Children and Families Bill
Earl Howe Excerpts(11 years, 7 months ago)
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Lord McColl of Dulwich (Con)
My Lords, I, too, support these amendments, and my name is attached to Amendment 264. I should declare that I have a history as regards smoking as I used to be a chain smoker but gave it up when I was six. About 15 years ago in your Lordships’ House I introduced an amendment to ban smoking in public places. I put it on the back of a criminal justice Bill, which is a convenient way of moving things. I was amazed that the House was full right up to midnight when my amendment was discussed. I fondly imagined that everyone had come to listen to my wisdom, but little did I know that the House had filled with smoking barons waiting to pounce. However, I got my own back on them because at the end of the debate I thanked everyone for their contributions and, instead of saying, “I beg leave to withdraw my amendment”, for some reason or other I said, “Amendment not moved”. They all looked very puzzled because we had just spent hours discussing it. However, the noble Baroness on the Woolsack quickly said, “Amendment not moved”, passed on and they lost the opportunity to vote. They were furious and I was very pleased. As a professor of surgery, of course, I fully back any move to reduce the amount of smoking and I am convinced that these amendments would do that.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this has been an instructive debate and let me say immediately that I have listened carefully to all the contributions, both today and on Monday. Perhaps I may start by addressing Amendment 263. I should say at the outset that I have enormous sympathy with the aim of this amendment, which is to protect children’s health from the harm that can be caused by second-hand smoke, and I am grateful to the noble Baronesses, Lady Finlay and Lady Massey, and the noble Lord, Lord Faulkner, along with my noble friend Lady Tyler for bringing this important issue to our attention.
We all agree that we do not want to see children exposed to second-hand smoke anywhere. The evidence of the harm caused by second-hand smoke is clear, but many children continue to be exposed to it, both in the family car and in the home. The question posed by this debate is whether legislation is the most proportionate and viable means of addressing the problem. We need to consider that question carefully and I must say that, while supporting the spirit of the amendment—which I certainly do—the Government are not convinced that creating new criminal offences is the right approach.
Of course, in some people’s minds there are civil liberties considerations, which might include what is often perceived as state intrusion into people’s private space. That is a complex area worthy of a debate on its own, but of course I acknowledge that any arguments on that score need to be balanced against the need to protect children. Since 2007, evidence shows that smoke-free legislation has been effective in reducing exposure to second-hand smoke in virtually all enclosed work and public spaces, public transport and work vehicles. Compliance with the law is high and we now benefit from clean air at work, in pubs and restaurants, and on public transport. However, it does not automatically follow from that that it is right to extend the scope of legislation to cover private cars.
There are many practical issues to be considered, particularly around effective enforcement, which is not something that we have heard much about during the course of the debate. Smoke-free legislation in England is enforced by local authority environmental health officers. They do not hold powers to stop vehicles or to detain people in vehicles that are already stationary. Consequently, it would be very difficult for them to take effective enforcement action without the assistance of the police. Since this is a public health issue rather than one of road safety, I expect that such an additional duty on top of their many other responsibilities would be a cause for concern for the police. The Chartered Institute of Environmental Health has identified other practical difficulties around enforcement. These include accurately identifying which vehicles are required to be smoke-free. For example, small children may not easily be visible from outside the vehicle. Further difficulties include obtaining evidence of smoking, identifying the driver and passengers, and proving the age of the child.
I hope that the Committee agrees that there would be real practical difficulties in effectively enforcing such an offence. If we cannot credibly enforce the law, then the credibility of the law itself is called into question. That is why the Government firmly believe that, rather than focus on what would be a complicated and resource-intensive enforcement process, we should continue the non-legislative approach that the evidence shows is working; namely, encouraging positive and lasting behaviour change among adults who place children’s health at risk. My noble friend Lord Storey urged us to do this. Our comprehensive tobacco control plan states:
“Rather than extending smokefree legislation, we want people to recognise the risks of secondhand smoke and decide voluntarily to make their homes and family cars smokefree”.
That is why Public Health England, building on last year’s success, ran another hard-hitting marketing campaign in June and July this year. The campaign aimed to encourage smokers to stop and think before smoking in front of children, whether in the home or in the car. It also encouraged smokers to order an NHS smokefree kit with tips on making the home and car entirely smoke-free spaces, together with support to help quit smoking altogether.
This year’s campaign is currently being evaluated, but emerging findings are encouraging. They show that the campaign has been successful in raising awareness and in changing attitudes and behaviour, with almost three-quarters of those surveyed agreeing that smoking out of an open door or window was not enough to protect children from second-hand smoke. Of those surveyed, 37% reported that they had taken action to reduce their children’s exposure to second-hand smoke, compared with 29% in 2012. In addition, 73% agreed that the adverts made them realise that smoking out of an open window was not enough to protect children, and there were nearly 85,000 orders for smokefree kits. That is an increase of 48% on the 2012 campaign.
