. I have already referred to them as,
“working with NHS England to provide independent regulation of pricing … protecting patient choice and”,
addressing,
“anti-competitive behaviour … and … working with commissioners to secure continuity of services”.
I just wondered where integration had got to. Have the Minister’s officials forgotten that? We debated this at great length and the Bill was amended to ensure the importance of integration. The noble Earl will recall that Monitor was given that express role. I am very disappointed to see that it is not referenced in the policy background but I am not surprised because, frankly, we have seen very little work on integration coming out of the various bodies concerned with the health service.
There has, however, been an awful lot to do with competition. As the noble Earl will know, in evidence to the Health Select Committee—I think it was only two weeks ago—the chief executive of the NHS railed against the way in which competition was being introduced in the health service. He knows, as everyone working in the health service knows, that a huge amount of money is being spent because of the enforced tendering of services that is undoubtedly taking place. It is very important that the Government reconsider the architecture that they have now put in place.
In addition to Monitor, we have the CQC, the NHS Trust Development Authority, the NHS Executive—I am sorry, I meant NHS England; that was a Freudian slip—and Ministers. Compared to the previous Secretary of State, the current Secretary of State takes a very different view of his role, and so we have a very confusing architecture. We also have the Office of Fair Trading making extremely unhelpful and unwelcome interventions, which again seems to act against the appropriate integration of services. It really needs to be sorted out.
I have no doubt that we will talk about this in a few minutes, but after Monitor’s welcome report on walk-in centres—I do not know whether it was as welcome to the noble Earl as it was to me—we have a situation where NHS England has undoubtedly been encouraging clinical commissioning groups to close down walk-in centres to make savings. However, yet another part of the architecture has come out with a report essentially saying that this has been a big mistake and has added to the pressure on A&E departments. One is entitled to ask: who on earth is really driving the policy at the moment?
Although I welcome the Monitor report, I was interested to know why it has produced it. At paragraph 1.2 on page 9 of the report, Monitor says:
“Our decision to review walk-in centre provision is grounded in our main duty as health care sector regulator: to protect and promote the interests of patients by promoting the provision of health care services that is effective, efficient and economic and that maintains and improves the quality of services”.
Well, yes, but is Monitor’s role really to look at this area of service provision? Fine—it is a good and welcome report, but it is confusing as to where one regulator’s role stops and the other starts. I have this great impression of five or six large, powerful bodies, all with well paid executives and strong boards, vying for influence. What that does at a time of huge pressure in the health service is to create uncertainty about who is leading, who is setting the policy and who is responsible for its implementation.
Finally, I come back to the question raised by Don Berwick in his very interesting report on patient safety, which the Government commissioned. In that report, which was published only a few months ago, he said:
“The current NHS regulatory system is bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies. It should be simplified”.
It certainly should be simplified. He went on to say:
“The regulatory complexity that Robert Francis identified as contributing to the problems at Mid Staffordshire is severe and endures, and the Government should end that complexity”.
Does the noble Earl agree that the order he brings before us today is simply a sign of greater complexity? I do not think that we have had a response from the Government on this recommendation. I know that the noble Earl has a regulatory Bill up his sleeve for the next Session. Given what Don Berwick said and the evidence that Sir David Nicholson gave to the Health Select Committee, does he not agree that it might be sensible to go wider and look at this whole business again, to get much greater clarity into what is a complex situation?
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Hunt, for his questions. I start with the issue that he raised initially, which was about the role of Monitor and what he perceives as the conflicts within that role. I address that by saying that there is no fundamental conflict, although he is perfectly right to say that Monitor has distinct, separate functions. Different executives within Monitor lead on each of those areas. Monitor has a board, which functions to ensure that David Bennett’s dual role as chair and CEO works effectively. At the same time, the Department of Health, as the steward of the system, keeps Monitor’s performance under review. It does that through quarterly accountability meetings. I suggest that the conflicts that the noble Lord perceives are much more in the perception than the reality. There are mechanisms in place within Monitor to ensure that the functions are kept distinct and that, where appropriate, Chinese walls operate.
The noble Lord referred to the nomination of Dominic Dodd as the chair of Monitor and the Select Committee’s view that he was not the right person to lead the organisation. That was a view which Mr Dodd himself accepted, and he volunteered to step aside. In the light of that, we are currently considering options for a sustainable solution to Monitor’s leadership. We will make an announcement as soon as we can on that, but, meanwhile, I emphasise that we have complete confidence in David Bennett’s leadership of the organisation.
Lord Hunt of Kings Heath
I meant no criticism of Dr Bennett in his role. I just point out that if one goes back to Cadbury and all sorts of reports since then, the evidence is clear that it is undesirable to have the same person carrying out both roles.
Earl Howe
I completely take the noble Lord’s point. We will of course be looking carefully at how best to proceed. It was, of course, with a view to appointing a separate chair that Mr Dodd’s name was put forward.
The noble Lord referred to the importance of integration. He is of course right that we debated the issue extensively during the passage of the Health and Social Care Act and have done so since. The Health and Social Care Act established Monitor as the sector regulator of healthcare. That involves a duty placed on Monitor to protect and promote patients’ interests by promoting provision of NHS services which is economic, efficient and effective and which maintains or improves the quality of those services. Within those broad headings, integration fits neatly.
The provider licence is a key tool which Monitor will use in carrying out its duties and in influencing and regulating the provision of NHS services. Specifically, the licence enables Monitor not only to set prices for NHS-funded care, which it does in partnership with NHS England, but to enable integrated care. The fact that that is not explicitly referenced in the Explanatory Memorandum is not something to which noble Lords should attach particular significance. Integration is part and parcel of Monitor’s overall duties.
Health and Social Care (Amendment) (Food Standards) Bill [HL]
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by congratulating my noble friend on securing the introduction of this Bill, which seeks to set standards for healthy and sustainable food in hospitals. The Government warmly welcome the role that my noble friend’s Bill has played in bringing this important issue to the attention of your Lordships’ House. Few subjects matter more than food and drink. Poor diet can cause serious illness and even increase the risk of early death. My noble friend has a supporter here when she talks about high standards. We both want nutritious food that meets the recovery needs of patients and the health needs of staff and visitors, and sustainable food that supports our farmers and accounts for the needs of our livestock. Above all, we want tasty food that that looks good and is available whenever it is needed. My noble friend and I are at one on this.
We agree that more needs to be done to be certain that hospitals comply with high standards. We are proposing a series of measures that include instruction, incentives and inspection—the three Is. These build on the work announced last year by my right honourable friend the Secretary of State for Health and will raise awareness and increase transparency so that there can be no excuse for poor food.
The cornerstone of this approach will be our hospital food standards panel, under the chairmanship of Dianne Jeffrey, chairman of Age UK. The panel, which I can tell my noble friend Lady Miller includes Sustain as well as patient representatives and others, will start with the needs of patients, especially older people. It will look at nutritional quality, mealtime experience and the help given to patients to eat. It will check the evidence on food production systems to understand how a meal can leave the kitchen as an attractive, tasty dish, but arrive at the patient cold and unappetising. Noble Lords who share my own frustration when struggling with a sachet of sauce or pat of butter, will be pleased to hear that the panel will not let such small details escape its scrutiny.
The panel will also consider sustainability. This year, around 80% of food commodities purchased through NHS Supply Chain will be UK-produced, but the panel will look at how we can further reduce our environmental impact, including waste from food and food packaging. The panel will also consider animal welfare.
In this way, we address my noble friend’s main concerns. However, our ambitions go further. We have asked Dianne Jeffrey to consider food served to staff and visitors, including food sold in vending machines. Noble Lords may be surprised to learn that less than half of the food served in hospital is eaten by patients. The majority goes to staff and visitors. We must not neglect their needs.
We have a serious obesity problem in this country and so have a responsibility to help people make healthier choices. That does not have to mean banning chips and fizzy drinks, but should certainly mean delivering healthier options to make it easier for people to choose healthily as well as simple to understand information and labelling on food—using the calorie labelling and front-of-pack schemes increasingly evident on our high street and in supermarkets.
This is not about undermining personal autonomy. What freedom exists in choosing between two meals if both are high in saturated fats and salt? Where is the freedom in choosing between a standard chocolate bar and a king-sized one? We are asking the panel to examine how the NHS can increase choice, not reduce it, and enable informed choice.
Twenty-one trusts have committed to measures for encouraging healthier restaurants, vending outlets and buffets under the responsibility deal’s pledge on healthier staff restaurants. We want more to do the same. How will we make all these things happen? Like my noble friend, we have been frustrated to see continued variation in food standards across our NHS. That is not because hospitals do not know what good food looks and tastes like. Good guidance and standards already exist, and the best hospitals are using them. For instance, government buying standards for food and catering were introduced in 2011, covering nutrition, sustainability and animal welfare. We have the British Dietetic Association’s guidance on nutritional content of patient meals, and we have our own guidance on healthy eating. So rather than produce new standards or guidance, our panel will identify which existing guidance should apply as a matter of routine, which should be aspired to as best practice and which should be left for local determination.
Standards are important but compulsion, in our view, is not. There is no evidence that making standards mandatory in Scotland or Wales has led to food that is any better than in England. Indeed, patient satisfaction ratings with hospital food in Scotland have actually gone down in recent years. Nor should standards relate to whether food is prepared in-house or not. Each NHS provider must decide for itself how to deliver its food services. What matters is not who provides the meals or how but that they are of high quality and meet the needs of patients. We are unaware of any clear relationship between the quality of food and whether it is cooked on-site or delivered frozen or chilled and regenerated. I agreed with the noble Lord, Lord Rea, on that point. There are many ways to produce food in hospitals. All can deliver good food.
