Care Bill [HL]
Earl Howe Excerpts(12 years ago)
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Baroness Eaton
I endorse what the noble Baroness, Lady Howarth, has just said because I am firmly of the belief that it will take time to find all the appropriate people for the move which the CQC has clearly said it would make, from generic to specialist inspectors. I am sure that this will make a huge difference to the outcomes of inspections. I, too, think that we should give this organisation time. From what I have seen, it has the drive and the initiative to make sure that things improve enormously.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been a very useful debate and in addressing this group of amendments, it might be helpful if I began by setting out why we believe this clause is necessary.
At the moment, there is no straightforward way for members of the public to get a clear view of performance in hospitals and care homes, nor is there a measure to help drive up performance, so we believe that a new system is needed to give patients and the public a fair, balanced and easy to understand assessment of the quality of care provided. Clear ratings on performance will help to incentivise providers to improve their services, as they will be able to see how well they are doing. One of the central principles behind this clause is that it will enable the CQC to develop the new performance assessment system—informed by the views of stakeholders, of course, but nevertheless independent of government. In its report into ratings, the Nuffield Trust said:
“While there is a legitimate role for … government … to influence priorities, the process should largely be sector-led including the public and users”.
I am rather pleased that we did not debate this group of amendments on the previous Committee day because the CQC has, in the mean time, published a consultation on changes to the way in which it regulates, inspects and monitors care. I draw that to the attention in particular of the noble Lord, Lord Campbell-Savours, whose points I will address in a moment. This consultation, A New Start, sets out the commission’s initial thinking on the timetable for implementing ratings. The consultation document also sets out some detailed thoughts on how the CQC will rate NHS acute hospitals. I take the point made by the noble Lord, Lord Sutherland: this rating process will have to have some fundamental differences from that followed by Ofsted. However, the ratings will be based primarily on inspection judgments. They will be informed by a series of indicators, using data already available and the findings of other bodies such as those from accreditation schemes, clinical peer review and the judgments of other regulators. The CQC will be consulting on this model more fully later this year.
Noble Lords have raised concerns about the ability of a rating system to reflect the complexity of NHS acute hospitals. I assure the Committee that both the CQC and the Government are fully alive to this risk. The CQC is committed to producing ratings at a level which recognises the complexity of NHS services and is useful to people who use them, as well as those who commission NHS care. It is therefore proposing to provide ratings for certain individual services, such as emergency and maternity services, as well as for each hospital.
A rating will also be provided against each of the CQC’s key questions. They are: is the service safe? Is it effective? Is it caring? Is it responsive to people’s needs, and is it well led? This will mean that where the evidence is available, a trust would have five ratings at three different levels—for the individual service level, for the hospital site and for the whole trust. I am sure that noble Lords will agree that this is an ambitious aim, and one that seeks to reflect the complexity of the organisations that provide care.
The Government will draw up regulations that will enable the CQC to develop the programme of performance assessment in the manner outlined in A New Start. The consultation is the first small, but important, step in the process of developing a robust system of performance assessment of providers of health and adult social care. The first ratings of acute hospitals will appear at the end of this year: I will come on to the timetable in a moment. This will be another significant step in developing a ratings system, but it will not be the end of the journey. The Government are clear that the development of ratings will be a process of continuous evolution.
Amendments, 74, 75, 76ZA, 76ZZA and 76ZAA set out areas that the CQC must or could consider as part of its performance assessment of providers. These amendments would mean that the CQC would be required to include or consider the specific issues raised as part of its methodology. The Government share the view of noble Lords on the importance of the issues they have raised through these amendments. I am sure we can all agree that they are useful ideas. However, I hope that they will equally accept the importance of the central principle that we believe should be adhered to: that the CQC should be given freedom to develop its own methodology for the new performance assessments. The clause is deliberately designed to be flexible in that sense. I therefore hope that noble Lords will be content to withdraw their amendments, in the knowledge that the CQC is ready and willing to listen to all good ideas as it puts its final plans together.
The noble Lord, Lord Hunt, has also tabled Amendment 76ZB, which would require the CQC to undertake a pilot of its new performance assessment system and require the evaluation report to be approved by Parliament. The Government agree that the CQC’s new performance assessment methodology should be subject to evaluation. This is why, in our response to the Francis inquiry, Patients First and Foremost, the Government made the commitment that:
“The Department of Health will commission an independent evaluation of the operation of the new ratings system, and this will inform future adaptations”.
The amendment would give Parliament a power of veto over the methodology which the CQC develops for performance assessment. This is not desirable as it would constrain the freedom of the CQC to act on the findings of its consultation with stakeholders. I therefore hope that noble Lords will be content not to move that amendment.
Amendment 74A would require the CQC to undertake performance assessments of commissioners of healthcare services, specifically clinical commissioning groups and NHS England. The wording of Clause 80 could enable the CQC to undertake reviews of local authority commissioning of adult social care services. The absence of a similar requirement for healthcare commissioning therefore requires an explanation. The requirement for the CQC to review healthcare commissioning was removed by the Health and Social Care Act 2012 on 1 April 2013 when primary care trusts were abolished. This is because the function of supporting the development of the commissioning system for healthcare in England has become the responsibility of NHS England. NHS England’s role is to determine how the performance of healthcare commissioners, including clinical commissioning groups, is assessed and managed. There is therefore no need for the CQC to carry out a virtually identical role. I trust that the noble Baroness will be content to withdraw her amendment, but I would like to address the particular points raised.
Lord Hunt of Kings Heath
I do not quite see the logic of that, because in a sense NHS England has a vested interest in ensuring that all is well with the CCGs. It is not an independent body in the way that the CQC would be.
The other question is about NHS England itself. It is a massive commissioner of specialist services. If a local authority is to be assessed, I still do not see why NHS England ought not to be subject to some kind of independent assessment. It could have a huge impact on where specialist services are going to be provided in future. We know that Ministers are no longer prepared to answer questions about lots of things that NHS England does, so there seems now to be a gap in the architecture.
Earl Howe
Ministers most certainly are willing and able to answer questions about what NHS England is doing, and will continue to do so. Parliament, of course, will be entitled to keep NHS England’s performance in the spotlight; that architecture was built into the 2012 Act very deliberately. I do not accept the noble Lord’s point about clinical commissioning groups, because it is for NHS England to assure itself that the commissioning system for healthcare in England is working properly. There will be a high degree of transparency in that regard. The performance management role of NHS England will be right there, and I think that the proof of that will emerge over the coming months.
Perhaps I could cover the individual points raised by noble Lords. The first point was raised by the noble Lord, Lord Hunt, and echoed by the noble Lord, Lord Campbell-Savours, about how we expect the CQC culture to change in a relatively short time. I say to both noble Lords that I firmly believe that the CQC is already very much a changed organisation. It has a new leadership team in which I have full confidence. It has a new board—which, incidentally, the noble Lord, Lord Hunt, may be interested to know will include Kay Sheldon—and I think it has a new attitude to openness and transparency, as its handling of the Grant Thornton report demonstrates.
On 16 July, the CQC’s chief inspector of hospitals, Professor Sir Mike Richards, will start in post, so that is very soon. By September the CQC will be publishing a list of hospitals that it has the greatest concerns about, and it will be using its new surveillance system to develop this list. The CQC is committed to learning from the past and pressing ahead rapidly to improve for the future. I agree with the noble Baroness, Lady Howarth, that the CQC needs stability.
Lord Campbell-Savours
On the question of the surveillance system that the Minister just referred to, what about the proposal that keeps coming up all the time of two unannounced visits per year for every care home within the United Kingdom? Why can that at least not be set down by the Government as a requirement, irrespective of all the other recommendations and decisions that the CQC comes to over its new so-called surveillance system?
Earl Howe
It is not for Ministers to do that. I say that with great respect to the noble Lord. In saying that, however, I also highlight the ability of the CQC to flex its inspection frequency in accordance with information received. The noble Lord will know that organisations such as local Healthwatch, and indeed local authorities themselves, are able to alert the necessary authorities through Healthwatch England, which, as noble Lords know, is an integral part of the CQC, to any problems that may be flagged up. The CQC will be consulting in future on its proposals for care home inspections, and I do not doubt that a difference of view will emerge about the frequency of those inspections. I am the first to say how important it is that the inspections take place, and I totally take the point that those assessments should not be allowed to drift in any way. However, for better or worse we have an independent body known as the CQC, which should be allowed to act accordingly. The noble Lord, Lord Campbell-Savours, took us back to the 2008 Act. I would say to him that, in agreeing with the noble Baroness, Lady Howarth, Robert Francis was clear in his report that the system should not be significantly reorganised.
Lord Sutherland of Houndwood
Perhaps I may ask for clarification on one further point relating to complaints. Amendment 76ZZA does not propose that the CQC should handle complaints, which was the gist of the Minister’s response. Rather, it proposes that there should be a clear and transparent method of handling complaints within each trust and relevant area. The role of the CQC is to open up that window, very much in line with the Francis report, so that we can know that complaints will be handled at the appropriate level and in the appropriate way.
Earl Howe
I completely understand the noble Lord’s point. He will remember that in the registration requirements for providers of health or social care, the existence of a complaints system is one factor on which the CQC will need to satisfy itself. On the quality of the complaints-handling system within that provider, my answer is that it is a powerful point and an important area, but in the end it is one on which we should let the CQC decide as it develops its methodology. I do not in any way dismiss the noble Lord’s suggestion, but it is one for the CQC to take forward.
Baroness Pitkeathley
My Lords, this has been a wide-ranging and well informed debate. It has focused on anxieties about the role and competence of the CQC. The anxieties seem to focus on questions about whether the job of the CQC is doable at all, doable in the very short timescale, or doable with current resources. Suggestions about how to address the anxieties and concerns have included piloting new structures, but there has been much support for the CQC being given time to improve its strategy and performance—although with strong reservations from my noble friend Lord Campbell-Savours. I am grateful for the support for my amendments on integration, and sorry that the Minister was unable to accept them. Given the concern and strength of feeling about the CQC, I am sure that we shall return to this matter on Report. For the present, I beg leave to withdraw the amendment.