The right reverend Prelate the Bishop of Chester rightly suggested that this is a global issue. I agree. We are, however, considered to be a leader in tobacco control internationally. The World Health Organisation has assessed us to be number one in Europe in this area, and through the Framework Convention on Tobacco Control we share this good practice as much as we can.
The noble Lord, Lord Palmer, suggested that the Government ought to introduce an offence of proxy purchasing. I know that shopkeepers and others are interested in making it an offence to buy tobacco for young people under the age of 18. I am sympathetic to that concern, but even were such an offence to be introduced, it would not stop family and friends sharing cigarettes with children. Therefore, we get back to the argument about behaviour change, which I think is more relevant here.
The noble Baroness, Lady Howarth, made an interesting point about this being considered as a road safety issue. I agree that any activity such as smoking—getting out a cigarette, lighting it, disposing of hot ash or stubbing the cigarette out—is likely to distract the driver, particularly if carried out in a moment that is critical for road safety. However, there are a host of things drivers do that have the potential to be equally distracting, be it eating, drinking, adjusting the radio, consulting directions or whatever it may be. First and foremost, it is the driver’s responsibility to drive safely at all times. Section 41D of the Road Traffic Act 1988 already provides a perfectly adequate offence if a driver fails to maintain proper control of a vehicle while driving. While a specific offence has been created for driving while using a hand-held mobile phone, the Government do not believe that there is any need to introduce a new and separate offence of smoking while driving.
I welcome the debate on this important issue and I can assure noble Lords that we shall consider carefully the findings of this year’s marketing campaign and decide what further action may be needed. I can assure the Committee that the Government will continue to work to protect children from second-hand smoke in family cars and in the home. We are not complacent but we remain to be convinced that legislation is the most effective and proportionate way of achieving this.
Baroness Young of Old Scone
My understanding of this is that, because the Government would not come forward with a more general provision, this amendment has been hitched on to the Bill in desperation because it seemed to be a sensible place to try to get it into. The convolutions that the Minister is rightly pointing out would be solved at a stroke if there were to be a ban on differentiated packaging across the board and standardised packaging were introduced for all cigarettes.
Earl Howe
That indeed is my understanding. Noble Lords have taken the opportunity of this Bill to raise the dangers of smoking, particularly of passive smoking for children, and I have no issue with that. I merely point out that there are problems with the amendment as drafted. I am not saying that it would not be possible to draft another amendment which noble Lords might care to consider between now and Report. Being able to enforce these provisions as drafted is also a significant aspect. For example, it may be hard to judge whether a product could reasonably be expected to attract children, as the amendment would require, or to determine what might be aimed at or would attract 18 year-olds but not, let us say, 17 year-olds or 13 year-olds.
I am grateful to noble Lords for raising this important issue and for keeping this debate at the front of our minds. It is a debate that we need to continue. As I have said, the Government have yet to make a decision on this policy, but if we were to bring in such a measure, we would not want it to be circumscribed in the way that is proposed. We would not want to set up a situation in which both branded and standardised packs could be sold legally depending on where they were sold and what other products were sold alongside them. I therefore urge noble Lords not to press their amendments and respectfully suggest that they consider other avenues for bringing this matter before the House on Report.
Lord Hunt of Kings Heath
I always admire the noble Earl’s eloquence when defending the indefensible and he has done that par excellence today, but is not the reality that this is an opportunity for the Committee and the House to express a view in principle on the issue? It would then be up to the Government. As the noble Earl knows, when that happens, the Government simply come back with an amendment at Third Reading to deal with the technical issues. Surely the issue here is whether the House goes forward to a vote in principle, which I hope it might be able to do.
Earl Howe
Well, my Lords, if I could repay the compliment to the noble Lord, Lord Hunt, he has very eloquently presented the case for the Government to go away and think further about this, which indeed we will do. I come back to what I said at the beginning of this debate: the message from this Committee has been delivered loudly and clearly. I am grateful to noble Lords for that. I say again that the Government’s mind is not closed on this issue.
Baroness Howarth of Breckland
As one of those who are not quite so eloquent but are equally committed to the cause, I think that the Government would be in a far better position if we had some timescale. We now know when Report stage is likely. I am much attracted to what the Minister said. I would much prefer that we had a universal position that protected adults as well as children because of, as he said, the influence that adults have on children. Many more noble Lords might, like me, be influenced if they knew that something was likely to happen. The anxiety is that, unless we press this, nothing will happen.
Baroness Finlay of Llandaff
My Lords, it falls to me to respond. I am most grateful to all noble Lords who have spoken. I am grateful that nobody has spoken against the amendment that would prevent people smoking in cars when children were there. The evidence is overwhelming. This must fall squarely within this Bill; it is about protecting children from harm. If I may draw on the analogy of a tin box used by the noble Lord, Lord Storey, that would be classified without doubt as child abuse. It would fall to the police to prosecute in such a case—indeed, with other traffic offences, it falls to the police.