We are determined to make sure that this happens. However, this Government have committed to creating new regulation only as a last resort, as the noble Baroness, Lady Thornton, observed. Because of that, we have identified other, highly transparent ways of delivering the change that my noble friend wants to see. Of course, legislation has a role. All healthcare organisations must register with the Care Quality Commission, whose powers are enshrined in law. The department is updating the CQC’s registration requirements to include new fundamental standards of care that all providers have to meet, and the CQC is developing compliance guidance. We will ensure that the work of the panel aligns with that.
Crucially, we have asked NHS England to amend the NHS standard contract so that it helps to deliver improvement. In the new contract, due out next month, hospitals will be required to have regard to guidance on the provision of catering services, including government buying standards for food and catering. We will work with NHS England to ensure that the panel’s work is appropriately highlighted in later contracts and technical guidance. Commissioners of NHS-funded services have the power to require remedial action to be taken where there is clear evidence that providers are failing to meet the terms of the standard NHS contract.
There are also incentives for excellence. Under the system of commissioning for quality and innovation, which we call CQUIN, commissioners can reward providers for delivering high food standards. For instance, providers might be rewarded for improving food quality, or meeting external standards such as those of the Soil Association’s Food for Life Partnership.
My noble friend also calls for a new inspection regime. We can respond to her call in the following way. The CQC has appointed Professor Sir Mike Richards as Chief Inspector of Hospitals and he is establishing a robust system of registration, regulation and inspection. The programme is not a rigid one-size-fits-all process, but a more measured, risk-based approach. This requirement has all the power of the Health and Social Care Act 2008—we do not need further legislation.
The Care Quality Commission has pledged to start rating NHS acute trusts and foundation trusts from December this year and aims to complete this process before the end of 2015. It will introduce a more specialised inspection model with a greater focus on culture and leadership and teams that include clinical and other experts and people with experience of care. It will use information and evidence in a more focused and open way, including listening better to people’s views and experiences of care in order to predict and respond more quickly to services that are falling short.
However, we need strong monitoring. We now review the food served in every single NHS hospital via annual patient-led assessments of the care environment —we call them PLACE inspections. This year, a small army of more than 5,000 patient assessors, including a patient who is a member of our panel, took part in PLACE assessments, including tasting the food on offer. If the vegetables were overcooked, or the gravy was cold, they reported it. If the custard was lumpy or the sandwiches dry, they reported that too. Their feedback directly helps hospitals to improve. As my noble friend said, there is no evidence of a direct link between cost and the quality of food. We are looking further into this to see if we can establish any link. Our PLACE inspections have given us detailed information directly from patients, which will help us understand how good food can best be produced without wasting money.
We also use PLACE to record whether hospitals comply with recommended guidance. We already ask about the government buying standard for food, and next year we will ask about the Soil Association’s Food for Life catering marks. Once the panel has reported, we will include a question about other recommended standards. Commissioners and providers together can use this information to improve services.
We know that this approach can work. In 2011, government buying standards for food and catering services were launched. They were compulsory for central government departments, but voluntary within the NHS. Yet already around half of all hospitals comply, with another quarter pursuing compliance. My colleagues at Defra are reviewing these standards, and members of the panel are involved in that.
My noble friend also asked for action where hospitals fail to comply with standards. The CQC already has these powers and can take action through civil enforcement or under the criminal law. As I said, commissioners can also act where the standard contract terms are breached by requiring providers to take remedial action and, in the case of serious failures, they can escalate that action. However, it is not just about punishment. What my noble friend wants, quite rightly, is improvement. Our approach is designed to achieve this, which is why PLACE requires hospitals to publish an action plan to show how they will address any problems. This has already started. In Sheffield, hospitals already score well on food but plan to increase menu choice with a £7 million capital development of their catering infrastructure. East Lancashire Hospitals NHS Trust plans to review ordering systems and improve service delivery by opening a second food production belt. It is also reviewing its vending machines. These are tangible improvements, identified by patients and planned and delivered locally. They are evidence of success.
The noble Lord, Lord Turnberg, spoke about the sourcing of food, a subject I mentioned a moment ago. He may like to know that some 60% of the food ingredients supplied to the NHS is procured under contracts negotiated at a national level by the NHS Supply Chain. It requires suppliers to provide information on product quality and provenance and to have a verification process in place. It is working with its contracted food suppliers to identify products that meet the food GBS and make the information available through its website. However, it is important to remember that, under public sector procurement rules, the NHS cannot promote or appear to promote a buy-British policy.
My noble friend Lady Cumberlege referred to the use and cost of nutritional supplements. It is always better if patients can get the nutrients they need from proper food rather than supplements—there is no argument about that—but some patients cannot digest normal food, or need extra calories, and they need supplements. The cost of £320 million that noble Lords may have read about is actually related to spend in the community, not in hospitals. It also includes the provision of real food such as gluten-free bread or low-protein biscuits. I would not want noble Lords to be misled by any press reports they may have seen on that score.
Malnutrition has many causes, a theme that was taken up to the noble Lord, Lord Rea, but it is most often seen in conjunction with other illnesses. The British Association for Parenteral and Enteral Nutrition estimated the cost in 2007 at more than £13 billion, but it did acknowledge that some of these costs may be unavoidable. This is because serious illness and injury will always result in loss of appetite associated with changes in the body’s metabolism, which in turn results in tissue breakdown and muscle loss. These costs are linked to malnutrition rather than being direct costs, so they cannot be assumed to translate into potential savings in the cost of care.
The noble Lord, Lord Rea, and my noble friend Lady Cumberlege referred to unhealthy foods being served to patients, such as foods that are high in fat and salt. The best food does no good if it is uneaten. For very ill patients who cannot eat large amounts, it may be better for them to eat high-calorie, higher-fat food. Our panel will work hard to strike the right balance between long-term health needs and the short-term requirement for high-calorie food. The noble Baroness, Lady Masham, and the noble Lord, Lord Turnberg, referred to the problem we hear about so often of food being left out of reach and patients not being given the help they need. It is unacceptable for food to be left out of reach. Where a patient is at risk of malnutrition, specific plans of care are introduced such as serving food on a red tray, which signals to the team that extra support is required. We support the notion of protected mealtimes whereby all non-essential clinical practices are avoided during those periods. Family members and volunteers who have had additional training are often invited to help patients with their meals.
Success is what we want. This Government want food that boosts health and recovery, that tastes good and impacts lightly on our environment. Our approach rests on what I referred to earlier as the three Is: instruction, incentives and inspection. Instruction is provided through registration standards and the NHS standard contract, incentives via the CQUIN scheme and inspection by PLACE and the CQC. These, we believe, are the way to success.
Female Genital Mutilation
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government welcome the intercollegiate report Tackling FGM in the UK, which is published this week. Female genital mutilation is illegal. It is important that children and young women are protected from this abhorrent procedure. My honourable friend Jane Ellison has supported the development of this report. As Minister for Public Health, she has stated that one of her priorities is to continue to work towards eradicating female genital mutilation with the organisations that are promoting the report, among many others.
Baroness Manzoor (LD)
I thank the Minister for his reply. Does he welcome, as I do, the proposal that FGM should be treated by healthcare workers as a crime and reported to the police? Does he also welcome the work of the Liberal Democrat Minister, Lynne Featherstone, in prioritising the eradication of FGM in her work in the Department for International Development?
Earl Howe
My Lords, I agree with my noble friend. Female genital mutilation is child abuse and violence against girls and women. It is also a criminal offence, and cutters and perpetrators need to be brought to justice. I pay tribute to the work currently in train in the Department for International Development, which has begun an ambitious programme to address FGM in Africa and beyond.
Baroness Butler-Sloss
My Lords, will the Minister ensure that the police and the Crown Prosecution Service put forward far more appropriate prosecutions?
Earl Howe
My Lords, the Government are as frustrated as I am sure the noble and learned Baroness is by the lack of prosecutions. We welcome the Crown Prosecution Service action plan, published last year with a view to bringing successful prosecutions. The CPS guidance on FGM prosecutions provides a useful framework for prosecutors to understand how to build stronger cases with the police to bring to court. It explains how they need to be aware of the fact that where there is a victim of FGM, the local authority or social services may well have material or information to support that.
Lord West of Spithead
My Lords, we have failed thousands of young women. This issue first came above my radar horizon as a Minister in the Home Office when one of my sisters, who was training as a midwife, explained the full horror and scale of FGM. I was completely horrified. I failed in my time in the Home Office to ensure that people were being correctly prosecuted. Since then, we have not done any better. I am glad to hear what is being said, but does the Minister really believe that now we will ensure we have a series of prosecutions? If we do not, we will not stop this vile thing happening.
Earl Howe
I completely agree with the noble Lord. It is clear that we need to make a step change in the landscape here. We have continued to prioritise FGM, both at home and overseas. The intercollegiate report, however, published this week, adds a very welcome dimension to the work we are doing. It was written by health professionals and FGM experts for health professionals, and the Government will naturally study the report very carefully and consider the recommendations as part of the cross-government programme of work to tackle and eradicate this awful practice.
Baroness Masham of Ilton (CB)
My Lords, is the noble Earl aware that I took through your Lordships’ House the Prohibition of Female Circumcision Act 1985? Is he aware that I, too, am most frustrated by the lack of prosecutions? Why has France convicted people with this horrific condition and not us?
Earl Howe
My Lords, I am aware of that. I was a new Member of the House when that Act went through, and I commend the noble Baroness for the work she did on that issue. She mentioned France. One of the features of the French system is the physical examination of all girls under the age of five. We will not be following that path. We do not think it would be right to do so. We think it raises ethical and human rights concerns. However, all children are routinely seen by healthcare staff in the universal healthy child programme that covers England, and prevention and safeguarding absolutely underpin that programme. It is an important channel for conversations to be held with parents and children, so that they can be provided with relevant support and advice.