Lord Beecham
My noble friend is right to draw attention, as many of your Lordships already have, to the need to integrate the provision and to avoid the sort of cost-shunting that can arise if organisations are kept separate. That is the point of the pooled budget: you look not just at the straightforward provision of care by one or other partner, or both partners, but at what will perhaps reduce the need for care in other ways. As I say, other local services such as leisure and adequate housing, in conjunction with the public health agenda, may very well reduce the demand for particularly expensive forms of care, as I am sure we all agree.
Of course, local government’s track record is not uniform, but it is right to say that local government has proved over the years to be the most efficient part of the public sector. There has been a huge improvement programme in local government, recognised by the shortly to be lamented Audit Commission, and others, over the years. The LGA in particular has sought, through a whole series of policies, including the very extensive and successful use of peer review, to engender new approaches and more cost-effective ways of dealing with a range of problems, including those in the social care arena.
I was about to conclude by drawing attention to another figure, which has just emerged today. It is a rather startling figure: £9.8 billion of uncollected VAT—10% of the total take—according to today’s Guardian. That dwarfs the amount that the Government are putting into the new arrangements. Just as local government needs, together with its partners, to engender the utmost efficiency in the mechanisms that it develops to provide services and make them cost-effective, as my noble friend suggests, so on the revenue-raising side central government has a massive obligation to ensure that it collects the taxes—instead of cutting the resources going into HMRC, which is responsible for collecting VAT, by a further 5% in the spending review.
We do not consider the cost of £3.8 billion and the welcome money that the Government are going to provide to be the last word in these matters. There will have to be a continuing process of establishing programmes that are effective and cost-effective. Looking at the totality, there is scope within the system to prioritise this area, providing that the Government take the right decisions—across the piece, not merely on the narrow front of health and social care but considering the implications for other services and functions of government—and collect the money that they are due anyway and which would relieve the huge pressure on these services and others.
I have a good deal of sympathy with the concerns expressed by the noble Lord, Lord Best, but I share the view of the noble Lord, Lord Sutherland, that it would not be right to hold things up. We must get on, but in doing so we must be realistic about the challenges that will be posed to those responsible for delivering these services. I look forward to hearing the Minister’s response to the various questions that have been raised in the debate.
Earl Howe
My Lords, I do agree with the spirit of this amendment. It is critical that care and support generally, and these reforms in particular, are fully funded. Without adequate funding, they will not deliver the benefits we all want to see. However, let me reassure noble Lords that we already have full procedures in place to ensure that there is proper funding for social care.
The first and very basic point is that the Government set spending plans for all areas of public expenditure at once during a spending review. This ensures that decisions can be taken about the future funding requirements of government as a whole, rather than assessing each part piecemeal. The noble Lord, Lord Sutherland, spoke about the review of priorities being a task of government. I agree, and that is exactly what spending rounds are designed to do.
Secondly, we have the new burdens doctrine in place, which requires that,
“all new burdens on local authorities must be properly assessed and fully funded”.
That ensures that all new funding pressures, including those that result from this Bill, are fully funded. I can tell the noble Lord, Lord Best, that our commitments are in line with the new burdens doctrine, the costs have been identified in the impact assessment, and the funding in the spending round will support local authorities to deliver on current and future commitments through to 2015-16. To answer the noble Lord, Lord Campbell-Savours, yes, the work has been done.
It is only right that the Government take spending decisions for all areas of public expenditure at once. This ensures that future spending plans are drawn up which are coherent and consistent across all public services. This is exactly the purpose of a spending round, the latest of which concluded last week, as noble Lords know, and set spending plans for 2015-16. Fundamentally, this settlement delivers the funding required to ensure that service levels in the care and support system can be protected and are able to deliver on all the commitments in this Bill.
However, with additional pressure on the system, we must ensure that the Government, the NHS, local government and care and support services are all working together to offer the best possible services for patients while also addressing the growing demand on the system that the noble Lord, Lord Best, rightly referred to. That is why we have announced in this year’s settlement a £3.8 billion pooled health and care budget to ensure that everyone gets a properly joined-up service, so that they get the care and support they need from whoever is best placed to deliver it, whether that is the NHS or the local authority.
In 2014-15, the NHS will transfer £1.1 billion to support social care with a health benefit. The pooled fund will include £2 billion more through the NHS in 2015-16. But this money will be given only on the basis that services are commissioned jointly and seamlessly between the local NHS and local councils. I hope that that helps to answer the question posed by the noble Lord, Lord Beecham.
Lord Campbell-Savours
Before the noble Earl moves on, perhaps he can answer this question. Is he saying that the statistics that were used in the report by the Committee on Public Service and Demographic Change were known to the department and were all taken into account, and that the calculations the department made were based on those statistics, which were well sourced, when the budget for these areas was decided upon by the Government?
Earl Howe
The statistics that the Government relied upon were official statistics and, I think, were exactly the same as the statistics used by the report to which the noble Lord referred. Of course, that report takes us forward 10 and 20 years. I am not pretending that the spending round has done that—it never does and I think it is safe to say that it never will. But we did look forward in a rigorous way to the pressures on the system in 2015-16 and based our assessment on the statistics that are officially issued.
As all plans will be jointly agreed by the NHS and local authorities in the pooling arrangements that I referred to, that in itself will provide a strong guarantee that the money is spent in a way that delivers on the priorities of health as well as of care and support. Not only will this fund help to deliver joined-up services, it provides the necessary funding for all the commitments and duties set out in this Bill, and the growth in demand from an ageing population and growing number of disabled people—I say in particular to the noble Lord, Lord Rix, and the noble Baroness, Lady Campbell. In particular, funding worth £335 million has been set aside for the introduction of the cap on care costs and the extension of deferred payment agreements.
Lord Beecham
My question was not about the purpose of the pooling, which I think we all share. My question was rather more detailed. If part of the funding is to be based on outcomes, how and when is that to be judged? If the outcomes are not achieved, how will the money be reclaimed? All this is something of a mystery as matters stand.
Earl Howe
The details of the payment-by-results system will be worked through. We are working with our partners in the sector including the LGA and NHS England to ensure that the system is designed with a view to incentivising integration. Further details of those arrangements are in course and we will announce them as soon as we can.
The kind of things that we will be looking for are, for example, the results that we have seen in places such as Cheshire West and Chester. The pilots, the whole place community budgets, showed that savings from integration could be substantial if implemented effectively. A business case needs to be presented. In that context, the pilot suggested that, once proposals are fully implemented, the net savings that could be achieved over five years are considerable.
Cheshire West and Chester has made savings of £26 million, with £3.8 million for Greater Manchester, £190 million for the Triborough authorities and £90 million for Essex. These savings are being identified. It gives us confidence to say that there is real potential to save money across the country, as shown by the pilots and other reviews, such as the Audit Commission review. Oxfordshire recently announced that it was nearly doubling the amount of money in its pooled budget for older people. That is a significant move.
I agreed with much of what the noble Baroness, Lady Wall, said. Savings are eminently possible without detracting from quality, by slowing and preventing the development of care needs or the onset of health conditions, or the loss of independence. We hope and believe that preventive care can increase the quality of life for individuals. A proactive stance by local authorities will deliver that. At the same time, preventive care will provide longer-term financial savings to the public purse. For the first time, Clause 2 creates a clear legal duty on local authorities to ensure the provision of preventive services.
I come to the point raised by the noble Lord, Lord Campbell-Savours, about the Dilnot package. I do not view the Dilnot package in the same way that he does. I do not see funding reform as being about protecting people’s inheritances. It is about providing hard-working people with peace of mind about how much they will pay for their care. Deferred payments will ensure that people will not have to sell their homes in their lifetime to pay for care. That will prevent distressing sales of houses and provide everyone with breathing space to make decisions and choices about what happens to their home. In the long term, the scheme is broadly cost-neutral to government, because the deferred payments will be repaid. Everyone will benefit from these reforms, but they will particularly help people with modest wealth who are most at risk in the current system of losing their entire home and savings.
Delivering on these transformational changes to health and care is the only way to secure the long-term sustainability of services, both for the NHS and local authorities. I would be firmly against delaying this —I think we would be heavily criticised if we did. The noble Lord, Lord Bichard, referred to the burgeoning weight of regulation during the past 60 years and one cannot argue with the statistics that he produced. This Bill serves to consolidate more than 60 years of legislation; it will repeal provisions from more than a dozen Acts of Parliament. Reducing the complexity of the statute and rationalising burdens on local authorities are our key aims in this context. I hope that, for the reasons that I have outlined, the noble Lord, Lord Best, will feel sufficiently reassured to be able to withdraw his amendment.
Lord Best
My Lords, I am deeply grateful to all noble Lords who have spoken: to the noble Lord, Lord Bichard, for pointing out that we cannot keep loading responsibilities on local authorities and others without willing the means to pay for those things; to the noble Baroness, Lady Howarth, who said that we cannot go on like this; and to the noble Lord, Lord Rix, who explained the position from the Mencap perspective—it could have been that of many other charities which are facing very tough times because local authorities cannot keep up the level of support that they used to have. The noble Lord, Lord Campbell-Savours, produced more impressive statistics, not least in relation to the people with long-term conditions and dementia who are living in the community and need to fund their care needs. The noble Baroness, Lady Campbell, brought us the users’ voice, pointing out that funding cuts have already meant people losing some of the control and choice which had been increasingly expected with use of direct payments and so on.
The noble Lord, Lord Sutherland, pointed out that the culprit is not local government or central government but demography, and that we need to make some choices as a result of those demographic pressures. However, in his view, one of those priorities is clear: it is that we should go ahead with this Bill. The noble Lord, Lord Beecham, also felt that it would be unwise for us to delay things, even though he accepted that cuts mean that social services in Newcastle have returned to the position that they faced in 1973 in terms of the resources available. He pointed that it is local government that has shown itself best able to be more efficient in these difficult times. We need to remember that. The noble Baroness, Lady Wall, pointed out that local authorities should try to make savings wherever they can, and the noble Lord, Lord Beecham, was right that statistics show that local government is doing just that.