I was intrigued to hear that the Minister places so much faith in the public education campaign and cites cost of enforcement as a problem. How much has the public education campaign cost in total, including its evaluation, and what are the cost estimates for the police?
In Wales there has been a public education campaign since 2012 to try to stop people smoking in cars when children are present, and it is currently being evaluated. I live there and I can tell noble Lords that it is not working. In supermarket car parks you see children being offloaded into the back of the car, the shopping offloaded into the boot and a cigarette offloaded out of a packet into the driver’s mouth before they set off. I would dearly love to tap on the car windows of those people and say, “You can’t do that” because they are endangering the children in the vehicle. I also refute the notion that it would be very difficult to identify who is smoking when there are children in the car. The Government are committed to children’s health and well-being and have shown that commitment in many different ways—for example, through sporting initiatives—yet they allow a practice to continue which permanently damages children’s lungs and physical development and leads to premature death in some cases. Indeed, the instances involving asthma sufferers cannot be ignored.
I remind the Minister that the legislation on smoking in public places has brought about huge behavioural change and been extremely successful. I have been repeatedly thanked for that legislation by smokers and non-smokers, as must have happened to other noble Lords who campaigned prior to that legislation going through. That legislation has made it easier for them to attempt to stop smoking or to cut down. I can honestly say that nobody has been angry with me about the legislation having gone through, although some anger was shown when it was being discussed.
I was intrigued by the Minister’s comment about the complexity of Amendment 264 vis-à-vis producing standardised packaging. He may not wish to comment on the detail of it, although I am happy to give way if he does. However, I hope that he will meet me and other Peers who are interested in this issue to explain what problems may arise in this area. I am grateful to him for his critique of the amendment and see exactly what he means. We certainly need to take it away, redraft it and bring it back on Report. We do not want to make it harder for retailers who sell other things to children, such as comics, by differentiating and having some kind of two-tier system.
As regards the point raised by the noble Lord, Lord Palmer, in relation to illicit products, Margaret Hodge, chair of the Public Accounts Committee, found that the illicit market reduced from 20% to 9% between 2000 and 2012-13. The 9% figure applied also to 2010-11, although it dipped to 7% in one year. Margaret Hodge commented that the tobacco manufacturers are complicit in this illicit trade by,
“supplying more of their products to European countries than the legitimate market in those countries could possibly require. The tobacco then finds its way back into the UK market without tax being paid. The supply of some brands of hand-rolling tobacco to some countries in 2011 exceeded legitimate demand by 240%”.
I understand that oversupply to Ukraine has been identified, which fuels a £2 billion black market that has reached across the EU, and that in 2011 Japan Tobacco International was investigated and is now under official investigation by the European anti-fraud office. So I am afraid that it is not a nice story. I am not certain that the argument about revenue saved can possibly be stacked up against the cost of lives shortened, health damaged, children left orphaned and all the other things that we know go on. I beg leave to withdraw the amendment but we will be coming back to it at the next stage of the Bill.
National Health Service (Approval of Licensing Criteria) Order 2013
Earl Howe Excerpts(11 years, 7 months ago)
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NHS: Mid Staffordshire NHS Foundation Trust
Earl Howe Excerpts(11 years, 7 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I shall now repeat a Statement made earlier today in another place by my right honourable friend the Secretary of State for Health on the Government’s response to Robert Francis’s report on Mid Staffordshire Hospital. The Statement is as follows.
“With permission, Mr Speaker, I would like to make a Statement about the Government’s response to the Mid Staffordshire NHS Foundation Trust public inquiry.
Let me start by paying tribute to the men and women of courage without whom this darkest episode in the history of the NHS would never have come to light: people like Julie Bailey and members of Cure the NHS, who stood outside the Department of Health in all weathers because no one would meet them to hear about the inhumane care given to their loved ones; brave whistleblowers like Mid Staffs nurse Helene Donnelly; and campaigners who suffered tragedies elsewhere, like James Titcombe, who never gave up the fight after losing his son, Joshua, at Morecambe Bay. They suffered greatly for their selfless determination to make sure that their personal losses were not in vain. All of us in this House today are humbled to stand in the shadow of their bravery.
Robert Francis and his team also deserve huge credit. Their diligence and thoughtfulness led to an outstanding report which will transform our NHS for the better. Finally, let me pay tribute to all NHS front-line staff, for whom reading about these events in the media has been immensely distressing. We owe it to them to make sure that poor care is never again allowed to take root and survive unchallenged in our NHS.
Since our initial response to the inquiry in March, much has happened. Thirteen hospitals have been put into special measures as part of a tough new failure regime. Those hospitals, where poor care had been allowed to persist, are now being turned around, and I thank the Keogh inquiry team for its painstaking work in this area.