Lord McConnell of Glenscorrodale (Lab)
My Lords, the 1985 Act was updated in Scotland by the Prohibition of Female Genital Mutilation (Scotland) Act 2005. It extended the maximum sentence from five years to 14 years. In Scotland, as in the rest of the UK, there have been no prosecutions. Will the Minister and the Government work closely with the Scottish Government to make sure that we have a unified approach across the UK to ensure that there are prosecutions in the future for this most extreme form of child abuse?
Earl Howe
Yes, my Lords, we work closely with our colleagues in the devolved Administrations. The noble Lord is absolutely right: FGM is a crime in the UK under the Female Genital Mutilation Act 2003, and in Scotland under the Prohibition of Female Genital Mutilation (Scotland) Act 2005. I am advised that it is a feature of both Acts that if someone is taken overseas for the mutilation, it is still a crime in the UK if the mutilation is done by a UK national or permanent UK resident.
Lord Chidgey (LD)
My Lords, the UNICEF report released in July sets out that 129 countries practise FGM. Most of those countries—which have 125 million girls—have strong community links with the United Kingdom. Does my noble friend agree that if we are to eliminate FGM on girls in the UK we must work alongside organisations such as Tostan and AWEPA, which are successfully campaigning for the abandonment of FGM throughout rural communities in much of Africa and elsewhere? What liaison is there between government departments in this country to address FGM at home and overseas? There must be some working together here.
Earl Howe
I agree with my noble friend. I referred to the work being done by DfID. The approach of DfID’s programme is to work with communities through civil society organisations in at least 15 of the most affected countries. Developments in FGM abroad tend to change attitudes towards communities here, which is why the Government are confident that the work of DfID will result in culture change and, hopefully, abandonment in both Africa and the UK. I would be happy to write to my noble friend with details of the co-operative work that we are doing.
Professional Standards Authority
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government have no plans to change the membership of the council of the Professional Standards Authority. The authority is required under the Health and Social Care Act 2012 to set standards for organisations holding voluntary registers for health and social care occupations, and accredits those which meet these standards. It is not required to make a judgment on the beliefs and practices of individuals registered with the organisations that it accredits.
Lord Taverne (LD)
My Lords, the Professional Standards Authority has recently approved the registration of the Complementary and Natural Healthcare Council—which is known in scientific circles, quite justifiably, as Ofquack. It means, in effect, that craniosacral therapists, reflexologists and homeopaths can now claim to be covered by the same professional standards as doctors and nurses. In the past, the Department of Health has sometimes suggested that it will not take sides between evidence-based medicine, which is based on science, and complementary medicine, which is based on pseudo-science. Does the Minister not agree that the Department of Health should not be neutral between sense and nonsense?
Earl Howe
My Lords, it is important to understand that the accreditation scheme that we are talking about does not endorse any particular therapy as effective, and that it makes clear that accreditation does not imply that it has. The principle remains that it is for individuals, in consultation with health practitioners, to decide which therapy is right for them. The scheme is not a form of regulation, nor is the PSA a regulator. It sets standards for organisations holding voluntary registers for health and social care occupations, and accredits those that meet the standards.
Baroness Pitkeathley (Lab)
My Lords, I declare an interest as chair of the Professional Standards Authority, and I pay tribute to the skill and experience of my board. Does the Minister agree that as by next March more than 75 occupations and 100,000 practitioners will be covered by the accredited voluntary register scheme, the public are much better informed and better protected than they have ever been?
Earl Howe
My Lords, I agree with the noble Baroness, and I pay tribute to her work as chair of the PSA. The benefits of accredited voluntary registration are clear. The point is to give the public, employers and commissioners choice to use people on a register that the authority has independently assessed and approved, and only those registers that the authority has accredited are allowed to use its kitemark.
Lord Willis of Knaresborough (LD)
My Lords, the 2013 annual report of the Professional Standards Authority states that its third strategic objective is to:
“Enhance public confidence in unregulated health and care occupations”.
How many voluntary registers of healthcare support workers are now registered with the standards authority, how many individual staff do they cover and how can the public get access to them? How long does the Minister expect it to take for all healthcare support workers to be registered, as the recent reports following the Mid Staffs inquiry suggested?
Earl Howe
My Lords, the Francis recommendations made no reference to voluntary registers for healthcare support workers. The broad position is that the PSA has not received any applications from organisations holding voluntary registers for healthcare support workers, and therefore no voluntary registers for healthcare support workers have been approved. As accredited registers are voluntary, I am afraid that the Government are not in a position to predict how long it will take for all healthcare support workers to be registered.
Lord Hunt of Kings Heath (Lab)
My Lords, going back to the question raised by the noble Lord, Lord Taverne, is the Minister confident that every intervention by a doctor is actually based on robust clinical evidence?
Earl Howe
My Lords, as the noble Lord knows, it is the responsibility of local NHS organisations to make decisions on the commissioning and funding of any healthcare treatments for patients, taking account of issues to do with safety, clinical and cost effectiveness and the availability of appropriate practitioners. However, it is interesting to note that there are a number of complementary and alternative therapies referenced in NICE guidance, and I would expect any self-respecting doctor to take account of those.
Lord Colwyn (Con)
My Lords, can the Minister give us any news about the proposed accreditation of herbal practitioners?
Earl Howe
My Lords, as my noble friend knows, this is a complex policy area. There have been delays to the Government’s original proposals around the regulation of herbal medicine practitioners. One of our main concerns here is to ensure safety for those who wish to use the products. Given that complexity, my honourable friend Dr Poulter announced his intention to set up a working group to consider matters relating to patient protection when using unlicensed manufactured herbal products. Officials are currently working through the details of that group, including its terms of reference.
Lord Laming (CB)
My Lords, will the Minister use his good offices to ensure that the Government continue to keep an open mind in respect of complementary medicines, and allow patients the greatest possible choice in these matters?
Health: Local Healthwatch Organisations
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Lord Harris of Haringey
To ask Her Majesty’s Government what assessment they have made of the number of local Healthwatch bodies whose budgets are less than the amount that has been allocated to the relevant local authorities for that purpose.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government have made no assessment. We believe that local areas are best placed to make funding decisions to ensure that local needs and circumstances are best taken into account. In total, we have provided £43.5 million to local authorities for funding Healthwatch this year. We believe that transparency on funding is important. We will be requiring each local Healthwatch to publish the funding it receives from local government in its annual report.
Lord Harris of Haringey (Lab)
My Lords, I am grateful to the noble Earl for that response. I am, however, amazed that he says that he has no direct information on this matter. Is he aware that at least 23 local Healthwatch organisations have budgets lower than those of their predecessor organisation and that one of them—the one covering the Mid Staffordshire area—has a budget 19% lower than its predecessor LINk organisation? Are the Government nonchalant about how this money is being spent and about how patients are to be represented at a local level because they want to ensure that there is no vociferous view from patients about the scandalous way in which local health services are deteriorating as a result of both the top-down reorganisation that this Government have imposed and the real-terms cuts in budgets that have taken place?
Earl Howe
No, my Lords. As the report from Robert Francis identified, the patient voice has to be at the heart of the health and care system, and Healthwatch plays a crucial role in supporting that as the new consumer champion for health and social care. It is very easy to get fixated on the amount of money that is going into Healthwatch. One additional consideration could be the investment that a local authority may be making in other areas to ensure that the voice of service users and the public is heard—for example, through the voluntary and community sector. Surely what matters are the outcomes that are achieved for service users and the quality of those services.
Baroness Gardner of Parkes (Con)
My Lords, are good activity and good results really coming out of these Healthwatch groups? In particular, have they done anything to help stroke victims or underprivileged or autistic children? Can the Minister give us an update on what good they are doing and whether they should be continued?
Earl Howe
I am grateful to my noble friend. The first annual report from Healthwatch England was laid before Parliament on 9 October and it outlined some encouraging progress at both a national and a local level. There are already examples of the impact that local Healthwatch is having—for example, the work of Healthwatch in Peterborough, which is looking at how to improve health outcomes for offenders. My noble friend mentioned autism. I am aware that Healthwatch Cornwall uncovered a gap in the services meant to deliver a diagnosis of autism in children. That work resulted in a really practical solution so that families could access a diagnostic service without losses to other services in the area.
Baroness Wall of New Barnet (Lab)
My Lords, will the noble Earl acknowledge that, certainly from the point of view of people who are working on the ground, the process we are going through is somewhat different from that set out by my noble friend, with whom I hate to disagree? There are obviously challenges at the moment, particularly in A&E, as the noble Earl is aware, but many of the changes have brought a lot of good news for health trusts, and my own in particular. However, the Healthwatch bodies—certainly locally where my trust is involved with them—need some support and guidance about what they are meant to achieve. It may seem odd but there is still some ambiguity about who is doing what. We are working with them as an acute trust to make sure that we can link with them, but there needs to be more clarity about their role.
Earl Howe
I am grateful to the noble Baroness. She is certainly right that some local Healthwatches have got off to more of a flying start than others. I am aware of many that are working closely with their local clinical commissioning groups and indeed with provider trusts. However, others need encouragement and support, and we have created Healthwatch England to provide exactly that kind of support. That is the route for the Healthwatches which find themselves in some uncertainty about their role.
Baroness Masham of Ilton (CB)
My Lords, does the Minister agree that Healthwatch members working in rural counties have extra travelling expenses and will these be considered? Healthwatch members should not be out of pocket.
Earl Howe
I am very much in sympathy with that thought. However, it is up to the local Healthwatch organisation to organise its funding as it sees fit and in the most cost-effective way possible. I would not want to dictate to them what they should do but, clearly, for a Healthwatch to work effectively, one has to have volunteers who are ready and willing to do the work, which might involve the need to reimburse them for some expenses.