I think that it is fair to say that the noble Lord, Lord Bentham, felt that it was necessary to find additional resources, but he thought that those could be found from the underspend in the NHS or the uncollected VAT or some other source. However, he did not want the amendment to delay the good things that the measures bring with them. The noble Earl, Lord Howe, agreed that we need fully to fund the measures—did I say Bentham?
Baroness Greengross
My Lords, I support Amendment 78ZA. Six years of serving on the Equality and Human Rights Commission taught me that if we embedded dignity and respect into the training of staff we would avoid many of the tragedies we have read about. This applies, right across the board, to staff in health, social care and housing. It is essential that we take dignity and respect as very serious elements of the training of all staff who come into contact with frail and vulnerable people.
Earl Howe
My Lords, the well-being principle in Clause 1 was devised on the basis of the Law Commission’s report on adult social care which this part implements. The report recommended that the new statute should set out a single, overarching principle that adult care and support must promote or contribute to the well-being of the individual. Not least in the light of our debate at Second Reading, I can therefore understand the noble Lords’ intention in tabling Amendments 78 and 79. It is to ensure that any functions that the Secretary of State exercises under this part take into consideration how such provisions will impact upon people’s well-being. I can give the Committee what I hope will be a welcome reassurance on that issue and, in the process, a rather better and fuller answer than I gave at Second Reading.
It is already the case that the Secretary of State must have regard to the general duty of local authorities to promote an individual’s well-being when making guidance or issuing regulations. This is because, when making regulations or issuing guidance, the Secretary of State must consider how local authorities can fulfil their statutory obligations. He cannot ignore those obligations and I believe this addresses the central concern of the noble Lord, Lord Hunt, and others who have spoken to the amendment. The question is whether the Bill should go further. The Government do not believe that it is appropriate to apply the well-being principle directly to the Secretary of State. The well-being principle is intended to apply at a very real, individual level. It has been designed to frame the relationship that exists between the local authority and the individual adult, in effect setting out how it is expected the local authority will behave when making a decision, or doing anything else, in relation to a person needing care and support or to a carer. The Secretary of State does not act at this individual level, and I am still reluctant to make any amendment which might be seen to detract from this important legal reform.
Having said that, I have listened with care to the strength of feeling in this debate, not least to the point made by the noble Baroness, Lady Pitkeathley, about the Secretary of State’s duty to have regard to the NHS constitution and whether there was something comparable that we could devise in this context. That is an interesting comparison and, while I am not yet convinced that it is fully comparable, I am happy to take the points that have been made away with me and give this matter further thought before the next stage of the Bill.
Amendment 78A seeks to bring in to the well-being principle the idea of spiritual well-being and I listened with care to my noble friend Lady Barker who spoke to this amendment. The Government believe that the clause, as it is already drafted, takes such a factor into consideration. Clause 1(2) sets out that well-being means an individual’s well-being in relation to emotional well-being. The Government believe that emotional well-being incorporates the concept of spiritual well-being.
I turn to Amendment 78B, which proposes that local authorities must take into consideration an individual’s beliefs, values and past practices. While we share my noble friend’s intention in this regard, we believe that the clause as it stands already incorporates the idea that people’s beliefs and values should be taken into account when a local authority has regard to an individual’s views, wishes and feelings.
The second part of the amendment would be to ensure that “past practices” were also taken in account. I reassure my noble friend that we will be setting out in guidance the importance of taking into consideration, when planning a person’s care, their views and feelings as well as considering any practices in the past that have been important to that individual.
The noble Lord, Lord Bichard, highlights the importance of dignity in care in his Amendment 78ZA, and he spoke about that concept very powerfully. I am pleased to say that the Government agree that this is important, which is why we amended the Bill to make an explicit reference to dignity into the well-being principle, following pre-legislative scrutiny. With respect to the noble Lord, I cannot agree with him that the word has somehow been lost; it is right there on the page.
I turn to Amendments 78E, 87K and 88J, tabled by my noble friend Lord Black of Brentwood. These amendments focus on the very important topic of pets. The Government have considered this issue carefully since the amendment was tabled, and we believe that the Care Bill already allows for the consideration of pets. First, Clause 1, the well-being clause, provides that local authorities, when exercising any function under Part 1 of the Bill, have a duty to promote the well-being of an individual. Well-being is composed of many aspects, including emotional well-being. A pet might be so important to an individual that their emotional well-being would depend in some way on their pet. If that is the case, a local authority will have to take it into consideration.
Furthermore, Clause 1(3)(b) sets out that in exercising any function under Part 1 of the Care Bill a local authority must have regard to an individual’s “views, wishes, and feelings”. This could include how an individual feels about a pet, and their wishes for the pet. Clause 9, which covers the assessment of needs for care and support, also allows scope for pets to be taken into consideration in the assessment process. As Clause 9(4)(a) sets out, a needs assessment must take into consideration a person’s well-being. This could certainly include an individual’s pet, from which they derive a lot of emotional well-being.
I turn to Amendments 78D and 88L. The Government believe that it is more important than ever that care and support services operate in tandem with health services. The Government have committed to breaking down barriers between health, care and support, as well as encouraging co-operation, integration and joined-up working between local partners. The Government believe that the Care Bill already allows for such co-operation to occur, and I shall explain how. First, Clause 1(2)(a) makes it clear that the well-being principle incorporates physical and mental health. Local authorities must therefore already consider a person’s health when exercising any functions under Part 1. Secondly, Clause 3 details how local authorities must exercise their functions under Part 1 with a view to ensuring the integration of care and support with health provision, where they consider that this would promote the well-being of an individual.
Regulations on assessments for care and support are also relevant. As Clause 12(1)(f) sets out, regulations may set out when a local authority must consult someone with expertise before undertaking an assessment. Regulations may also set out conditions around co-operation with the NHS, by specifying the circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare.
The noble Lord, Lord Hunt, expressed the view that the eligibility regulations do not sufficiently promote integration. I note the point that he made and look forward to debating this in perhaps fuller measure when we come to discuss eligibility. However, I ought to point out that the draft regulations published last week are subject to consultation, and I am sure that the discussion will explore the points that he made.
My noble friend Lady Tyler said that the regulations do not mention dignity specifically. I think that they have to be read in context. The well-being principle, including the reference to dignity, applies to the assessment of the adult’s needs and to the local authority’s determination of whether those needs are eligible.
To return to my noble friend Lord Black’s amendment on companion animals, we are clear that there should not be any limitations on the uses of direct payments, which was an issue that he raised, as long as they are used to meet needs for which they are paid and not in a way that is unlawful. The key is that direct payments are used to improve people’s outcomes.
I understand the intentions of noble Lords in tabling these amendments but I hope that they feel reassured that they are not necessary, although I will take back the specific issue that I referred to earlier. In the light of that, I hope that the noble Lord, Lord Hunt of Kings Heath, will feel able to withdraw the amendment.
Baroness Masham of Ilton
Before the Minister sits down, I would just like to ask him: does he not really want to get things right? When there were problems at Mid Staffordshire, people were desperately thirsty, drinking out of flower vases, and were lying in their own refuse in their beds. Surely dignity must be written in all over the Bill.
Earl Howe
I agree that dignity is a very important concept, which is why we expressly amended the Bill to include that word right at the beginning. Clause 1, which defines the well-being principle, is the foundation for everything that follows. While one could pepper the Bill with references to the word “dignity”, I am not sure that that would add very much in practice.
Lord Hunt of Kings Heath
My Lords, I am grateful to the Minister for that response. I hope that he will reflect a little on the amendment from the noble Lord, Lord Bichard, and the noble Baroness, Lady Tyler. I understand what he is saying about the words in the Bill; I think that noble Lords just wanted to find a way of giving that greater focus. That will be well worth giving further consideration to. With regard to the amendment from the noble Baroness, Lady Barker, I am grateful for the reassurance that the Minister has given.
On Amendments 78 and 79, the Minister has essentially said that he still sticks to the general principle that the well-being clause applies to local authorities and individuals. The point here, though, and the reason why I am glad he is taking it away, is a point raised by a number of noble Lords: this legislation, which is a wholesale recasting in the light of the Law Commission’s work, is likely to endure for many years to come. That is why it is so important that the link between the Secretary of State’s duties, and those of local authorities, and the Secretary of State’s powers regarding guidance and regulations are brought together. I hope that the Minister will find a way of getting this into the Bill.
The noble Baroness, Lady Campbell, was very eloquent when she talked about what happens if health and social care do not provide an integrated service. She gave an example of a very distressing case of someone who could be out of hospital and back into work. This was down to a failure of two public bodies to sort things out. I know that the Minister says that in fact the legislation is okay; the problem is that these public bodies will continue to fail people who fall between two stools. These bodies do not seem to have an understanding that it is imperative for them to look after the interests of those individuals. I hope that the noble Baroness might return to this at a later stage.
The noble Lord, Lord Black, made some wholly persuasive arguments. My noble friend Lady Wheeler reminded me that Canine Partnerships is another organisation that is very much involved in pet companions for people with stroke, epilepsy and other illnesses. I myself have come across organisations in Birmingham in connection with the health service that do a fantastic job. All I would say is that if the noble Lord put this to a vote, the Opposition would be right behind him, so let us see. I beg leave to withdraw the amendment.
Health: Diabetes
Earl Howe Excerpts(12 years ago)
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Lord Harrison
To ask Her Majesty’s Government what assessment they have made of the quality of healthcare available to diabetics with eye problems.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we have set clear objectives for the NHS and Public Health England to improve the care and quality of life for people with diabetes. The public health outcomes framework includes an indicator on preventable sight loss, which will track three of the commonest causes of preventable sight loss, including diabetic retinopathy, to drive improvements in quality.
Lord Harrison
My Lords, given the decline in the regular and important annual check-up for diabetics, does the Minister acknowledge that the retinopathy screening for diabetics introduced by the previous Government is being undermined and underresourced? On cataract operations, will the Minister explain why, among our European Union colleagues, we are the most demanding regarding the threshold required to have such operations? Given the importance of cataract operations, especially for older people in retaining their vision, will the Minister meet me and other colleagues to discuss these matters and allied subjects?