Independent, Ofsted-style ratings of hospitals are under way, led by Professor Sir Mike Richards, the new Chief Inspector of Hospitals. The first 18 trusts are currently being inspected, with quality of care and safety paramount. We have appointed new Chief Inspectors of Adult Social Care and General Practice, whose robust inspections of care homes, domiciliary care and surgeries start next year. Surgical survival rates for 10 major specialties have been published by individual surgeons, making the NHS a world leader in transparency.
Today, the Government are publishing their further response to the inquiry as well as our response to the Health Select Committee’s report on the inquiry. Both these responses have been laid before Parliament.
The NHS is a moral being or it is nothing. It was set up 65 years ago with the noble ideal that no one should ever be prevented by background or finances from accessing the best care. That is why it remains the most loved British institution, and rightly so. But each and every case of poor care betrays those worthy aims. I do not want simply to prevent another Mid Staffs; I want our NHS to be a beacon across the world not just for its equity but its excellence. I want it to offer the safest, most compassionate and most effective care available anywhere, and I believe it can.
But that is only if there is a profound transformation of the culture in the NHS. The inquiry shows the devastating effects of overly defensive responses: hurting families, suppressing the truth and preventing lessons being learnt. Failure cannot be addressed when it is covered up, so today I am announcing new measures to promote a culture of openness and transparency.
From 2014, every organisation registered with the CQC will have a statutory duty of candour. Patients must be told promptly about any avoidable harm, but there will be a statutory requirement to notify any harm that has led to avoidable death or serious injury.
We will consult on whether hospitals that are found not to have been open and transparent with patients or families at the earliest reasonable opportunity should risk having their indemnity from litigation awards reduced or removed by the NHS Litigation Authority. The signal must go out loud and clear to all clinicians: if in doubt, report an incident and tell the patient.
The professional regulators have agreed to place a new, strengthened professional duty of candour on all doctors and nurses. Failing to inform a patient, not reporting avoidable harm, or obstructing someone else seeking to do so will be subject to sanctions, including being struck off.
Inspired by the airline industry, this duty will cover “near misses”—occasions when mistakes were made that could have led to harm and from which we need to learn. Conversely, prompt reporting may be considered as a mitigating factor in a professional conduct hearing. This is not about penalising staff for making mistakes; it is about enabling them to learn from them. The NHS will adopt a culture of learning, as recommended by Don Berwick and his expert committee. I thank them for their seminal report.
A culture of openness also means learning from complaints. In line with the recommendations of the right honourable Member for Cynon Valley and Professor Tricia Hart’s excellent review, all patients will be able to access independent help in making their complaint, with clear signs in every ward explaining how to do so; the Chief Inspector of Hospitals will inspect complaints handling to establish whether trusts are genuinely seeking to understand and learn from them; every quarter, trusts will publish the number of complaints received and the lessons learnt; and the Health Service Ombudsman will dramatically increase the number of cases that she looks at.
It is impossible to deliver safe care without safe staffing levels. All hospitals will be required to monitor their staffing levels on a ward-by-ward basis, analysing precisely how many shifts meet safe staffing guidelines. By the end of next year, this will be done using models independently approved by NICE. No hospital will be able to conceal unsafe staffing from the public because from next June all these data, both at ward and hospital level, will be published alongside other safety data on a new NHS safety website, triggering CQC action if there is cause for concern.
Things are already changing for the better and I am pleased to report that trusts are planning to recruit an additional 3,700 nurses compared to a year ago. However, we need to go further to train and motivate staff, particularly healthcare assistants and social care support workers who perform so much vital care. Healthcare assistants and social care support workers will be required to have a new care certificate to ensure that no one is ever asked to perform personal care without adequate training, whether in hospitals or care homes. The title “nursing assistant” will be used widely in hospitals and paths to nursing careers will be improved. I thank Camilla Cavendish for her excellent work in this area. We also need to broaden the talent pool going into NHS management positions, in particular attracting more clinicians and those with good external experience. We have introduced a fast-track leadership programme, sending 50 people a year to a world-leading business school, followed by time shadowing top NHS chief executives.
Robert Francis correctly highlighted the failure of regulatory systems to identify quickly what happened at Mid Staffs. Subsequently it has become clear that Ministers put pressure on regulators which may have led them to tone down news about poor care. This is totally unacceptable, so we will strengthen the statutory independence surrounding reports into care quality. The chief inspector will be the nation’s whistleblower-in-chief and nothing must ever be allowed to stand in his way. The CQC can prosecute when fundamental standards are breached. Trusts put into special measures will have a strictly limited time to get their house in order before administration is considered. Foundation trusts in special measures will have their autonomy suspended and action will be taken to ensure that they quickly improve. No trust will be able to progress to foundation status unless they are rated good or outstanding.