Baroness Barker (LD)
My Lords, will the Minister confirm that local Healthwatches retain the power to merge and reconfigure their services with neighbouring bodies if that would make for better outcomes for patients?
Lord Campbell-Savours (Lab)
If they are to have a role with regard to complaints following the recommendations in the Clwyd report, will additional resources be provided?
Earl Howe
My Lords, we will be responding to the recommendations from the Clwyd/Hart review in the context of our response to the Francis inquiry, so there is a limit to what I can say today. In answer to the noble Lord, I think that the local Healthwatch has an important role to play as patient champion and it is right that individual local Healthwatch organisations have access to information about complaints so that they can spot the themes and trends that emerge from them.
NHS: London
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, with the leave of the House, I shall now repeat a Statement made by my right honourable friend the Secretary of State for Health in the other place earlier today on changes to health services in London.
“With permission, Mr Speaker, I would like to make a Statement on the Shaping a Healthier Future programme, a locally led review of NHS services across north-west London.
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. The population of north-west London is growing, and will reach approximately 2.15 million by 2018. Around 300,000 people have a long-term condition.
However, there is great variation in the quality of acute care. In 2011 there was a 10% higher mortality rate at weekends for emergency admissions, and the number of hospital readmissions differs considerably across the area. The Independent Reconfiguration Panel expressed concerns that the status quo in north-west London was neither sustainable nor desirable, and might not even be stable.
In order to address these challenges, the NHS in London started the Shaping a Healthier Future programme in 2009. It proposed significant changes to services, including centralising A&E services at five hospitals rather than nine; 24/7 urgent care centres at all nine hospitals; 24/7 consultant cover in all obstetric wards; a brand new trauma hospital at St Mary’s Paddington; brand new custom-built local hospitals at Ealing and Charing Cross; seven-day access to GP surgeries throughout north-west London; over 800 additional posts created to improve out-of-hospital care, including a named accountable clinician for all vulnerable and elderly patients, with fully integrated provision by the health and social care systems; and increased investment in mental health and psychiatric liaison services.
These changes represent the most ambitious plans to transform care put forward by any NHS local area to date. They are forward thinking and address many of the most pressing issues facing the NHS, including seven-day working, improved hospital safety, and proactive out-of-hospital and GP services. The improvements in emergency care alone should save around 130 lives per annum and the transformation in out-of-hospital care should save many more—giving north-west London probably the best out-of-hospital care anywhere in the country.
The plans are supported by all eight clinical commissioning groups, the medical directors of all nine local NHS trusts, and all local councils except for Ealing. It was as a result of a referral to me by Ealing Council on 19 March 2013 that I asked the Independent Reconfiguration Panel to conduct a full review. The panel submitted its comprehensive report to me on 13 September 2013, which I have considered in detail alongside the referral from Ealing. I am today placing a copy of the panel’s report in the Library, alongside the strong letters of support for the changes I received from all local CCGs and medical directors.
The panel says that Shaping a Healthier Future provides,
“the way forward for the future and that the proposals for change will enable the provision of safe, sustainable and accessible services”.
Today I have accepted the panel’s advice in full, which will be published on the panel’s website.
The panel also says that while the changes to A&E at Central Middlesex and Hammersmith hospitals should be implemented as soon as practicable, further work is required before a final decision is made about the range of services to be provided from the Ealing and Charing Cross hospital sites.
Because the process to date has already taken four years, causing understandable local concern, I have today decided it is time to end the uncertainty. So while I accept the need for further work as the IRP suggests, I have decided that the outcome should be that Ealing and Charing Cross hospitals should continue to offer an A&E service, even if it is a different shape or size to that currently offered. Any changes implemented as part of Shaping a Healthier Future should be implemented by local commissioners following proper public engagement and in line with the emerging principles of the Keogh review of Accident and Emergency services.
I have written today to the chair and vice-chair of the Health and Adult Social Services Standing Scrutiny Panel of the London Borough of Ealing Council, the chair of the IRP—Lord Bernard Ribeiro—the chief executive of NHS England and local MPs, informing them of my decision. These much needed changes will put patients at the centre of their local NHS, with more accessible, 24/7 front-line care at home, at GP surgeries, in hospitals and in the community. More money will be spent on front-line care which focuses on the patient. Less will be wasted on duplication and underperforming services.
Let me be clear that, in the joint words of the medical directors at hospitals affected, there is a,
“very high level of clinical support for this programme across NW London”.
Local services will be designed by clinicians and local residents and be based on the specific needs of the population. None of these changes will take place until NHS England is convinced that the necessary increases in capacity in north-west London’s hospitals and primary and community services have taken place.
I want to put on the record my thanks to the IRP for its thorough advice. As the medical directors of all the local hospitals concerned said in their letter to me, these changes will,
“save many lives each year and significantly improve patients’ care and experience of the NHS”.
When local doctors tell me that is the prize, then I will not duck a difficult decision.
I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Hunt of Kings Heath, for his questions. I preface my answers by saying that this is the first significant set of local reform proposals under the Government’s NHS reforms and it is a set of proposals that has been led clinically by the CCGs. There is an unprecedented level of clinical support for the changes that I outlined. The chairs of all the local CCGs wrote to the Secretary of State personally expressing absolute support; the medical directors of all the local hospitals affected wrote to him expressing absolute support; and the Independent Reconfiguration Panel report is crystal clear that the principles of this scheme are right and will benefit patients.
The noble Lord asked me about A&E services, in particular, at a time when we know that A&E departments are under pressure—a fact which I do, of course, readily acknowledge. The key to these recommendations is twofold. First, the way investment will be deployed will mean that we shall have centres of excellence in emergency care which will copy, in some respects, the way that stroke and trauma care has been centralised across London. This was controversial at the time but is now acclaimed by clinicians and, I think, politicians alike as proving to save hundreds of lives every year. There will be more critical care consultants on duty 24/7; more obstetric consultants on duty 24/7 on labour wards; consultants in other specialities, such as paediatrics, on duty between 12 and 16 hours a day, seven days a week; more trained and experienced emergency doctors on site 24/7 in A&E departments; and more investment in mental health, so that psychiatric liaison services can better co-ordinate care for vulnerable mentally ill people. In general, we will have all nine of the hospitals concerned across north-west London with urgent care centres open 24/7.
That is one half of the equation; the other half is investment in the community. I mentioned that there will be access to GP surgeries seven days a week across north-west London. That is not to specify which surgeries —the key is access to GP services. It will be for the local commissioners and NHS England to work out which surgeries they should be. Eight hundred additional posts will be created to improve out-of-hospital care and some £190 million will be spent recurrently every year on GP and other local services by 2017-18. Therefore the preventive aspect of these proposals should mean that fewer people land up in A&E in the first place.
The noble Lord asked me about the proposals for Ealing and Charing Cross. The IRP’s advice is clear that the current problems and future challenges faced by the NHS in north-west London require large-scale change in the way that services are designed and delivered. I concur with that entirely. However, it also says that while the changes to A&E at Central Middlesex and Hammersmith Hospitals should be implemented as soon as practicable, further work is required before a final decision is made about the range of services to be provided from the Ealing and Charing Cross Hospital sites. As the process to date has already taken four years, as I mentioned, my right honourable friend has decided that it is time to end the uncertainty. Therefore, while he accepts the need for further work, as the IRP suggests, he has decided that the outcome should be that Ealing and Charing Cross Hospitals should continue to offer an A&E service, even if in the end that is of a different shape or size from that currently offered. What does that mean?
In the first instance, we are clear that a 24/7 urgent care service should be run from both those sites, involving senior consultant cover and the ability to admit patients 24/7. Any changes implemented as part of the Shaping a Healthier Future proposals should be done by local commissioners following proper public engagement and in line with the emerging principles of the Keogh review, as I mentioned. However, none of the changes to these critical services will take place until NHS England is assured that all the necessary increases in capacity in north-west London’s hospitals and primary and community services have been satisfactorily developed.
The noble Lord asked me about Lewisham. I will not disguise the Government’s disappointment at the result of the court judgment yesterday. However, we respect that judgment. Our priority now is to end the uncertainty for patients in south London. It is time for the new Lewisham and Greenwich NHS Trust to move on and work with its commissioners and the community to develop a local solution that is clinically and financially sustainable. The proposals that we came forward with earlier in the year cannot be proceeded with in their entirety. In our view that is a pity, because we now have a local health economy with an annual financial shortfall, which has to be addressed in some way. In so far as we can assist local commissioners to find a way through that problem, we will be happy to do so. However, it is largely up for local determination.
As regards the appeal, we felt that that was the right and responsible thing to do. This is the first time that the trust special administration provisions have been used and it was important that the law should be tested to be absolutely clear what it meant. We make no apology for the fact that our interpretation of the law as Ministers was different from that of the judge. However, as I said, the judge has made his ruling, and we need to respect it.
I hope that I have answered most of the noble Lord’s queries. However, he ended his remarks by observing that, as he perceives it, the Government have created a situation where service configuration can take place in the future without local clinical support or consultation. I would just like to assure him that that is not so. Indeed, the importance of having local clinical support could not be stronger. We see it here in the example of north-west London, and even in the rare case where trust special administration is required, the consultation involved is clearly set out in legislation. Local people will not be left out of the dialogue. I hope that that is of some reassurance to the noble Lord.
Baroness Hanham (Con)
My Lords, may I say how glad I am to hear that the proposals have support from all the clinicians and the CCGs? The noble Lord will know that I was chairman at St Mary’s Hospital when the Imperial College Healthcare NHS Trust was formed —and it was formed on the basis of full support from clinicians and the local community. The local community is not always at one with change, so I shall ask the noble Lord a couple of questions. First, this is not a short programme. These proposals will not take five minutes to implement. Most of the changes in the health service over recent years have taken an enormous amount of time, and it would be fair to say that the Imperial Trust, which includes Charing Cross, has probably only just completed its previous reorganisation, and now it is being reorganised again. The first question is: what is the proposed timescale?