Earl Howe
I would be happy to meet the noble Lord. I am aware that the whole area of the cataract threshold and, perhaps more importantly, the interpretation of that threshold, is one that NHS England is now actively looking at to ensure greater consistency around the country.
I do not agree with the noble Lord’s interpretation of the screening figures. The UK countries, I believe, lead the world in the area of diabetes eye screening. This is the first time that a population-based screening programme has been introduced on such a large scale. The latest figures show that up to March 2013, 99% of people with diabetes who were eligible for screening were offered it in the previous 12 months.
Baroness Finlay of Llandaff
My Lords, given the importance of prevention, have the Government been monitoring the progress of access to insulin pumps for children with diabetes, in order to prevent eye problems later in life, given that they have better control with insulin pumps?
Earl Howe
My Lords, that tends to be a matter for provider trusts, working in conjunction with clinical commissioning groups. I am aware that there is concern about the variability of access to insulin pumps. Of course, they are not a universal remedy for every diabetic patient, but where they are appropriate they should be commissioned. If I can give the noble Baroness the latest information on that, once I have consulted NHS England, I would be happy to do so.
Baroness Jolly
My Lords, the House has heard that eye screening is critical for those with diabetes. As the national screening programmes are now commissioned by NHS England on behalf of Public Health England, and while diagnostic and treatment services are commissioned by clinical commissioning groups, will my noble friend tell the House what challenges these arrangements pose to the patient when trying to assess quality?
Earl Howe
The key thing here is for NHS England, Public Health England and local commissioners to work closely together, which is indeed what they are doing, so that the patient experiences a seamless service. Essentially, the new commissioning arrangements for national screening programmes enable effective commissioning and oversight of the whole screening pathway, alongside integrating those with the diagnostic and treatment services. To ensure a quality service, local programmes are assured by NHS screening programmes’ quality assurance teams and services are measured against 19 standards.
Lord Low of Dalston
My Lords, I declare my interest as vice-president of RNIB. The Minister will be aware that NICE has recently approved the use of Lucentis as a treatment for those suffering from diabetic macular oedema. We are hearing reports from various parts of the country of queues building up of people requiring treatment for diabetic macular oedema. Will the Minister undertake to do his best to ensure that the necessary resources are put in place to relieve these backlogs and enable people to benefit from this new treatment that has now become available?
Earl Howe
My Lords, I am aware of the issue that the noble Lord raises. He will know that NHS commissioners are statutorily required to fund clinically appropriate drugs and treatments which have been recommended by NICE. The Centre for Workforce Intelligence has been commissioned to review the ophthalmology medical workforce after discussions were held between the royal college and Health Education England earlier this year. That review is due to report in the summer and the results of it should, I hope, point the way to a resolution of the issue that the noble Lord has raised.
Lord Collins of Highbury
My Lords, as a type 2 diabetic, I benefit from annual retinal check-ups at UCH; it is an excellent service. However, despite there being a national screening programme, there is a large variation in take-up, which in some areas is as low as 65%. What steps are the Government taking to ensure a higher and more consistent take-up?
Earl Howe
In the end, accepting the offer of screening is a matter for each individual. There are some people who, for personal reasons, will choose not to take up the offer. However, as part of the process of continuous improvement, we would expect the gap between the number of people offered and the number of people receiving screening to reduce, and for there to be greater consistency in numbers offered and received across local screening programmes.
NHS: Association of Medical Research Charities Report
Earl Howe Excerpts(12 years ago)
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Baroness Wheeler
I, too, congratulate my noble friend Lord Turnberg on securing this debate, especially his timing following hot on the heels of our scrutiny of the Health Research Authority under the Care Bill. My noble friend is a much respected and tireless champion for research and innovation, leading to improved quality care for patients, and we in our party rely strongly on his expertise and support.
My noble friend and other noble Lords from across the House between them ensure that the importance of research and innovation to the NHS is kept to the fore, by this debate and, for example, in recent debates by the noble Lord, Lord Kakkar, on the impact of the EU healthcare in the UK and the concern over the UK losing its global allocation of clinical trials, and in the powerful debate earlier this year of the noble Lord, Lord Saatchi, on medical innovation, which reinforced the need to deal with the regulatory burden, to which noble Lords have referred, and to speed up the availability of innovative treatments.
Like other noble Lords, we welcome the progress on speeding up research approvals made by the HRA through the single portal of entry and single application procedure and bringing together the various research ethics committees. However, the point about the need for progress in getting the local R&D committees of NHS trusts singing from the same hymn sheet is well made and I look forward to the Minister updating us on the action that the Government are taking.
Like other noble Lords, I congratulate the AMRC on its excellent report and the accompanying survey of healthcare professionals’ views on the importance of research to the NHS and to staff working for it. Under the Care Bill, the need for Health Education England to ensure that research and innovation are incorporated into education and training for healthcare staff was a major theme, echoing the Joint Select Committee on the Bill on this issue. All NHS staff need to be able to make use of research throughout their careers and should be equipped with the tools to understand and support research and to assess and use evidence to inform their decisions when caring for patients or supporting clinical staff.
As noble Lords have pointed out, the association’s survey showed the challenges to be faced. The good news was that staff overwhelmingly recognised the value and importance of research, but the barriers to taking part in research, identified by the majority of staff surveyed, including doctors and nurses, was deeply worrying. It is clear that these barriers of lack of time, problems over funding and support and the difficulties of navigating regulation have to be overcome, particularly the need to develop stronger support among GPs to become personally involved in research. After all, they are such an important gateway to spreading the message to get patients interested and involved in research. As my noble friend put it, there is still much to do at the coal face. This is where the ARMC report is so valuable. It offers an authoritative but very practical vision of how the goal of having every clinician a researcher and every willing patient a research participant can be progressed and achieved, as well as how the leadership and support that the NHS staff need can be developed and built into a service-wide research culture.
The case studies in the report are particularly informative, providing examples of excellence and best practice in cancer, arthritis and other key research areas of patient consultation and involvement, and of building staff support and confidence about participating and using research findings so that they can show their patients the benefits of them taking part.
In the context of this debate it is important also to reflect on the progress being made on the UK life sciences and the innovation, health and wealth strategies, the central aim of which is for innovation to become the NHS’s core business. No one reading these reports and the recent one-year reviews can be in any doubt of the dramatic pace and scale of change in the medical and life sciences, such as the breakthrough in genomic medicine, which is changing fundamentally the way disease is diagnosed, prevented and treated, and the progress on regenerative medicine, which are all breathtaking to a lay person such as myself.
There are important developments on the service side, too, as part of the high impact innovation programme, such as in wheelchair design. Can the Minister update the House on progress on implementing the strategies? I could not find any details on the website about further review reports or of the Government’s response to the MHP Communications review of the strategies, which charted good progress but also some continuing problems, including implementation of NICE technology appraisals by NHS trusts and the poor level of awareness of the IHW strategy; only 30% had discussed the strategy at board level. How are these issues being addressed?
Finally, on the association’s vision, I would reinforce the need to keep our foot on the pedal to ensure that we continue to be a world leader in clinical research. We must ensure that CCGs in the absence of SHAs and PCTs continue the focus on research and do not allow it to diminish. The AMRC vision highlights the need for leadership and guidance to CCGs to promote research; to encourage NHS managers so that they understand the value of research and actively support it through their management decisions and processes; and to ensure that all parts of NHS support research, including primary care and all non-NHS providers. I look forward to the Minister’s response updating the House on the Government’s actions to ensure that real progress is made on all these fronts.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Turnberg, for having tabled this debate. He has spoken with both authority and passion about Our Vision for Research in the NHS, the report by the Association of Medical Research Charities. The Government welcome the report; it is a challenging and insightful contribution to the debate on optimising the research potential of the NHS.
It is now more than seven years since the National Institute for Health Research was established in April 2006. The NIHR has a wide-ranging role that is central to our debate today. It provides the framework through which the Department of Health can position, maintain and manage the research, research staff and research infrastructure of the NHS in England as a national research facility. Indeed, together, NIHR people, facilities and systems represent the most integrated clinical research system in the world—driving research from bench to bedside for the benefit of patients and supporting economic growth.
My noble friend Lady Sharp referred to the importance of clinical trials, and of course, that is centre stage for the NIHR. As a result of the NIHR, large numbers of patients have the opportunity to take part in research. In the past financial year, more than 630,000 participants were recruited to trials and studies hosted by the NIHR Clinical Research Network Portfolio, and more than 99% of NHS trusts were involved in the recruitment. During the whole of 2013-14, the NIHR is promoting the fact that, “It’s okay to ask” about clinical research. We want everybody to get involved—patients, medical professionals and the public to support the campaign.
In March 2013, the Government published the revised NHS constitution, which contains a pledge to inform patients of research studies in which they may be eligible to participate. The pledge aims to give people better access to the potential benefits of participating in research studies, including clinical trials. We have already improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I just say to the noble Lord, Lord Aberdare, who spoke very powerfully about pancreatic cancer and the need to enlist more patients into trials for that condition, that the launch of the gateway was promoted through leaflets and other printed materials, including postcards and posters, and the gateway is also being actively promoted by INVOLVE, which is the NIHR-funded patients and public involvement body. In the course of just one month, May of this year, there were 11,570 visitors to the gateway website. Although not all of them will be related to pancreatic cancer, I hope that that gives an indication of the powerful influence that we hope the gateway will have in alerting patients to relevant studies.
Crucial to all this activity is the need to both protect and promote the interests of patients and the public in health research. That is why we established the Health Research Authority in 2011, and provisions in the Care Bill will give it added stability and independence. To my noble friend Lady Sharp I would say that the HRA has a programme of work to enable the implementation of a unified approval process and to support the authority in promoting consistent and proportionate standards for compliance and inspection. The programme includes a feasibility study with a number of pilots to test the effect of rationalising and combining elements of NHS study-wide review with elements of the research ethics committee review into a single HRA assessment. The findings are expected to identify and show how to release the potential to improve both study set-up times and the quality and consistency of ethical review.