Proper accountability must be at the heart of the NHS. I have therefore accepted Professor Don Berwick’s recommendation of legal sanctions for those found guilty of wilful neglect or ill treatment. There will be a new criminal offence for care providers that supply or publish false or misleading information. A new “fit and proper persons” test will enable the CQC to bar unfit directors from boards. Every hospital patient should have the names of a responsible consultant and nurse above their bed. Starting with over-75s from next April, there will be a named accountable clinician for out-of-hospital care for all vulnerable older people.
One of the most chilling accounts in the Francis report came from Mid Staffs employees who considered such care to be “normal”. Cruelty became normal in our NHS and no one noticed. The Francis report made 290 recommendations. I accept the principles behind all of them and, wherever possible, have adopted the practical solutions suggested by the inquiry.
Robert Francis himself has welcomed today’s announcement as a carefully considered and thorough response to his recommendations, which he says will contribute greatly towards a new culture of caring and making our hospitals safer places for their patients.
Today’s measures are a blueprint for restoring trust in the NHS, reinforcing professional pride in NHS front-line staff and, above all, giving confidence to patients that after Mid Staffs the NHS has listened and learnt and will not rest until it is delivering the safest, most effective and most compassionate care anywhere in the world. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, first, I welcome the noble Lord’s very positive comments about the various reviews that have been commissioned in recent months. I am glad that he agrees that, in broad terms, the Government are on the right lines in accepting the recommendations that have come forward.
The noble Lord asked a number of questions, the first of which was about why we have not implemented all the recommendations of Robert Francis in full. Most of the recommendations have been accepted in principle, in part or—in the main—in their entirety. In some cases, we are taking an alternative approach to that suggested in the inquiry if we believe it is likely to be more effective in reaching the intended outcome. In total, we have rejected just nine of the 290 recommendations and where recommendations have been rejected, a full response outlining the reasons for doing so and the alternative action that organisations are taking is provided in our system-wide response.
The noble Lord asked about the regulation of healthcare assistants, a matter to which we return at regular intervals in this House. I assure him that the Government keep this issue under regular review but, for the time being, our view is to tackle the key issue at its root, focusing on making sure that healthcare support workers have the right training, values, support and leadership to provide the high-quality care that we all want patients to receive. We are committed to ensuring that this part of the workforce receives high-quality and consistent training. We have commissioned Skills for Care and Skills for Health, as the noble Lord knows, to develop a code of conduct and minimum training standards. We have also announced the development of a care certificate, which I am sure will be particularly welcome to a number of my noble friends.
The noble Lord asked me about a situation in which employers might find that a healthcare assistant or social care support worker no longer met the standards required by the care certificate. In that event, Health Education England and the sector skills council will set out in guidance the requirements for ensuring that appropriate retraining is given or other disciplinary action is taken. The guidance will be that the worker in question should not work unsupervised until the problem has been resolved and the employer is confident that their care certificate remains valid. Of course, if a healthcare assistant is found to have harmed patients or have been a serious risk to patients, the Disclosure and Barring Service needs to be considered as the ultimate remedy to make sure that that person does not put patients at risk in future. However, that is an extreme situation, which I believe will not be the norm.
The noble Lord referred to the nurse numbers. In the last spending review, the NHS budget was protected in real terms, with cash funding rising by £12.7 billion by 2014-15. Alongside that, Health Education England has been working with NHS trusts to develop the overall workforce plan for England for next year, reflecting the strategic commissioning intentions. That work indicates that a number of trusts have already increased their nurse staffing levels during the current year and others are planning to do so, as I mentioned in the Statement. Initial plans indicate that trusts intend to employ an increase of more than 3,700 nurses this year.
Moving to staff ratios, nursing leaders have been clear—indeed, there is a letter in today’s Times about this—that hospitals should publish staffing details and the evidence to show that staff numbers are right. However, we do not think that prescribing a rigid set of rules from the centre is the right way forward. The National Quality Board and the Chief Nursing Officer are publishing a guidance document that sets out current evidence on safe staffing. By next summer, NICE will produce independent, authoritative, evidence-based guidance on safe staffing and review and endorse associated tools for setting safe staffing levels in acute settings. From next April, by June at the latest, NHS trusts will publish ward-level information on whether they are meeting their staffing requirements. A review every six months will allow for those staffing levels to be quality assured.