Secondly, the noble Lord mentioned consultation, and may I say that it is absolutely vital that the local community be brought along with this? Otherwise, it will take even longer. Thirdly, there is an expectation that there will be a lot of new consultant and other medical posts. I am aware that A&E is not flush with clinicians taking up the specialty, so may I ask what encouragement is being given, by the colleges in particular, to ensure that there will be enough staff available to deal with the new services? Finally, may I say how glad I am that St Mary’s has figured again in trauma services?
Earl Howe
My noble friend, with her experience, asks some very pertinent questions. On the question of timescale, we believe that it will take between three and five years for the proposals to be actioned to their fullest extent. It will be necessary to take that kind of time. Some elements can happen relatively quickly, but my noble friend is absolutely right that there are important workforce issues to be taken into account. Indeed, one of the IRP recommendations was that the NHS should review its workforce programme and ensure that it has the means in place to deliver what is required. I am sure that in working through the proposals, local commissioners, as well as NHS England, will need to satisfy themselves on that point—not least with regard to the new posts to be created in the community, but also in terms of accident and emergency consultants in the A&E departments of the relevant trusts. On local communities, again I agree with my noble friend. As the Shaping a Healthier Future proposals are developed by the clinical commissioners, it will be vital that any further proposals are consulted on locally, and that there is real buy-in from patient groups and the public generally.
Lord Winston (Lab)
I declare an interest as a member of Imperial College London and a practitioner who has been a consultant in north London for a long time. It is right that the financial shortfall means that there has to be considerable reconfiguration. In this case that is a move in the right direction. However, it raises a number of questions to which I would be very grateful if the Minister would respond. One is that if you close casualty you affect the training of surgical trainees. Do the Government have a view on that issue?
The Minister also referred to obstetrics in west London. As he will almost certainly know, the neonatal paediatrics department at one of the best obstetric hospitals in the country—Queen Charlotte’s, based at Hammersmith Hospital—has always been somewhat threatened. Is that secure, given that one of the issues in north-west London is undoubtedly that of duplication in many hospitals, which is expensive? Does the Minister feel that this is the only reconfiguration that will be required, given the amount of duplication that there is?
Earl Howe
To answer the last point, it is clear from the IRP report that its authors believe that this is a comprehensive set of proposals which will stand the test of time in north-west London. It is a very thorough set of proposals which takes into account every aspect of healthcare provision. On maternity and paediatrics, I can tell the noble Lord that under these proposals there will be more obstetric consultants on duty 24/7 in labour wards. As he will know better than anyone, that, of course, is designed to reduce the number of complications during birth and to ensure one-to-one midwifery care for women during labour. Consultants in other specialties such as paediatrics will be on duty, as I mentioned, for 12 to 16 hours a day, seven days a week, providing much better cover than at present.
It was very striking in the IRP report that the first point made by the noble Lord, Lord Winston, did not elude the panel. The panel concluded that the pragmatic and explicit approach used by the NHS reflected the clarity of the aim to improve quality outcomes by implementing life-saving standards through the establishment of major hospitals. The report referred to the economic realities of the NHS and the urgency of making progress in the light of known risks to the sustainability of emergency services such as the abilities of staff, A&E and emergency surgery rotas, and the desire to minimise the negative impact on access of concentrating services. That was shorthand—as the noble Lord will see if he reads the rest of the report—for saying that the desirability of concentrating expertise in centres of excellence is a clear imperative for the quality of care that patients receive. As regards surgical experience, I think that if my noble friend Lord Ribeiro were here, he would confirm that that is absolutely the direction of travel, but that we must ensure that surgical expertise is built on a sufficient number of hours and cases for the quality of care to be maintained. That is exactly what underlies this whole set of proposals.
Lord Walton of Detchant (CB)
My Lords, since the relevant professional bodies, not least the British Medical Association, have decided that they wish to support a move towards the provision of all acute and relevant services in the NHS for a full seven-day period, it is inevitable that there will be major reconfiguration of services not just in north-west London but in many other parts of the country. This will involve the concentration of specialist services in fewer hospitals and could even result in the closure of some smaller hospitals. However, that is not immediately relevant. The point I will make is that it is good to know that the clinical commissioning groups and the local hospital trusts have all supported this proposed reconfiguration.
However, I must ask the Minister a couple of questions. First, is he satisfied that the five A&E departments into which all accident and emergency services are to be concentrated, with four others closing, have the capacity to provide facilities for all the relevant staff and to deal with the increased number of patients who will go through those five hospitals? That is point number one, which is crucial.
Secondly, is the Minister satisfied that this concentration of services, with the new 800 posts in the community to which he referred, can be carried out within the existing financial constraints? Have these changes been costed? As the Minister knows, under the so-called Nicholson challenge, the NHS is required to make substantial savings across the country over the next year or so, and it is crucial that he can reassure the House that the necessary money will be available to provide this reconfiguration, which is clearly in the best interests of patients and their communities.
Earl Howe
My Lords, the noble Lord raises the important question of capacity. The key point is that none of these changes will be implemented until such time as commissioners and the relevant providers are satisfied that the necessary capacity exists. That is a key point. Secondly, on the costing and the financial aspects of the proposals, the way in which we will be able to spend more money on front-line care and better-quality facilities is by spending less on duplicated facilities, underperforming services, and badly designed and out-of-date buildings, which cost a lot to maintain. Therefore, as part of this package, there will be new custom-built hospitals at Ealing and Charing Cross, costing about £80 million each, designed to deliver the specific services needed in those respective communities. That will be part of the way in which the money released will be invested for the betterment of patients in the area over future years.
Baroness Barker (LD)
My Lords, the most important part of this Statement is the part stating that none of these changes will come into effect until NHS England is convinced that the necessary primary and community services are in place. How will that be determined by NHS England? Secondly, who will be responsible for the integrated commissioning of community and primary services to bring about the necessary preventive services on which this reconfiguration is based?
Earl Howe
Largely, the judgment by NHS England will be made by local area teams—but not in isolation. It has to be a collaborative exercise, which is my overall answer to my noble friend’s second question. The successful integration of services must depend on close collaboration between the different constituent parts of the NHS but also with adult social care and local authorities. It is striking that already we are seeing this happening in north-west London, as we are in many other parts of the country. For the system to work as we want it to, all the constituent parts need to be effective and efficient. The integration of services, which is one example of how the NHS can become more productive in the future, as well as more clinically effective for patients, is an essential way of ensuring that we have a sustainable NHS in the future.
Lord Kennedy of Southwark (Lab)
Will the noble Earl confirm, first, that there will be no further appeal in respect of Lewisham hospital after the decisions of two courts; and, secondly, that there will be no attempt to change the law in respect of Lewisham hospital? What lessons have been learnt by the noble Earl and his ministerial team that they can apply to what is going on in north-west London? We are all aware that the Minister has never visited Lewisham hospital; the last ministerial visit was in May 2010. Will he tell the House—if not from the Dispatch Box, then by writing and placing a copy in the Library—when Ministers last visited the hospitals in north-west London that have been mentioned?
Earl Howe
I can certainly find out the answer to that last question. As regards the appeal, we have only just received the judgment, as the noble Lord will know. But that is only the outline judgment. We have not received the full text. It is important that we read that and inwardly digest it before we finally decide on the way forward. The lessons of Lewisham are very clear. I confirm that we shall not be legislating around Lewisham and the recent provisions in the Care Bill were not retrospective, as the noble Lord is aware. I have not personally visited Lewisham, which is clearly an omission that I should at some point rectify, but it is important for me to put on the record that the concerns expressed by the people of Lewisham are, and have always been, entirely understandable. Ministers greatly respect the wish of local residents to see their hospital thriving, as it always has in the past. Nevertheless, as I said earlier, Lewisham and Greenwich now have a challenge. There is a financial issue that needs to be addressed and I hope that commissioners and providers, acting together, can do that successfully over the months ahead.
Baroness Masham of Ilton (CB)
My Lords, can the Minister say whether, if A&E departments are shut, hospitals will be downgraded? Will the resources of the ambulance service be increased to transport ill patients around, as the ones with A&E departments may not have enough capacity to treat them?
Earl Howe
I do not think that it is appropriate to talk about downgrading in this case. However, it is appropriate to talk about changing the way in which services are delivered to the local population. In the case of two hospitals, we are seeing fully fledged A&E departments becoming 24/7 urgent care centres. That means that the most serious A&E cases, such as trauma and cardiovascular emergencies, will be taken to centres of excellence where patients will have a much higher chance of survival. That is a pattern that we are seeing throughout the NHS and one that has been proved to be successful and in the interests of patients. On ambulances services, we are already seeing in London, for example with stroke care, ambulances taking patients to centres of excellence for stroke care. Eight of these centres now exist compared to 32 some years ago. That means longer journeys in an ambulance but also much higher survival rates for the patients. I do not think that we should look on the kind of reconfiguration that I have described in a negative way. On the contrary, the whole thrust of these proposals is to improve the quality of care for patients.
Lord Rea (Lab)
The noble Earl said that, as part of this reconfiguration, there will an increase in the services available in the community. Can he say whether this will be done in co-operation with the royal colleges and the British Medical Association rather than being imposed from above? The latter solution is unlikely to work.
Earl Howe
The noble Lord is absolutely right. These solutions should not be imposed from above. Indeed, the Shaping a Healthier Future proposals were designed by local clinicians in consultation with their patients. It was not a prescription dreamt up in Whitehall. We are very clear that the local NHS should continue to feel local ownership of these ideas as it takes them forward. I have no doubt that, if it feels it necessary, it will turn to the royal colleges for particular kinds of advice. It is free to do that as it wishes.