The noble Lord, Lord Kakkar, very helpfully acknowledged that enactment of the Health and Social Care Act is a milestone for research in the NHS. It recognises the need to promote research and the use of research evidence and created unprecedented powers and duties at all levels to meet that need. The Government’s mandate to the NHS Commissioning Board—now NHS England—sets an objective to ensure that the new commissioning system promotes and supports participation by NHS organisations and patients in research funded by both non-commercial and commercial organisations, most importantly to improve patient outcomes, but also to contribute to economic growth.
The noble Lord, Lord Kakkar, specifically asked how CCGs will be held to account. The mandate asks for demonstration of progress against the five domains and all the outcomes indicators in the NHS outcomes framework. The framework document emphasises that vital to the quality and delivery of these outcomes will be continued research and the use of research evidence in the design and delivery of services at a local level.
NHS England welcomes the vision for research set out by the AMRC and shares its aspirations to empower patients to take part in research; to engage clinicians and other NHS staff; and to implement research findings to lead to better outcomes for patients and the public. Although NHS England is a new organisation, the NHS—as I do not need to tell the noble Lord, Lord Turnberg—has a strong existing culture of research, although we want to strengthen that culture. There is a wide wealth of research activity already taking place and considerable expertise within organisations. However, NHS England recognises there is further work to do to ensure that all NHS commissioning staff embrace a research culture, which was the theme of my noble friend Lord Saatchi’s excellent contribution, that they have access to research evidence and use it to inform commissioning decisions. It has recently recruited a team to lead the research agenda and develop and implement its research strategy. It is anticipated that a draft strategy will be in place by autumn this year, when extensive consultation with key stakeholders and partners, including patients, will be undertaken.
The noble Lord, Lord Turnberg, and my noble friend Lady Sharp rightly referred to the vital role of clinical commissioning groups within the new system. Through their formal declaration of compliance, all these groups have confirmed that they understand and will comply with their statutory responsibilities regarding promoting research. They have also confirmed that they are committed to following the policy of ensuring the NHS meets the treatment costs for patients taking part in research funded by government and research charity partner organisations. Alongside NHS England, Health Education England has responsibility for promoting high quality education and training that is responsive to the changing needs of patients and local communities. It will work with stakeholders to influence training curricula as appropriate.
HEE will work to build a workforce that is research-literate, with the skills and confidence required to diffuse the latest ideas and innovations. HEE will establish mechanisms to ensure that ongoing engagement takes place with a wide range of partners. This will include building relationships with academic health science networks and academic health science centres to align education with research and innovation. The noble Lord, Lord Turnberg, referred to the role of LETBs, which are responsible for commissioning education and training and securing quality and value from education and training providers. Indeed, they will need to ensure that the education and training that they commission is in line with national objectives, which include building a flexible workforce that is receptive to research and innovation. HEE and the LETBs are working with the NIHR to ensure appropriate investment in education and training, to develop clinical academic careers and to increase the number of staff accessing academic careers programmes across all clinical and public health professions.
I say to the noble Lord, Lord Rea, that the NIHR supports a wide range of programmes for research training and career development. The purpose of these is, self-evidently, to create the next generation of researchers focused on people-based research. The programmes provide support for the academic training paths of all healthcare professionals and other key disciplines involved in health and social care research, including, importantly, general practice. The NIHR is actively building research in general practice—for example, through its School for Primary Care Research. Through its integrated academic training programme, the NIHR has already taken a lead in reversing the decline in clinical academic careers.
The noble Lord, Lord Turnberg, spoke about investing in research, and of course I very much identify with the need to do that. As part of the commitments announced by the Government yesterday to invest in Britain’s future, the department will provide £150 million of capital investment in 2015-16 to fund health research infrastructure in the areas of dementia, genomics and imaging.
As regards clinical excellence awards and the consultant contract, discussions are ongoing between the UK government health departments, NHS employers and the BMA about changes to the consultant contract. The aim is to agree a heads of terms next month and to move to detailed negotiations. I will write to the noble Lord with further details about that.
My noble friend Lord Selborne spoke very powerfully about data from the NHS. One million people have some form of contact with the NHS every 36 hours. That produces, as he rightly said, a staggering amount of data, which can be used to drive forward research into new treatments. The NHS is in a unique position in that sense. We can draw on linked datasets on a scale unprecedented elsewhere in the world. Provided that we ensure confidentiality and privacy for individual patients, the opportunities for research and innovation are vast. In April last year, we established the Clinical Practice Research Datalink, which enables access to anonymised patient records to support the development of novel treatments. I can reassure the noble Lord, Lord Turnberg, that the CPRD is working with the NIHR primary care research network to recruit more GP practices to contribute their data to the CPRD’s data assets.
The clock is moving against me, so noble Lords will have to forgive me if I do not cover all their questions today but I undertake to write to those noble Lords whose points I have not covered—and there are many. I hope that the noble Lord, Lord Turnberg, in particular, has gained a sense of the importance that the Government attach to promoting research in the NHS, and a sense that we need, and have, a whole-system approach to this agenda, which is so vital for the future health and prosperity of our nation.
NHS: Mid-Staffordshire NHS Trust
Earl Howe Excerpts(12 years ago)
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Lord Monks
To ask Her Majesty’s Government what steps they are taking to issue guidelines about public statements by NHS executives following the announcement of reviews of hospital care launched following the Francis review into Mid-Staffordshire NHS Trust.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in the context of Mid Staffordshire, it is right that prompt action is taken whenever there are concerns about patient safety. We agree that there is a need for an authoritative voice on the quality of hospital care in the NHS. In future, the CQC, through its new Chief Inspector of Hospitals, Professor Sir Mike Richards, will play this role and provide expert judgment.
Lord Monks
I thank the noble Earl for that reply. I can well understand and share the nervousness, as does the whole House, about some NHS managements after the disasters of Mid Staffs and now Morecambe Bay. Does the noble Earl agree that it is important to avoid a lurch to the other extreme with a sort of shoot first and ask questions later culture? Does he further agree that there have recently been some instances of such a trigger-happy approach at Bolton and Leeds hospitals? In those cases the falsely accused were later completely exonerated. What steps can be taken to avoid panicky reactions which cause destabilisation and demoralisation in important parts of the NHS?
Earl Howe
I agree with the noble Lord’s general point that it is important to avoid oversensationalising or exaggerating a situation. I am not aware that official NHS spokesmen have been guilty of that in either of the two cases that he refers to. If there is cause for concern about any aspect of the NHS, it is surely right that that concern is made public. The important thing is for those public statements to be balanced and authoritative. That will be one major advantage of having as Chief Inspector of Hospitals a professional who is as widely respected as Professor Sir Mike Richards.
Lord Walton of Detchant
My Lords, is the Minister aware that, many years ago, the General Medical Council imposed on registered medical practitioners an obligation to report any serious deficiencies in practice or other serious failings which they observed on the part of medical colleagues? It was a kind of medical whistleblowers’ charter. Bearing in mind what happened not only in Staffs but in Furness hospital in Cumbria, is it not time for a similar formal obligation to be imposed on executives and managers in the NHS and in relevant bodies such as the Care Quality Commission?
Earl Howe
My Lords, the noble Lord raises a very current issue. As he will remember, we have introduced a contractual duty to raise concerns. We have issued guidance to NHS organisations on that subject. We have also strengthened the NHS constitution to support staff in the NHS and in social care on how to raise concerns. There is a free helpline to enable them to do that. We are considering in the context of the Care Bill the whole issue of the duty of candour. I feel sure that the noble Lord will make a valid contribution to that debate.
Baroness Jolly
My Lords, communication of complex issues is a vital part of any press department’s role. Will my noble friend the Minister tell the House how large the press teams within the Department of Health and NHS England are, how much they cost the taxpayer and how their effectiveness is managed?
Earl Howe
My Lords, the latest figure that I have for the cost of the Department of Health’s media centre is for 2011-12 and is £2.57 million. I will write to my noble friend as soon as I have more recent figures. She may be interested to know that the names and contact details of each of the department’s press officers are published on the GOV.UK website. Currently, 28 Department of Health press officers are listed there. I do not have to hand the details of the number of press officers employed by NHS England, but, again, I shall write to my noble friend with that information. In the department and in NHS England, internal line management arrangements are in place to measure performance.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. I was very interested in the Minister’s first response, in which he agreed that oversensational statements about the NHS are doing great damage. Has he shared that view with his right honourable friend the Secretary of State? Hardly a day goes by without the Secretary of State taking an opportunity to attack various aspects of the National Health Service. Will he take it from me that this is having a very bad effect on morale in the NHS? His right honourable friend should desist, and a period of silence from him would be very welcome.
Earl Howe
The question surely is whether my right honourable friend is saying things that are true. My judgment is that he is very near the truth, if not spot on. Most people will ask themselves whether it is the Department of Health or the press which oversensationalises things. I think I know the answer to that.
Lord Mackay of Clashfern
My Lords, in considering the way forward in inspections, might not prominence be given to local inspection systems? After all, a national system cannot be in all the places at once, whereas local people can see what is going on in their local area. There might be something to be said for strengthening that aspect of the inspection system.
Earl Howe
My noble and learned friend makes an important point. Of course, that will be the virtue of local Healthwatch, which will be the eyes and ears of the local community in a particular area. We have also strengthened the role of governors of foundation trusts, whose job it will be to have an equally up-to-the-minute view of their organisation’s performance.
Baroness Wall of New Barnet
My Lords, I want to reinforce the message put to the Minister this afternoon and tell him what it feels like at the sharp end of the health service. Both my noble friends who have spoken echoed the comments—misquoted or otherwise—made by the Secretary of State. Those comments have caused absolute fear and I am not exaggerating. We had the CQC at our trust on Friday. Our regional person for the CQC is fantastic, the CQC’s reporting is really good and, as noble Lords know, I am supportive of it. However, will the noble Earl please ensure that the messages stop? These people carry out a really important job and if we stop believing that what they do matters, then I do not know where we go. Can we please make sure that the reinforcement of the CQC, with new people involved, will make a difference?