On the issue of candour, we have had a number of debates on this subject, both during the passage of the Health and Social Care Act and, more recently, in the Care Bill, and I believe that we have reached a place for which this House can take some credit because the Government have moved a considerable distance from their original position. We agree with Don Berwick’s intention that professional regulators are in the best position to strengthen the duty of candour for individual professionals working in a hospital. Of course, the duty of candour applies to the corporate entity but the GMC and the NMC will be working with the other regulators to agree consistent approaches to candour and the reporting of errors, including a common responsibility to be candid with patients when mistakes occur, whether serious or not, and clear guidance that professionals who seek to obstruct others in raising concerns or in being candid would be in breach of their professional responsibilities. The professional regulators will issue new guidance to make it clear that it is the responsibility of professionals to report near misses for errors that could have led to death or serious injury as well as actual harm, and they must do so at the earliest opportunity. We will seek advice from experts on how to improve the reporting of patient safety incidents, including whether the threshold for the statutory duty of candour should include moderate harm.
The noble Lord referred to the NPSA. He is right that the NPSA’s function of reporting safety incidents has transferred to NHS England, into which the National Reporting and Learning System has been absorbed. I do not see that transfer as, in any way, inhibiting staff confidence in reporting safety incidents. The essence of the system remains as it always has been.
The noble Lord asked about the responsibility for patient safety being transferred back to the CQC. I am sure that, on reflection, he will agree that patient safety is everybody’s business. In part, it is the business of the CQC but, above all, it is the business of those who work in the NHS. It is the business of trust boards and of commissioners. It is also very much the business of those whose job it is to look at the performance of the NHS on behalf of patients—chiefly Healthwatch, but also patient organisations. Therefore one cannot single out an individual organisation as taking sole responsibility for this.
I will write to the noble Lord about the Freedom of Information Act. However, he should not forget that the standard contract that the NHS operates binds anyone who provides services to the NHS into certain contractual terms, and the disclosure of relevant information is a part of that.
On death certification, the noble Lord asked me about medical examiners. We agree that they must be independent of the deceased person and their medical practitioner. That is because medical examiners need to carry out independent scrutiny of the medical circumstances and cause of apparently natural deaths to make sure that the right deaths are notified or referred to a coroner. However, we need to ensure that there are sufficient numbers of medical examiners to carry out this work, particularly in rural areas, so appointees are likely to have some sort of professional relationship with local care providers. Therefore the draft death certification regulations for medical examiners do not require that medical examiners are independent of the organisation whose patients’ deaths are being scrutinised. However, we are mindful of the need for a greater level of independence within the spirit of this recommendation and the Government will review how they can include further safeguards on this front.
The noble Lord suggested that the NHS constitution was not the right means of changing the culture of the NHS, and I agree with him. However, declaratory statements in the constitution are an important part of signalling to the NHS its vision and values in the broadest terms, and the duties that people should feel they are under. The values, rights and pledges set out in the NHS constitution form the basis of everything the NHS does. NHS England, Health Education England, the department and CCGs are developing a joint strategy to embed the constitution further, as we promised they would during the passage of the Health and Social Care Act.
On the system that we have put in place and the complexity that the noble Lord sees in that system, I say, simply, that the system we now have is more transparent than the one we had before. Accountabilities are clear, responsibility is clearly placed where it should be and it is backed by robust lines of accountability, including to Ministers and Parliament.
I hope that that answers most of the noble Lord’s questions, but I will of course write to him if I have omitted anything.
Baroness Brinton (LD)
My Lords, we on these Benches welcome both the Francis report and the Government’s Statement. In particular, we welcome the importance of openness, transparency and access to information to ensure that there is a change in culture. Can the Minister confirm that the new care certificate will be an NVQ qualification so that the public can be confident that staff have the right skills and training? We would also welcome registration and regulation for those staff in the way that the noble Lord, Lord Hunt, referred to earlier. Can the Minister also confirm that when complaints and other items have to be published, it will not be as a few lines in an annual report but on the web, and that it will easily accessible by patients and the public?
Earl Howe
My Lords, I very much agree with the spirit of my noble friend’s questions. Certainly as regards complaints, the public should have a clear view of the nature of the complaints that have been registered with a particular organisation. They should be able to have a sense of what those complaints relate to and what action the organisation has taken to address the matter in question.
On my noble friend’s first point, we are currently working through the question of the care certificate and will seek advice. It is important to arrive at an agreed formula that gives the maximum assurance, both to care assistants and to those they look after, that basic standards of training have been learnt and are being adhered to. It is important to define as closely as we can what we mean by that, and as soon as we have further details we will announce them.
Lord Patel (CB)
My Lords, I thank the Minister for repeating the Statement, and I welcome the Government’s comments on the Francis report. I apologise on behalf of my noble friend Lady Emerton, the matron, who is not here today as she is unwell, and also my noble friend—he is a friend, although he sits on the wrong Benches—Lord Willis. He cannot be here because he has been asked to undertake the duties of my noble friend Lady Emerton. They asked me to represent their views—which I will not do, because I would get them wrong, but perhaps I may make my own comments. I realise I am not allowed the same time as the noble Lord, Lord Hunt, had. That is a pity, because I have much to say about the Statement.