Lord Tomlinson (Lab)
Is the noble Earl aware that on this side of the House he is very highly regarded as a model of clarity? However, in the second part of his answer to the noble Lord, Lord Hunt, today, he was somewhat equivocal in relation to the future of Lewisham Hospital. I hope that he will accept an invitation to visit Lewisham Hospital. I declare an interest as somebody who lives in that area and has opposed the closure. Does he also realise that such is the strength of feeling in Lewisham, he had better have read the whole judgment carefully and cleared all his lines before he goes there? The threatened closure created such community anger as I have never seen before and he would be most unwelcome unless he were able to give a clear and unequivocal response about its future.
Earl Howe
My Lords, I certainly understand the noble Lord’s strength of feeling on this. It is certainly my intention to read the judgment when we receive it in full. Nothing is closing in Lewisham. The service remains as it has been. There is nothing that Ministers intend to do to change that situation. However, as I mentioned earlier, there is an issue to be addressed in Lewisham and indeed in Greenwich. It is a pressing financial issue that commissioners as well as the hospitals themselves have to face. I have no doubt that a visit to Lewisham would benefit me enormously and I shall await an invitation to that effect.
Care Bill [HL]
Earl Howe Excerpts(10 years, 6 months ago)
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Lord Hunt of Kings Heath
My Lords, I do not seek to brush it aside. However, this clause relates to the responsibility,
“of a local authority, in exercising a function under this Part … to promote that individual’s well-being”.
Spiritual issues are subsumed under the amendment moved by the noble Earl, Lord Howe. With the greatest of respect, this does not relate to an employment law issue between an employer and an individual. This is very much around the kind of support that should be given to an individual by the local authority. There is a distinction between the situation that the noble Lord raised, and the issue that is set out in this clause.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, before I move to the matter in hand, I thank noble Lords for the tremendous dedication that they have shown to the scrutiny of the Bill during its passage through the House. It is a landmark piece of legislation, and I hope that the House will agree that the changes that the Government have made in response to the debates that we have had have strengthened the Bill so that it will pass to the other place in an even better state. Many noble Lords across this House have dedicated impressive time and energy to improving the provisions in all parts of the Bill, but time does not permit me to thank all noble Lords individually, as I would like to. However, I thank again those noble Lords who played such an important role in improving the Bill as members of the pre-legislative scrutiny committee.
I turn to my noble friend’s amendment. Under Clause 1, local authorities must promote individuals’ well-being and must also have regard to individuals’ views, wishes and feelings. As I set out during our debate on Report, we consider that these provisions mean that a local authority would take a person’s spiritual views, wishes and feelings into account in promoting their well-being. However, in response to concerns raised by a number of noble Lords on Report, I have now tabled an amendment to make it absolutely clear that these matters should be considered where they are of importance to the individual.
My amendment adds “beliefs” to the matters to which a local authority must have regard when exercising care and support functions. Having regard to someone’s beliefs includes their spiritual beliefs; for example, ensuring access to an appropriate figure of religious authority during palliative care. This approach achieves the same aim as Amendment 1 in the name of my noble friend Lord Hamilton, but I suggest to him and to the House that the government amendment is preferable, for two reasons.
First, my amendment quite deliberately does not refer specifically to “spiritual” well-being, but applies instead more widely to beliefs, which was the point made very effectively by my noble friend Lady Barker. That is because we do not wish to exclude those who may not consider themselves to have “spiritual” beliefs. That issue was raised by the noble Lord, Lord Warner, on Report, in relation to humanists.
Secondly, despite the comments of the noble Baroness, Lady Warnock—to whom I listened as always with great attention—spiritual well-being is not a well understood or defined concept. It carries a risk because it may confuse the practical application of the well-being principle on an individual level. There is another problem here. My noble friend’s amendment would effectively mean that local authorities had a duty to promote an individual’s spiritual well-being or beliefs. It is not appropriate to require a local authority to promote spiritual matters, except in so far as they affect the emotional well-being of a person.
Lord Cormack (Con)
This is a question not of local authorities promoting but of their protecting. There is surely a real difference there.
Earl Howe
I hope that my noble friend will on reflection agree that promotion is very much a part of the local authority’s role here. However, subsection (2) makes adequate provision as regards the emotional well-being of a person.
My noble friend Lord Hamilton compared what we are proposing in the Bill to the situation in the National Health Service. The NHS does not have a duty to promote spiritual well-being and, if it did, that potentially would have the negative consequences that I outlined. Having said that, the noble Baroness, Lady Emerton, is of course right—the NHS must take a patient-centred approach when planning and delivering services, and that would naturally include having regard to an individual’s beliefs where relevant. It is exactly this position that the Bill will replicate for local authorities when they plan and deliver care and support. To support the NHS in fulfilling its functions the Department of Health has produced best-practice guidance on NHS chaplaincy but I struggle to understand how that can equate to a duty in primary legislation on local authorities to promote spiritual well-being as my noble friend would have it.
Lord Framlingham (Con)
I am minded to vote for the amendment but perhaps the Minister can explain why there is a great deal of difference—or any difference —between the National Health Service and local government in terms of patient care.
Earl Howe
I tried to explain that there is none. There is no primary duty in statute on the National Health Service to promote spiritual well-being, which is why we are trying to make the Bill entirely consistent with that position. We have aimed for a system built around individuals and I have tabled my amendment to make absolutely clear that a person’s beliefs, spiritual or otherwise, should be taken into account in this personalised approach to care.
As noble Lords may expect, I asked my officials to consider my noble friend’s proposal and whether anyone could benefit under his amendment who would not do so under the Government’s amendment. The advice that I received is clear that no such example can be found. I struggle to understand why my noble friend might feel it necessary to divide the House on this matter if he is minded to do so.
Baroness Knight of Collingtree (Con)
Does my noble friend appreciate that only very recently we were given a sharp lesson? Unless a law is clear in its wording for those who have to live by it, any interpretation can be put on it. He will well remember what has happened regarding the Abortion Act. Because it was not thought necessary at the time to put certain wording in, it is assumed that it is legal to ignore it.
Earl Howe
I agree with my noble friend, which is precisely why I am resisting the word “spiritual”. I do not think that that is a concept that is well defined in law and I think that it could give rise to enormous confusion. It is for that very reason that I am resisting the suggestion of my noble friend.
I hope that noble Lords will agree that my amendment achieves the aim of ensuring that a person’s beliefs, including those of a spiritual nature, are taken into account where that is important to the individual concerned. I propose that local authorities may promote an individual’s spiritual well-being by taking their beliefs into account, while avoiding any negative consequences. I hope that the House will agree not to follow my noble friend in this instance.
Lord Hamilton of Epsom
My Lords, I must say that my noble friend has put before us a rather fine argument. It strikes me that if we are saying that spiritual needs cannot be named, but that on the other hand they are covered under the expression of taking into account “beliefs”, that does not hold a lot of water. I very much take my noble friend’s point—we must make this absolutely clear. People must understand the legislation. I do not think that just putting in “beliefs” will necessarily mean much to people. I am sure that “spiritual well-being” would mean something to people. As I said in my opening remarks, I think that it would give great reassurance. In the circumstances, I must test the opinion of the House.
Lord Hunt of Kings Heath
My Lords, perhaps I may raise a couple of points with the noble Earl, Lord Howe, on this. First, to reinforce the point made by the noble Lord, Lord Best, about the cost falling on local authorities in providing facilitation to independent, regulated financial advice, there is a much more general point about the capacity of local authorities to implement the measures in this Bill. The Bill leaves us, albeit with many amendments, with an underlying concern about whether local authorities will have the wherewithal to implement a raft of new responsibilities over the next few years.
Secondly when the noble Earl argued against similar amendments on Report, he spoke of the concerns of local authorities that they might be held liable if they referred a person who comes under the Act to a financial adviser who subsequently gave poor financial advice. We have heard from the noble Lord, Lord Best, that the LGA supports the general thrust of my noble friend’s amendment. Can the noble Earl confirm, first, that a regulated financial adviser will be subject to FCA requirements and come under its disciplinary and regulatory codes? Secondly, can he reassure local authorities that they can offer names of regulated financial advisers in the way that I understand a number of local authorities do at the moment without fear of subsequent action being taken against them? I was puzzled by the argument put forward on Report and it would be good to have this cleared up at this stage.
Earl Howe
My Lords, Amendment 3 brings us once again to the important matter of financial advice. As we have covered this subject at some length previously, and in the interests of time, I will endeavour to keep my response reasonably short. At the same time, I do not intend to make brevity a substitute for substance.
My discussions with the noble Lord, Lord Lipsey, my noble friend Lord Sharkey and the noble Baroness, Lady Greengross, and my officials’ discussions with the financial services industry have persuaded me that we are all seeking the same end point for financial information and advice. I believe that any apparent distance between the positions of the Government and noble Lords on this issue reflects only the way that I have expressed our intentions thus far. We want to ensure that when people take decisions about how to fund their care it is done in a considered and informed way. We agree that the local authority has a pivotal role to play in ensuring that this happens. I want to set out what I see that role as being in the hope that noble Lords will agree that we are indeed in concordance.
We believe that the local authority should take a proactive role. What does that mean in practice? Under the new system we expect many more people, a large number of them self-funders, to approach the local authority to start their meter running. This provides an invaluable opportunity for local authorities to reach out to these people and tell them about the support that is out there to help them better plan, prepare and provide for the costs of their care. It is particularly important for self-funders that this includes the relevance and the availability of regulated independent financial advice. To pick up the word in the noble Lords’ amendment, this should be a facilitative role for the local authority, providing a nudge in an appropriate direction.