National Health Service (Direct Payments) (Repeal of Pilot Schemes Limitation) Order 2013
Earl Howe Excerpts(12 years ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in 2009 we debated piloting direct payments for healthcare as part of the wider personal health budget pilot programme. Personal health budgets allow people to have choice and control over the care and support that they receive. A care plan is drawn up between individuals and their healthcare professionals, which is person-centred and designed to allow them to access care that works in the best way for them. It is already possible to offer personal health budgets where the money is held by the NHS or by a third party, but direct payments would allow personal health budgets to be held by the individual in the form of cash sent directly to their bank account, albeit one separate to their own personal funds.
Direct payments—and, indeed, personal health budgets more widely—are new to the NHS and we wanted the pilots to explore whether they would be beneficial. We wanted to find out which people and services were likely to benefit most and how we should implement them in order to get the best results. The pilot programme ran from 2009 to 2012 and I am delighted to report that the independent evaluation of that programme supports the wider use of direct payments in healthcare.
I will spend a few minutes talking about what the evaluation and the learning from the pilot programme tell us about direct payments for healthcare and personal health budgets more widely. The evaluation demonstrated that personal health budgets were most beneficial for people who had higher levels of health needs. In particular, it identified benefits to people with long-term physical or mental health conditions and disabilities who access the NHS most frequently. For these people, having real choice and control over how to manage their budget to meet their individual needs is a key factor in how they handle their own condition and improve their quality of life.
The most important element of our debate today is the discussion around whether we should take a step further and allow direct payments for healthcare as a new option for people who have or want personal health budgets, building on the success of the pilots. If the House agrees with the principle, secondary regulations, which will be laid before the Summer Recess, will set out the rules for the making of direct payments for healthcare.
The current debate focuses on direct payments for healthcare because this is the only part of the personal health budgets policy that requires legislative change. The other two ways to manage personal health budgets, where money is held by the NHS or alternatively by a third party, are currently lawful. However, direct payments for healthcare are a great deal more than money in lieu of NHS services. They are designed to allow people more flexibility and control over how their health needs are met.
The pilot programme showed that the success of direct payments for healthcare is dependent on good-quality, personal, holistic planning. The secondary regulations set out that individual care plans must be agreed before a direct payment can be approved. Importance is placed on the development of the plan being led by the individual or their carers, or a collaboration of both, using the right information and support. It should bring together their knowledge and experience of what works for them alongside clinical knowledge and expertise. The role that healthcare professionals play is still vital, but the conversation between the individual and specialists involved in their care should be a different, more real partnership.
So where does the NHS constitution fit into all this? It is vital, as we are absolutely clear that the budget must meet the full cost of the care and support agreed in the plan. NHS care provided through a direct payment for healthcare remains comprehensive care, free at the point of delivery, based on need rather than on ability to pay. This means no top-ups.
In the vast majority of cases, direct payments for healthcare will continue to be used on traditional care and support. However, a personal budget will give people the freedom to set arrangements that work for them. For example, people will be able to employ their own carers. In these circumstances, they will have greater control over who comes into their home, when they are scheduled to come and what tasks care staff perform. This can make a real difference to people’s lives and to their families’ lives by encouraging them to organise care that is more appropriate for their needs and the lifestyle they wish to lead. It is crucial to note, however, that direct payments for healthcare are not about new money; they simply allow people to use money already being spent on their care in a different way.
The NHS provides a huge range of care, support and treatment, and it would not be appropriate to include all NHS services in direct payments. Secondary regulations will set out what services should be excluded from a direct payment for healthcare. These will include, for instance, GP services, as we believe that disruption to the holistic care currently provided by a GP would be detrimental.
In addition, we do not think that it is appropriate to include the costs of unplanned care in a direct payment for healthcare. This would include things such as a visit to accident and emergency or admissions to hospital. However, it is important to point out that the evaluation of the pilot programme suggests that people with personal health budgets use secondary care services less. We are therefore confident that there is merit in giving people budgets to help them access care and support which works for them and prevents their unnecessary admission into hospital. Everyone will be able to reap the benefits as individuals will experience a more infrequent need for acute care and the overall cost of care for each individual will decrease, meaning an overall saving to the public purse.
Another area where we do not think that the use of direct payment for healthcare would add value is payment for medication. Deciding what medication an individual requires is a core responsibility of GPs and it should remain that way. This is currently dealt with using a two-stage process whereby a GP gives a prescription and pays for the cost of the medicine, and the individual then contributes with their prescription fee. We do not believe that direct payments should be used for either stage, or for any other area where NHS charges apply.
There may be concerns surrounding the proper or improper use of funds, or people’s needs not being met. In order to monitor this, there will be periodic reviews to ensure that the care and support being delivered are meeting the individual’s needs. In the case of direct payments for healthcare, these reviews will include a financial review to ensure that the money is being used appropriately. The details of what the review should entail will be set in the secondary regulations and explained to the individual as part of the care-planning process.
The evidence from the pilot programme suggests that people spend their money as set out in the individual care plan. What is more, they were happy to give money back if it was not needed. However, safeguards will be written into the secondary regulations to ensure that action can be taken where there is an excess that people are reticent to return, or where fraud has occurred.
In implementing direct payments for healthcare we are keen to ensure that integration between health and social care is taken into account. There are a few differences between direct payments for healthcare and direct payments provided by local authorities to fund social care. For example, the latter rely on means-testing, whereas direct payments for healthcare do not. Nevertheless, where possible the policy and regulations for direct payments for healthcare mirror those for social care. This will help to facilitate integration across health and social care. In future, it is intended that adults who have both health and social care needs could have a joint plan and budget.
I will now turn briefly to the issue of who should be able to have a direct payment for healthcare. We do not believe that such a payment would be appropriate for everyone who uses NHS services, or for all the services that an individual may use. The founding principle is that there needs to be a benefit from having a direct payment and that this should outweigh any additional costs. The evaluation suggests that those with higher health needs and inevitably larger budgets benefit most.
I make it clear that direct payments for healthcare will always be voluntary. No one will be forced to have one or be asked to take more control than they would find comfortable. However, where they add value and the individual is interested in using them, the right information and support should be made available so that people can make informed choices about how they wish to proceed. The need for information and support is intrinsic to this entire process, and this will be set out in the secondary regulations.
The pilot programme and the evaluation that followed provided evidence that the concept of direct payments for healthcare is beneficial and cost effective if properly implemented. Nevertheless, we accept that there is still much to learn and that we are only at the beginning of the journey. Therefore, it is important that direct payments for healthcare are introduced gradually and in a way that guarantees the sustainability of the programme. As of April 2014, people receiving NHS continuing healthcare will have a right to request a personal health budget and direct payments. It is thereafter anticipated that this progression, allowing more and more people the opportunity to have direct payments, will continue into 2015 and beyond.
In conclusion, I trust that I have demonstrated how the draft order removing the pilot scheme limitation will enable direct payments for healthcare to be made to patients using the NHS in England, and how secondary regulations will clearly set out the details of how they will be implemented. I commend the draft order to the House.
Baroness Wheeler
My Lords, I thank the Minister for his comprehensive explanation of the background and purpose of the order. We recognise that it is a technical amendment, but this is nevertheless a good opportunity to be updated by the Minister on the consultation on the extension of direct payments for healthcare and how the learning points from the pilots are to be translated into the revised regulations. Labour is fully supportive of extending personal health budgets, having pioneered them in social care through our personalisation and transformation of social care agenda, and set the ball rolling into 2009 on the PHB direct payments pilot.
It was also right to focus on exploring the use of PHBs and direct payments where people had the highest needs, such as those with long-term health and mental health conditions and who access the NHS most frequently. The pilot group covered CIPD, diabetes and long-term conditions, mental health and stroke and patients eligible for NHS continuing care. Labour was particularly concerned that PHBs do not stop at physical health but also include people with learning disabilities.
The national rollout target for PHBs to be extended to 56,000 people by April 2014 is challenging but is necessary to boost the take-up of PHBs across the country, as is the NHS mandate provision for every patient who will benefit to have the option of a PHB by 2015. Is the Minister confident that in the current circumstances, the resources will be available to support achieving these targets?
The pilot evaluation concluded that the majority of budget holders and their carers reported positive impacts of PHBs on patients—on health and well-being, care and other support arrangements for family members. As we know, PHBs have the potential to improve quality of life and satisfaction for both patients and carers, including psychological well-being. Helping patients design packages of care and support from clinicians, primary and secondary care and community health services also helps to provide joined-up integrated care, as the Minister pointed out, and in many instances has led to a reduction in the number of hospital visits. This is exactly where we need to be in terms of future service provision.
As a member—like many Members on all sides of both Houses—of the Westminster Health Forum, I recently chaired a specialist conference on PHBs which was attended by staff, providers and practitioners from across health and social care. The forum conferences are a valuable exchange between experts and staff on the ground including, in this case, those who are part of the multidisciplinary teams supporting and delivering PHBs. There was strong support for PHBs but it is clear, as the Minister said, that we are still very much in a learning process about their development. As usual, as you would expect, there were many questions and answers about some of the implementation, monitoring, accountability and evaluation issues.
I should like to finish by asking the Minister three questions on the issues that arose. First, there were widespread concerns at the conference that the evidence on the impact and effect of PHBs needed to be sharpened up in the future evaluation process. The pilot evaluation showed that there did not appear to be an impact on health status per se. Can the Minister explain whether there are plans in the rollout to assess possible measurements of health improvements, although of course we recognise that these can be hard to achieve in long-term health conditions?
Secondly, a number of GPs at the conference spoke about the challenge of getting wider GP buy-in to PHBs. Can the Minister update the House on discussions with the Royal College of GPs and the BMA on addressing this important issue? The college’s guidance on PHBs was especially commended by conference participants.
Finally, there was widespread concern about how PHBs will be taken forward by commissioners, health professionals and service users. Can the Minister update the House on advice planned or issued by the Department of Health in this respect?
Earl Howe
My Lords, this is most definitely one area of policy where all sides of the House are at one and I am grateful to the noble Baroness for her comments. She is right that the pioneering work on social care budgets was carried out during the previous Administration and gave us—and her own Government in 2009—sufficient confidence to institute these pilots for healthcare. I am pleased that she is as gratified as I am that the pilots have been a success, although as I emphasised earlier, we still need to feel our way in rolling them out.