I welcome the statutory requirement to give notification of any harm or serious misses that have happened. During my time as chairman of the National Patient Safety Agency I tried to get that into statute and failed; it was not under the current Government, but that does not matter. I am therefore delighted that this will be a statutory requirement. The important thing is that, as Don Berwick said, this is about learning; reporting by itself is not enough. The Minister referred to the airline industry, which learns from what has happened by doing root-cause analysis. We need that system established in the NHS if we are to learn from avoidable harm and near misses. Whose responsibility will it be to do that, and how will that expertise be gained?
On staffing ratios, the Minister knows that if my noble friend Lady Emerton had been here she would have asked about ratios of trained to untrained staff. Now that there will be a new care certificate to ensure training for all care assistants and nursing assistants, which I welcome, she would have asked for regulation. However, we have passed that stage, and I welcome the fact that there will be a new care certificate following the training. Why, however, is all this to be only for hospitals? What about care homes? Why were care homes excluded from reporting on staffing ratios?
Lord Patel
The Statement refers particularly to hospitals. They will have to report on staffing ratios, but it did not say that care homes will have to do that.
Earl Howe
I am grateful to the noble Lord. I am in complete agreement with him on his first point. The best thing might be for me to read out a very short passage from Professor Don Berwick, who said:
“The best keys to health care safety do not lie in blame, or regulation, or punishment, but rather in learning, support, and encouragement to the health care staff, the vast majority of whom are dedicated to excellence in care.
Leaders who aim for safe and effective care have a duty to supply the workforce with the tools, knowledge and encouragement to do the work that adds meaning to their lives”.
We have attempted, as far as we can, to make that philosophy the guiding principle of our response on patient safety. We do not want to create a blame culture; we want to create a culture that encourages everybody to feel ownership of the work that they do, and to feel well led. That is the other side of the coin to the culture that we have spoken about in other debates about innovation—about making innovation everybody’s business in an organisation. It comes down, in the end, to good leadership.
We are not insisting that every organisation should carry out root-cause analysis. On the other hand, we are saying that it is the business of trust boards to make complaints, mistakes, and lapses in patient safety central to their work and to the scrutiny that they undertake of their organisations, and for those matters to be discussed openly and resolved openly.
As regards care homes, as I said, we have commissioned NICE to work through the guidance that will underpin safe staffing. It is not yet apparent whether that will cover care homes and it is difficult to see how it could do so because care homes are clearly very different organisations from acute trusts. On the other hand, we expect the CQC to have some way of judging whether a care home can call itself safe. We will certainly look at the noble Lord’s points as we carry that work stream forward.
Baroness Pitkeathley (Lab)
My Lords, I am sure it will be welcome to patients and their families that the name of a responsible consultant will now be above the patient’s bed, but will the noble Earl say a bit more about the new attention to 75 year-olds that has been promised? In the extensive leaks of the Government’s response over the weekend, GPs were definitely named as the people who would be responsible for the over-75s. The Statement refers to “a named accountable clinician”. Is there a difference between the two?
Earl Howe
Yes. There were no leaks. The report that the noble Baroness saw was a report on the new GP contract that we announced at the end of last week. That was legitimate reporting by the press of an element of the new contract for next year, when we want all NHS patients over the age of 75 to have a named, accountable GP. However, we are saying in this response that every patient in a hospital setting should know who their consultant is, and therefore that there should be a named responsible consultant for every hospital patient. The two issues are, therefore, related but different.
Lord Mawhinney (Con)
My Lords, the Statement said that the NHS has to be a moral organisation or it is nothing. I am sure that my noble friend carried the whole House with him when he said that. Therefore, the raft of changes and the new legal accountability that will come in next year are very welcome in their own right as they will bolster that concept. However, how is it that no individual or individuals have been held accountable for the tragedy and disaster at Mid Staffordshire? I know that my noble friend keeps saying, on behalf of the Government, that they do not want to encourage a blame culture, but will he explain to your Lordships’ House how we can have an accountability structure without any blame attached?
Earl Howe
My Lords, the trust board at Mid Staffs was ultimately responsible, and individuals on it have been replaced. That was the first step in holding the system to account. We are introducing strengthened accountability for the future, including a fit and proper persons test for directors, as well as a single-failure regime triggered by failures in care. We have also appointed a Chief Inspector of Hospitals with power to ensure that the system acts quickly to tackle unacceptable care. In a range of ways I hope that we have addressed the central point in my noble friend’s question, which is very well placed.
Baroness Masham of Ilton (CB)
My Lords, I am pleased to hear about the transparency and the duty of candour, but will the noble Earl give the House an assurance that patients will be listened to? I am thinking about the young man who implored staff for a drink, and even telephoned the police on his mobile, but was ignored by staff. This was not Mid Staffordshire but a London teaching hospital. Further, will staff be protected when they blow the whistle? Will the noble Earl give an assurance that they will not lose their jobs?