In trying to define what we mean by facilitation, I wholeheartedly agree that handing out a leaflet or placing a page on a website is not sufficient. Instead, local authorities should talk to people and use the opportunity of contact with self-funders and others to give them individually tailored advice that suits their personal circumstances. They are likely to know something about a person’s financial situation and so will be able to tell them about the range of information and advice that might be most relevant to them in considering their care options, whether that is light-touch budget planning or advice from a regulated organisation. It would not be sufficient for local authorities just to tell a person about the types of information and advice available. They will also have to explain how it could be accessed and provide information to enable them to do so.
There is more work to be done before we can finalise what the guidance will say. To get it right, we will need to work collaboratively with stakeholders, including the financial services industry. We have begun to do that already and have had initial discussions and workshops involving representatives from the finance industry. They have confirmed what we all know of some of the necessary complexity in the system, so how and at what stage a person or their family is facilitated to take up regulated financial advice will depend on how and where they have made contact to obtain information and advice. We will gather examples of best practice to inform statutory guidance to help local authorities identify the types of information and advice that different people may need, inform them of those options at the right time and help them to access them.
In addition to the call for evidence and responses to the consultation on funding reform, background work has already been undertaken over the summer that supports the development of statutory guidance. Work commissioned through the Think Local Act Personal partnership has resulted in two publications on information and advice, principles for the provision of information and advice and an interactive map evidencing the difficult pinch points in people’s typical journey through the care system.
We have commissioned detailed work with six local authorities chosen from 40 examples of current practice collected earlier this year to draw together evidence on benefits and effectiveness in developing information and advice services. A number of those examples, including West Sussex, involve directing people to regulated independent financial advice. Helpfully, the ABI has invited my officials to participate in a workshop on access to financial advice being held on 14 November, which we expect further to support the development of guidance.
I am confident that no further amendments are needed to effect what I believe is a shared ambition. The Bill sets out the framework, the skeleton if you like, but it is the statutory guidance and implementation support that will put meat on those bones. What I have set out today is what we will put into practice through guidance. This guidance will be developed in co-operation with all interests, including the Association of British Insurers and the Society of Later Life Advisers, SOLLA, which will build on the good practice that already exists in many areas. We really want this to be the product of co-development which achieves the aims that I firmly believe that the noble Lord and I share.
The noble Lord, Lord Hunt of Kings Heath, expressed concern about what I said on Report about the possibility that local authorities could be held liable in the event that a regulated financial adviser gives poor advice. He pointed out, quite rightly, that such an adviser would be covered under FCA codes, and so on. The issue here is about the local authority making a recommendation to an individual adviser. We do not consider that there is any problem with local authorities providing a list of advisers from whom a person could choose.
On the impact of local authority responsibilities, we have established a partnership with the Local Government Association and the Association of Directors of Adult Social Services and have set up a joint programme and implementation board. We have a lot of ground to cover, and I think that no one would deny that we have our work cut out over the next few months, but I can tell the noble Lord that, together, we are absolutely committed to providing the support that is needed by local government to enable it to fulfil its functions. I hope that we have achieved a meeting of minds on this matter and that what I have said today will give the noble Lord, Lord Lipsey, sufficient reassurance to withdraw his amendment.
Lord Lipsey
My Lords, I could not have put it half as well myself. I beg leave to withdraw the amendment.
Earl Howe
My Lords, it will probably be of assistance if I speak to these two amendments. In moving Amendment 4, I shall speak also to Amendment 6. These amendments are designed to correct minor drafting errors in the Bill.
Amendment 4 concerns Clause 17, which relates to financial assessment. Subsection (10) clarifies that the regulation-making power to set a financial limit allows for regulations to provide for different financial limits for different types of care and support—or support, in the case of carers. Paragraph (b) states that the regulations may set,
“different levels for different levels of support”.
The amendment would correct this erroneous repetition and ensure that it reads instead:
“different levels for different descriptions of support”.
This ensures that the regulation-making power in subsection (10)(a) mirrors the regulation-making power in subsection (10)(b).
Amendment 6 relates to transition assessments of a young carer’s needs for support in Clause 64. The other provisions containing duties to carry out transition assessments—Clauses 59 and 61—require there to be “significant benefit” to the person in question. However, this clause only talks about “significant benefit” with no mention of the individual and so is quite abstract. This was an oversight. The amendment would therefore clarify that the significant benefit must be “to the young carer”, to bring it into line with the other similar provisions.
I hope that noble Lords feel able to support these minor and technical amendments, which will help ensure that the Bill is clear and works as intended. I beg to move.
Baroness Tyler of Enfield (LD)
My Lords, I rise briefly indeed to welcome Amendment 6 and what I see as the further strengthening and joining-up between this legislation and the Children and Families Bill in relation to young carers. I particularly welcome the greater rights it gives to all young carers. I am really pleased to see the entitlements to both assessment and support for young carers as they reach that very critical age of transition at age 18. This will help because these young people often face additional barriers at that age as they are trying to access further education, employment and training, which is so important to their wider well-being and outcomes. I welcome it very much.
Lord Hunt of Kings Heath
My Lords, I am looking forward to the response of the noble Earl, Lord Howe, and hope that he can reassure the House on this point. It is important that the House should be reminded that the universal deferred payment scheme was discussed on pages 65 and 66 of the Dilnot commission report, which set out an analysis and evidence supporting its recommendations. It explained why the current arrangements and deferred payment schemes were not widely used, and why in the main report the commission recommended extending the current system to a full universal offer across the country.
In its arguments, the commission accepted that local authorities should be able to charge interest and recover their costs and that a scheme would be cost-neutral to the state, although it might require an initial cash injection. Dilnot also made it clear that the Government needed to strengthen and standardise the deferred payment scheme in the light of their decision on the level of the cap, means-testing and the contribution to general living costs.
I accept that the scheme was not intended to be generally available to the very wealthy and asset-rich. As my noble friend Lord Lipsey has so convincingly argued, though, being required to spend your assets down to £23,250 seems far too restrictive to deliver a viable scheme. Indeed, as it would be of no use whatever to people of middle income, it is very difficult to see if anyone at all is going to use the scheme. My question is: why have the Government been consulting on such a figure? Does that actually mean that they do not want the scheme to succeed? Do they recognise that it cannot possibly succeed if you have to get down to such a low figure before the scheme can apply?
My only reading of why the Government have consulted on this low figure is because of Treasury concern about the initial cash injection. Is that so? Will the Minister also acknowledge that there is a question about whether in the long term—or indeed in the short term, because the scheme will begin to pay for itself within a very short time—his department thinks that there is going to be a cost-neutral scheme? It will be interesting to hear from him about why the Government seem so cautious and have been consulting on what seems to be such a low figure.
For the reasons that my noble friend has persuasively put forward, although in the end the number of people who will use the scheme may be counted in their thousands rather than their tens of thousands, there is no doubt that having a scheme available will provide a great deal of comfort to many people and their families, and it would be a great pity if this was going to be stillborn. We need to see a scheme that will be practical and will not squeeze middle-income people. I hope that the Minister will be able to reassure the House that the Government are having second thoughts in this area.
Earl Howe
My Lords, Amendment 5 returns us to the issue of deferred payments. I begin by saying that I welcome the opportunity to debate this subject again. Unfortunately, the Government’s position on it has been fraught with misunderstandings, and I would like to take this opportunity to dispel at least some of those.
First, I remind the House that a consultation on funding reform has been running over the past three months, and it closed last Friday. During these three months, officials have travelled across the country explaining our proposals and seeking people’s views. What we have put forward so far are proposals—something for people to consider. These are not set in stone. We will listen to what we have heard through our consultation, and indeed in this Chamber, as we develop our policies over the next few months.
The purpose of this amendment, as the noble Lord, Lord Lipsey, has explained, is to ensure that anyone—even people with assets of great monetary worth in addition to their main home—can have a deferred payment agreement. I have to make it clear that if one takes this amendment literally, I disagree with that principle. I do not think the public purse should be helping people who do not need financial support to pay their care fees. This would seem a long way from the Dilnot commission’s view that deferred payments should be used to support people who,
“would be unable to afford care charges without selling their home”.
For a person with a substantial sum in their bank account or substantial liquid savings, a deferred payment agreement might be a cheap loan—a convenience, one might say—but it would not be serving its core purpose.
I hope that we can therefore agree that the principle of having an upper threshold for non-housing assets is a sound and a necessary one. If we agree that this is a sound principle, all that is left to do is agree on an amount. Our consultation sought views on that amount. The noble Lord, Lord Lipsey, asked what was wrong with an asset threshold of £118,000. From April 2016, we are extending means-tested support for people with up to £118,000 when the value of a person’s home is taken into account in the financial assessment. This determines when an individual may be eligible for local authority support with their care costs. Deferred payment agreements are designed to help people to pay for their care costs; their ability to meet these costs in the short term will be dependent on their liquid non-housing assets rather than housing wealth. I can say to the noble Lord that we are happy to consider using a threshold of £118,000 as we analyse the consultation responses. We are happy to consider a range of figures.
The noble Lord, Lord Hunt, asked why we proposed the £23,250 threshold. We were seeking to identify those people most at risk of having to sell their home to pay for their care. The reason we proposed £23,250 specifically is because it provides consistency with the threshold for means-tested support when the value of someone’s home is not taken into account, and with the principle that people with non-housing assets under that amount are likely to need state support to pay for their care costs. Indeed this is the same figure and the same reasoning that the previous Government applied in their White Paper. Therefore, from that point of view if no other, it is a little surprising to hear the noble Lord, Lord Hunt, arguing against it.