The noble Baroness mentioned specifically people with learning disabilities and I agree with what she said. Although the number of people with learning disabilities involved in the pilot was small, it is clear from their stories that people with learning disabilities and their families benefited from the flexibility and control offered by personal health budgets. As the final report on Winterbourne View identified, personal health budgets have the potential to improve commissioning for people with complex needs and challenging behaviour. Many people in out of area placements, or who are at risk of such placements, are funded entirely through NHS continuing healthcare or have some NHS funding. These groups could be offered personal health budgets as the basis for a person-centred approach, meaning that they could have more control over where they live and the care they can access. It is that kind of intangible benefit—the noble Baroness asked about health benefits—that is very difficult to capture metrically, but it is nevertheless an important factor.
The noble Baroness asked me about resources and whether they will be available. As I mentioned earlier, personal health budgets are not about new money, they are about using existing money more effectively. Funding for budgets will need to be found from within normal NHS allocations and how that is done will be a decision for local CCGs. The personal health budget toolkit contains learning from the pilot programme on this and more information will become available during the early rollout phase as Going Further Faster sites consider sustainability issues. NHS England will be publishing guidance to help CCGs consider how to introduce direct payments for healthcare and personal health budgets on a local level in a sustainable way.
In answer to the noble Baroness’s question about health outcomes, it might be helpful to run through some of the findings from the pilots, which I think show that we can hold our heads up and say that they benefit people. First, we are clear that personal health budgets are cost-effective. They improve or maintain outcomes and reduce costs or are cost-neutral. These results are particularly true for people eligible for NHS continuing healthcare and people with mental health problems. When personal health budgets are implemented so that the person has choice over services and how they receive the budget, the cost-effectiveness increases. People can choose to meet their needs in different ways through lower-cost interventions, for example by training their personal assistants to carry out some health tasks, such as changing dressings. This means that people’s needs can still be met but in a different way, and perhaps in a way which is less stressful for them.
Personal health budgets also clearly resulted in an increase in the quality of life. The study found that effects were greater when people had budgets of more than £1,000, and this generally applies to people who have higher levels of health need, as I mentioned earlier. People benefited more from personal health budgets when there were fewer restrictions in place around what they could spend the money on and how they received the budget—that is, having a choice of a direct payment, a third-party budget or a notional budget. I hope that that is helpful to the noble Baroness in answer to her question.
In answer to the noble Baroness’s further question, I can tell her that the review will include a review of whether the budget is meeting the individual’s needs. That is clearly an important factor. We need to make sure not only that the money is adequate but that the plan itself and the money that goes with it are in step with each other. As regards the Royal College of General Practitioners and wider GP buy-in to personal health budgets, we have been very careful to engage with the royal college at all stages. We met them in conference last week to discuss their role going forward. It is important, as the noble Baroness stressed, that we engage GPs in this process, and I hope that we can continue that active co-operation with them.
Care Quality Commission: Morecambe Bay Hospitals
Earl Howe Excerpts(12 years ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House, I shall now repeat a Statement made in another place yesterday by my right honourable friend the Secretary of State for Health on Morecambe Bay Hospitals. The Statement is as follows.
“I wish to make a Statement about today’s independent report into the CQC’s regulatory oversight of University Hospitals, Morecambe Bay. What happened at Morecambe Bay Hospital is, above all, a terrible personal tragedy for all of the families involved. Before saying anything else, I want to apologise on behalf of the Government and the NHS for all the appalling suffering they have endured and, in that context, I know that the whole House will wish to extend our condolences to every one of them.
Joshua Titcombe’s tragic death was one of 12 serious untoward incidents, including five in the maternity department. His family and others have had to work tirelessly to expose the truth—and I want to pay tribute to them for that—but the fact is that they should not have had to go to such lengths. As we saw with Mid Staffs, a culture in the NHS had been allowed to develop in which defensiveness and secrecy were put ahead of patient safety and care. Today I want to explain to the House what the Government are doing to root out that culture and ensure that that kind of cover-up never happens again.
The independent report was commissioned by the new chief executive of the CQC, and the new team running the organisation has made it clear that there was a completely unacceptable attempt to cover up the deficiencies at the CQC. The report lists what went wrong. Unclear regulatory processes, reports commissioned and then deleted, lack of sharing of key information and communication problems throughout the organisation. Most of the facts are not in dispute. All of them are unacceptable. They have compounded the grief of the Titcombe family and many others.
The role of the regulator is to be a champion for patients, to expose poor care and to ensure that steps are taken to root it out. It must do this without fear or favour. It is clear that at Morecambe Bay the CQC failed in that fundamental duty. We now have a new leadership at the CQC and we should recognise its role in turning things around. David Behan was appointed chief executive in July 2012. One of his very first acts was to commission the report that we are now debating. David Prior was appointed the new chairman in January this year. He has rightly insisted that this report be published as soon as possible. Those two outstanding individuals have never shrunk from addressing head on the failings of the organisation they inherited and are wholly committed to turning the CQC into the fearless independent regulator the House would like to see. While I do not underestimate the challenge, I have every confidence in their ability to undertake it. David Prior will now report back to me on what further actions the CQC will take in response to the report, including internal disciplinary procedures and any other appropriate sanctions on individuals.
Working with the CQC and following the Francis report into the tragedy at Mid Staffs, the Government are putting in place far-reaching measures to put patient care and patient safety at the heart of how the NHS is regulated. The CQC is appointing three new chief inspectors—of hospitals, social care and general practice. This will provide an authoritative, independent voice on the quality of care in all the providers that the CQC regulates. The commission has already announced the appointment of Professor Sir Mike Richards as the new Chief Inspector of Hospitals and on Monday the CQC launched a consultation, “A New Start”, which outlines its new much tougher regulatory approach. This includes putting in place more specialist inspection teams with clinical expertise. It will include Ofsted-style performance ratings so that every member of the public can know how well their local hospital is doing, just as they do for their local school.
The Government will also amend the CQC registration requirements so that they include an emphasis on fundamental standards—the basic levels below which care must never fall, such as making sure patients are properly fed, washed and treated with dignity and respect. Failure to adhere to these will result in serious consequences for providers, including, potentially, criminal prosecution. The revised registration requirements will also include a new statutory duty of candour on providers that will require them to tell patients and regulators where there are failings in care—a failure that was identified clearly in today’s report.
Finally, we are putting in place, through the Care Bill, a new robust single failure regime for NHS hospitals. This will provide a more effective mechanism to address persistent failings in the quality of care, including the automatic suspension of trust boards when failings are not addressed promptly.
The events at Morecambe Bay, Mid Staffs and many other hospitals should never have been covered up, but they should never have happened in the first place, either. To prevent such tragedies we need to transform the approach to patient safety in our NHS. The Prime Minister has therefore asked Professor Don Berwick, President Obama’s former health adviser and one of the world’s foremost experts on patient safety, to advise us on how to create the right safety culture in the NHS. He and his committee will report later this summer.
In addition, later this year we will start to publish surgeon-level outcomes data for a wide range of surgical specialties. Most of all, we need a culture where, from the top to the bottom of NHS organisations, everyone is focused on reducing the chances of harming a patient in the course of their care, and a culture of openness and transparency to ensure that, when tragedies do occur, they are dealt with honestly so that any lessons can be learnt. Our thousands of dedicated doctors, nurses and healthcare assistants want nothing more than to be allowed to make this happen. We must not let them down or the families who suffered in Morecambe Bay”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Hunt, for his measured comments, and I am the first to agree with him that the report we now have is very deeply worrying. It sets out conclusions about the CQC’s leadership and operation during the period in question that are very shocking. What happened was totally unacceptable.
The CQC today is a different organisation and I was glad to hear that the noble Lord recognised that. Its board and management team have been completely overhauled. A new chief executive and chair are in post. A powerful new Chief Inspector of Hospitals has been appointed, an appointment that has been welcomed widely. The new leadership, as the Statement said, commissioned and published this report to make sure that the events of the past are exposed and that lessons can be learnt from them.
I am very pleased that the CQC will now be overseeing the production of a report within the next two months to provide assurance that any cover-up has been fully exposed and stopped and that the mistakes made by the CQC in regard to Morecambe Bay hospitals are being put right. That will ensure that the organisation’s structures and procedures are such that these shocking events cannot be repeated.
The noble Lord referred to what I agree with him is the troubling issue of the anonymisation of names in this report. Our clear understanding from the CQC was that its legal advice was that the report had to be anonymised prior to publication to comply with data protection legislation. We asked the CQC to consider this further and to provide advice on whether it was possible to release the names. Yesterday, it gave a commitment to do just that. It has now done so and my understanding is that it will later today publish the names of certain individuals currently anonymised in the Grant Thornton report.
The noble Lord asked whether the Department of Health had seen the report prepared by the CQC, which was then withheld. We have extensively asked officials throughout the department. There is no evidence to suggest that anyone in the department knew that the CQC had commissioned a report into its handling of Morecambe Bay and subsequently withheld it, still less that anyone actually saw it.
The noble Lord raised the issue of the whistleblower, Kay Sheldon. Her concerns about the CQC’s capability were considered alongside a range of other evidence as part of the DoH performance and capability review that was carried out between October 2011 and February 2012. The issues she subsequently raised have been considered along with other information as part of the department’s ongoing oversight of the regulator. The appointment of David Prior as chair of the CQC in January and David Behan as chief executive last July, combined with a strengthened board and the CQC’s new strategy, puts the organisation in a good position for the future.
When Kay Sheldon approached the department she was asked to raise the issues with the CQC board, and DoH officials also raised the issues with the CQC team in line with our normal approach to operational issues. The noble Lord asked whether we will release the minutes of the meeting with Kay Sheldon and the Secretary of State. I am happy to take that request away and I will let the noble Lord know whether that will be possible.
The noble Lord rightly raised the issue of culture in the NHS. The overriding message from the document that we published, Patients First and Foremost, which arose out of Mid Staffs, is that the culture of the NHS governs the quality of everything it does. We are clear that radical transparency, excellence in leadership, clarity of accountability and consequences for failure are together necessary if we are to maintain in the NHS the focus on quality and safety and for concerns to be identified quickly and acted upon.