Earl Howe
My Lords, I completely agree with the noble Baroness that the voice of the patient is an essential part of maintaining a culture of safety in the NHS. Improving the way in which the NHS manages and responds to complaints will be critical in shaping a culture that listens to patients and learns from them and ending a culture of defensiveness or, at worst, a culture of denial about poor care. That is why we welcome and accept the spirit of the review of the NHS hospital complaints system by Ann Clwyd MP and Professor Tricia Hart and the principles behind their recommendations.
On whistleblowers, the amendments to the NHS constitution have enhanced the protection for whistleblowers, but we are not complacent and we are already considering whether there is a need for more developments both to protect whistleblowers and to ensure that action is taken, where necessary, in response to concerns. We are looking, with the national regulators, at how whistleblowing concerns are dealt with at the moment and, where appropriate, we will introduce improvements to systems in the future.
Baroness Knight of Collingtree (Con)
My Lords, much of what my noble friend has said has given us satisfaction, but it is perfectly true, as we have already been reminded, that troubles were going on not only in the Mid Staffordshire area but all over the place. It is also true that it is not just the whistleblowers who warned time and time again about what was going on and who should have been listened to. I spent four or five years raising cases of people who had written to me. On one occasion I presented the then Minister, the noble Lord, Lord Hunt of Kings Heath, with a dossier of some 25 cases, all of which had been checked very carefully. All the details were correct, all the patients, or their relatives, had given permission for these cases to be raised and they were raised in this House. I am not blaming the noble Lord for failing to take these cases forward, or failing to listen to the arguments put out clearly in this House, because I think that he passed them on, but they were never properly investigated.
It is upsetting that for such a long period warnings were being given and were allowed somehow to filter into the ground and away, or into the past. I particularly warned about the practice, which was fairly unknown at that time, of failing to feed patients because food was put too far away from them and other examples. I worry about the people who suffered for those long years when something could have been done if those responsible at the grass roots had taken care of what was being said in this House. I beg the Minister not to leave aside the really serious point that cases raised with great sincerity and truth in this House should be regarded and not just pushed aside in the future.
Earl Howe
My Lords, my noble friend should be listened to with great care. Of course, I remember those cases. I was not the Minister in charge at the time she submitted those cases to the Department of Health, but she shared them with me, and I share her concerns, which are, of course, directly relevant to the matters we are discussing today. We have the new duty of candour and in April the Enterprise and Regulatory Reform Act strengthened the main whistleblowing legislation introduced by the Public Interest Disclosure Act so that an individual who suffers harm from a co-worker as a result of blowing the whistle now has the right to expect their employer to take reasonable steps to stop this. The idea is to ensure that people do not feel intimidated from speaking up. The Care Quality Commission is using staff surveys and the whistleblowing concerns it receives as part of the data in its new intelligent monitoring system. That data will guide the CQC about which hospitals to inspect. Since September, the commission’s new inspection system includes discussions with hospitals about how they deal with whistleblowers and handle them.
Baroness Hayman (CB)
My Lords, I declare an interest as a member of the General Medical Council. In no way do I speak on its behalf today, but it is obvious from the remarks that the Minister has made that the GMC has been working with the Government and other regulators and is committed to underlining professional responsibilities, particularly in relation to the duty of candour. That work will, of course, continue. On a personal level, I welcome the return to naming the consultant and the nurse responsible for an individual patient. It is emblematic of that personal sense of responsibility and accountability for patient welfare.
In respect of the new complaints procedure, as the Minister said, the care of patients and their safety are the responsibility of not only the named consultant and nurse but everybody in that institution. Does he agree that there is also a particular responsibility on the trust’s non-executive directors in that respect and that the new system should ensure that they are taking their responsibilities seriously? I know from decades ago, when I chaired the complaints panel at a London teaching hospital, that that resource, in terms not only of the ability to protect patients but of improving efficiency and the quality of care by understanding complaints, was a treasure trove that should not be abandoned.
Earl Howe
I entirely agree with the noble Baroness, who of course has immense experience in these fields. I agree with her in particular about the role of the non-executive director. If an organisation has what may look like quite a high number of complaints, it should be regarded as a sign of openness, transparency and the right kind of culture in that organisation. It is only where suspiciously low numbers of complaints have been recorded that alarm bells should start ringing. I agree that boards of directors, led and encouraged in this area by the non-executives, should make it a central part of their business to analyse complaints and make sure that they have been followed through, not just that the matters have individually been remedied but that any systemic issue has been properly addressed.
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.
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.
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.
Health and Social Care (Amendment) (Food Standards) Bill [HL]
Earl Howe Excerpts(11 years, 7 months ago)
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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.
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?
Female Genital Mutilation
Earl Howe Excerpts(11 years, 7 months ago)
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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.
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.