There is an interesting point about people with more than £23,250 in savings. About 60% of people entering residential care are state-supported, meaning that they have only limited assets. Of the remaining 40% who enter residential care as a self-funder, less than half have liquid savings of more than £23,250. This means that the proposed threshold of £23,250 excludes only the richest 15% of people entering residential care. By increasing the liquid savings threshold to £118,000, the scheme would be available to all but the richest 5% of people entering residential care. I hope that that is a helpful contextual analysis. However, I reiterate—particularly to the noble Lord, Lord Lipsey—that we are not wedded to the figure of £23,250. We will analyse the responses to the consultation before making any further decision.
To answer the question posed by the noble Lord, Lord Hunt, about whether the scheme will actually be cost-neutral, we intend and believe that in the long run the scheme will be cost-neutral. We have committed £330 million to fund the implementation of the cap cost system, and deferred payments to cover the initial set-up costs.
I hope that in the light of what I have said the noble Lord will, on reflection, agree that his amendment would be undesirable as drafted and that he will be content to withdraw it.
Baroness Oppenheim-Barnes (Con)
Before the Minister sits down, will he confirm that if a house has to be sold, after the repayment of the debt, the proceeds remain the property of the person whose house was sold? Would it be possible for the potential beneficiaries to pay the debt in advance so that the house does not have to be sold?
Lord Lipsey
My Lords, I thank the Minister for his reply. It is tempting to go further into the minutiae of these issues, but I think I have been in politics long enough to recognise when a Minister is elegantly preparing for a government retreat. Believing that we have just heard an exemplar of such a speech, I beg leave to withdraw the amendment.
Baroness Wheeler (Lab)
My Lords, from what my noble friend Lord Patel has said, it is clear that the issue of safeguarding inquiries is not at all sorted. He has highlighted a substantial gap in the Bill that could have a very serious impact on some of the most vulnerable people in our communities and prisons. He rightly seeks equivalence of care and protection for adults detained in prison and those residing in approved premises such as bail hostels—care and protection that all other vulnerable adults have when it comes to safeguarding inquiries by local authorities. We take on board his deep concerns about prisons and what appears to be a lack of co-ordinated and clear responsibilities in respect of safeguarding inquiries. I ask the Minister to look further into the matter, as my noble friend suggested.
My noble friend raises some key issues on whose responsibility it is to carry out a safeguarding inquiry for adults living in the community in approved premises. Given all the uncertainty about future service delivery as a result of the Government’s major reorganisation and break-up of the probation service, if that responsibility is currently with the local probation trust, this amendment, which calls on the Secretary of State to report to Parliament within one year of this clause of the Bill coming into force, becomes even more necessary. To require the new community rehabilitation companies or their successor bodies to account for how they have discharged their responsibilities for safeguarding adults residing in approved premises is an acceptable way forward.
I look forward to hearing from the Government about how they intend to deal with the matter in the light of the serious concerns expressed by my noble friend today and in previous discussions on the Bill, and in light of the huge confusion that will result from the proposed changes to the probation service. I very much hope that the Minister will be able to support my noble friend’s endeavours to fill what is potentially a serious gap in the Bill, and to ensure future adequate protection of these vulnerable adults.
Earl Howe
My Lords, I will begin by making absolutely clear that we agree that all prisons and approved premises should have arrangements for safeguarding the adults in their care. They should have a comprehensive policy that is understood by all staff and which ensures that vulnerable adults are identified and given appropriate support. I hope that we also agree that we cannot relieve prisons and probation providers of their duty of care by imposing a duty on a local authority to make safeguarding inquiries into suspected abuse or neglect in a prison or approved premises.
We need clear guidance for prisons, probation providers and local authorities to ensure that the procedures within prisons and approved premises are informed by best practice and local expertise. My officials will work with the Ministry of Justice and the National Offender Management Service, together with the Association of Directors of Adult Social Services and other stakeholders, such as the Prison Reform Trust, to develop instructions and guidance for prisons, probation providers and their local authorities. Those instructions and guidance will be in place by the time the Bill is implemented and will give improved clarity about the Prison Service and probation providers’ roles and responsibilities in safeguarding adults in their care, including the need to have a whole-institution approach to safeguarding, and cover their relationship with the local safeguarding adults board.
The Ministry of Justice encourages prison and probation staff to be involved with local safeguarding adults boards. The guidance on how safeguarding should be carried out in conjunction with local authority partners can draw attention to the duty in Clause 6 that local authorities and their partners must co-operate in the exercise of their respective functions relating to adults with needs for care and support. The guidance will be consistent with the broader advice and guidance on safeguarding adults in the community to ensure that good practice on safeguarding policies and inquiries is routinely shared.
In addition, the guidance will set out clearly the need for locally agreed relationships with local safeguarding boards, including clear local protocols around the circumstances for involvement of local SABs. The guidance will also make clear how prison and probation staff can benefit from the expertise of social services and local authority safeguarding teams.
For approved premises, the probation provider has a clear responsibility in relation to safeguarding but there is nothing to prevent it seeking advice from either the safeguarding adults board or the local authority safeguarding team. This already happens in many areas. Since a local authority’s duties in relation to safeguarding would not extend to safeguarding adults who are at risk of abuse or neglect by reason of their detention or their offence, a joint approach would be much more effective where there is a particularly difficult safeguarding challenge in an approved premises.
Her Majesty’s Inspectorates of Prisons and Probation and the Prisons and Probation Ombudsman will take account of the guidance and local agreements and make recommendations for improved practice, if relevant, when inspecting services and investigating complaints within the prison and probation services.
I wish to be clear in answering the noble Lord, Lord Patel of Bradford, who said that the document No Secrets said that local authorities have responsibility for safeguarding in approved premises. Local authorities do not have a statutory duty at the moment. It is the duty to conduct inquiries that will not apply—not that local authorities cannot conduct an inquiry if invited to by the probation trust or provider. Guidance and probation instructions will provide further detail on how local authorities and probation trusts, as they currently are, can work together at a local level. The guidance will go to all probation providers who run approved premises. Probation services will be contracted out in due course, so these will be approved premises provided by the probation service and by voluntary or private providers. The guidance will make it clear that the provider running the accommodation has a duty of care and a safeguarding responsibility.
I hope that, with those assurances and clarifications, the noble Lord will feel able to withdraw his amendment.
Baroness Masham of Ilton (CB)
My Lords, how will the Government ensure that the guidance is carried out? Would a report not be useful?
Earl Howe
My Lords, the Ministry of Justice will want to ensure that the guidance is adhered to and the department will have oversight of the way that this works in practice, as the noble Baroness might expect. As I say, there is best practice already out there; we want to build on what we know works, with joint working across the prison and probation services and local authorities.
Lord Patel of Bradford
My Lords, I thank the noble Earl for taking time to talk to me about these concerns and providing a comprehensive response. I am really pleased about the guidance that is going to be produced and shared. The noble Earl said that comprehensive policies and procedures are in place, and I should say for clarity that I have no argument with that. A number of institutions do not have them in place and that is where the guidance will come in handy.
However, I have no desire to see the local authority relieving the prison or probation trust of any duty of care. What I was saying—although it is probably a play on words—was that the No Secrets guidance seems to suggest that a local authority is probably the only agency that would investigate or inquire into a safeguarding issue. I am not saying that probation trusts will not do so but the feeling is that that duty falls on the local authority at the moment. My big anxiety is that Clause 75(7) expressly states that Section 42 should not apply. The Bill therefore actually states that local authorities should not carry out a safeguarding inquiry for people in prison or approved premises. The fact that it says in the Bill that they should not do it, but at the same time we are giving guidance to say that if everybody works together it should be okay, leads me to ask the Minister how we square that circle. It gives an awkward flavour to the debate. I hope that the noble Earl is willing to go back and have a look at both the guidance and the clause, as I believe that that is where the problem lies.
As regards safeguarding adults boards, I am very pleased that the noble Earl has said that prisons and probation trusts should join the safeguarding boards. Initially the Bill said that they should not be forced to do so. Then it was drafted to say that they “may” do so. I suggest that they should. This is crucial, as the noble Lord, Lord Ramsbotham, said, as otherwise their skill base is missing.
Those two areas are crucial. I do not know what will happen if and when the probation trusts are abolished, and what problems that will cause, but at least the amendment requiring that there is a report within a year will give us that information.
Lord Patel of Bradford
The fact that we each have looked at that provision in a different light suggests that it may be useful to look at that again when the guidance is produced so that we are very clear and we give local authorities the confidence to play the lead in co-ordinating this.
I again thank the Minister for taking away all the issues and re-examining them. I beg leave to withdraw the amendment.
Care Bill [HL]
Earl Howe Excerpts(10 years, 6 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the reason for this Motion is that the Government wish to give the House the opportunity to amend the order in which we take our Report stage debates today. Last week, I became aware of some concern that my Amendment 168A, relating to trust special administration, would have fallen for debate at a rather late hour this evening. I assure the House that this was not by design and that the Government are more than happy to facilitate an earlier debate. Clearly, the issue of trust special administration is an important one. I understand the wish of some noble Lords to debate it fully in prime time. Accordingly, the Motion in my name would allow the debate on Amendment 168A to be taken at the start of today’s proceedings on the Bill. I should also indicate to the House that in response to the request put to me last week by the noble Lord, Lord Hunt of Kings Heath, I would have no objection to relaxing the rules of debate that normally apply on Report so that this amendment can be debated in full if that, too, is the desire of the House. I beg to move.
Lord Hunt of Kings Heath (Lab)
My Lords, I am most grateful to the noble Earl, Lord Howe, following my intervention last week. I made a similar proposition to the usual channels last Thursday, only to be told that there would be dire consequences for everything that your Lordships hold dear. I am glad that sense has none the less prevailed. I very much welcome this and support the noble Earl in his Motion.