Transforming culture is a complex challenge that will be different in each organisation. We believe that a combination of the steps that we have set out, such as ratings, which we will debate during the course of the Care Bill, a Chief Inspector of Hospitals and a failure regime that puts quality on a par with financial failure will contribute to making a real difference to the experience of patients. I look forward to the debate on ratings because I know that the noble Lord has concerns about the idea.
The noble Lord referred specifically to the duty of candour. In our response to the Francis report we said that we would introduce a new statutory duty of candour on providers. We agree that it is essential that providers of health and social care must be open in their dealings with patients and service users. We intend to introduce an explicit duty of candour on providers as a CQC registration requirement. That will require providers to ensure that staff and clinicians are open with patients and service users where there are failings in care.
As with all requirements for registration with the CQC, our intention is that the duty of candour will be set in secondary and not primary legislation. I am sure that my right honourable friend the Secretary of State would not mind me saying that he made a slip of the tongue yesterday. He meant to say that a statutory duty of candour will be put in place. However, I emphasise that the duty will have the same legal power in secondary legislation as it would in primary legislation.
The noble Lord made a number of powerful points on false and misleading information. The Care Bill will make it a criminal offence for care providers to give false or misleading information where information is required by a legal obligation. We will specify through regulations the type of information within scope of the offence. However, a failure to provide information would be a breach of the relevant legal requirement to provide it and would be subject to appropriate action.
In determining the scope of the false or misleading information offence, our current focus is on information supplied by providers who are closest to patient care, in which inaccurate statements can allow poor and dangerous care to continue. We need to give further consideration to the events highlighted in the Grant Thornton report and to reflect on whether a false or misleading information offence should apply to other health bodies such as regulators.
Baroness Northover
I remind noble Lords that brief questions are allowed. As the Companion states, this is not the occasion for an immediate debate. I note that many noble Lords want to speak, so the briefer the better, please.
Earl Howe
My Lords, I recall the noble Lord, Lord Patel of Bradford, making those points very powerfully some years ago when we debated the Bill that created the CQC. He makes an extremely important point. I think that we can take it from the statements of David Prior yesterday that the decision taken in 2009 to take a generalist approach to inspection was a mistake. The CQC’s inspectors are in one sense specialist inspectors who are trained and supported to carry out their role, which they do to the best of their ability. However, requiring inspectors to have oversight of a wide range of service types from slimming clinics to acute hospitals, and indeed mental health establishments, has spread expertise too thinly.
We are clear that we must now work with the CQC to create a much more specialist approach to inspection, including on mental health. I think that the three new chief inspectors we are appointing will help to do that. It is not the whole answer, because they need to be supported by clinical expertise and by the people who are experts by virtue of their experience in care services. However, I will take away the noble Lord’s idea of a chief inspector of mental health. I must be honest with him that we have not discussed this, but I am sure that we now should.
Lord Mackay of Clashfern
My Lords, I wonder if my noble friend would take account of the suggestion of the noble Lord, Lord Hunt of Kings Heath, that legal advice can sometimes prevent people from doing the right thing. I was very sorry to hear that. I think that good legal advice should in fact produce the result of people doing the right thing. The second point I want to make relates to the claims against the health service for negligence. These have been quite substantial over the years. Could the CQC look at that area and examine the grass-roots standard of care given to patients?
Earl Howe
My Lords, the deputy Information Commissioner is quoted as saying that confidentiality and data protection issues should not stand in the way of disclosure where disclosure is clearly in the public interest. I completely agree with that. That is why our instant reaction yesterday, when we were told by the CQC that legal advice had said that the names of the individuals had to be kept confidential, was to challenge that. I am pleased that that decision is to be reversed and the names will be released.
On my noble and learned friend’s second point, most certainly yes: the CQC should take a view about matters relating to negligence. However, I would add that apart from the CQC, we now have the new Healthwatch bodies, part of whose function will be to make sure they provide good soft intelligence on what is happening in NHS and social providers in their local areas. The Healthwatch bodies can then act as the eyes and ears of the CQC, which, with the best will in the world, cannot be everywhere at once. In terms of the future—this is clearly a longer-term agenda—I hope we will have a system that is better equipped to pick up this kind of incident should it ever occur again.
Lord Blair of Boughton
My Lords, I welcome the idea of a statutory duty of candour and all the other means of regulation being discussed, but what appears to have happened here—and obviously it is just an allegation—is a simple case of malfeasance in public office. One of the things that seem to have happened over scandals such as Stafford, or even LIBOR, is that the ordinary criminal law of the United Kingdom has not been considered. I assume that the CQC is a public body. It is certainly paid for by public funds, and therefore its officials are subject to the common law.
Earl Howe
My Lords, clearly it is a matter for the police to investigate criminal offences and for the Crown Prosecution Service to consider whether the test for prosecuting individuals has been met in this case. It is too early to reach a conclusion about whether this case highlights a gap in the law but if it does, I can assure the noble Lord that we will pursue it. We keep the criminal law under review. It is too early for me to say—I am not a lawyer—whether he is right, but I am sure that his comments will resonate strongly with the House.
The Lord Bishop of Liverpool
My Lords, chaplains occupy a unique position in hospitals in relation not just to patients but to staff. Will the Department of Health keep under review the role of the chaplain in relation to both patients and staff, especially when a culture of carelessness and intimidation emerges?
Earl Howe
The right reverend Prelate makes an extremely important point. The Government have been very supportive of the concept of hospital chaplains, who play an enormously important role in supporting not just patients but staff. I am concerned because I have heard anecdotally that in some hospitals there are moves to dispense with hospital chaplains. I am in touch with one of his right reverend colleagues about this. Once again, we have a mechanism—if I may call them a mechanism—that could be deployed to good effect in this context.
Baroness Pitkeathley
The Government’s support for the current leadership and the newly launched New Start consultation will be welcome to all those of us who know the current people. Can the Minister assure the House that the Government will stand firm in this support when the tabloid press starts calling, as it surely will, for more heads to roll? Will he further assure the House that he believes that the last thing that the CQC needs is more change at the top?
Earl Howe
I agree fully with everything that the noble Baroness has said. We have in the CQC the right team to take it forward. They are very clear that there needs to be a complete refresh of the senior team where doubts emerge about the individuals concerned. We are already seeing a complete refresh of the board. I share her worry about the tabloid press and calls for heads to roll. Nevertheless, it is appropriate, in the particular context of Morecambe Bay, for there to be a close look at the role of certain individuals: exactly what they did, what they knew, when they knew it and whether what they did was either wrong morally or against the law.
Baroness Emerton
My Lords, I wish to refer to the introduction of a new, robust, single-failure regime for NHS hospitals. This will provide a more effective mechanism to address persistent failings in the quality of care, including the automatic suspension of trusts. As a nurse, I was trained to look at prevention rather than cure. Ought we to be looking at, and including in this, the preparation of trust boards, as well as the staff, looking across the consensus of the trust rather than concentrating on targets? It is often mentioned in reports that they do not look at the quality. We need to see a much more cohesive trust report.
Earl Howe
My Lords, this is one of the reasons why the previous Government introduced quality accounts, which are becoming more and more sophisticated and which focus the minds of a board on quality of care. It is easy to give the impression that we want to introduce a punitive culture into the NHS: we do not. However, there should be sanctions in the background to back up any serious failings of care. That is broadly what Robert Francis was driving at in talking about fundamental standards below which no care provider should fall. The CQC will be consulting on those standards later in the year, but I take the noble Baroness’s point about trust boards. It remains within the powers and competence of Monitor to suspend trust boards, either in whole or in part, where concerns arise over the governance of an organisation. That is a drastic power to invoke and they can take measures which fall short of it where appropriate.
Lord Hamilton of Epsom
My Lords, am I alone in being surprised that it should be necessary to have legislative change to secure a duty of candour? Does this mean that, in the absence of this change, the CQC has the right to tell lies?
My other question is on the inspection regime. I understand that a generic system used to work in the past, whereby somebody whose expertise was in dentistry was sent off to inspect an A&E department. Who was responsible for the decision to run the inspection regime in that way?
Earl Howe
My Lords, there has never been a right to tell lies, either professionally or in statute. My noble friend is right that we should be shocked that it is necessary to put in legislation that there has to be a statutory duty of candour. Candour has been part and parcel of the ethical framework for professionals in the health and care sector for many years. It is a sad reflection on those involved in the events at Mid Staffs and Morecombe Bay that we should be thinking in these terms at all, but we must, because unless we do we lay ourselves open to matters being brushed under the carpet, as they have been in these cases.
The inspections themselves have not been generic: it is the skills on the part of the inspectors that were considered to be adequate as those individuals were deployed generically. That decision was taken very early on when the CQC first came into being in 2009. We now think, as does the CQC, that that was wrong and that skills should be altogether more specialist.
Lord Clark of Windermere
As someone who lives in the catchment area of Barrow-in-Furness hospital, I have followed the story very closely. Does the Minister agree that, while we are discussing the cover-up by the CQC today, it in turn was investigating shortcomings by what was presumably the previous management of Morecambe Bay hospitals? Did he see the very pointed quote yesterday in the other place by the MP for Barrow-in-Furness, John Woodcock, who has done so much in this? He quoted the report as saying that there could be a “broader and ongoing cover-up”. Can he give the House an assurance that any investigation will not stop at the CQC but will look at the main cause of the disturbance and Mr Titcombe’s complaint initially?
Earl Howe
My Lords, I can give that assurance. In part, we have the answers in the Grant Thornton report commissioned by the CQC on the actions that the CQC took or did not take. As I said in answer to the question asked by the noble Lord, Lord Hunt, it is reassuring that the chief executive of the CQC has undertaken to produce for the department within the next two months a report to provide assurance that any cover-up has been fully exposed and that we will learn fully not only the facts but the lessons that we can draw from them.
Baroness Wall of New Barnet
I thank the noble Earl for repeating the Statement. It has caused quite a stir. My worry is two-fold. First, we had a big reaction to what happened at Mid Staffs, and now we have this. I would want us to be very careful not to become desensitised by some of these things—I do not mean in this House, but elsewhere.
I will pick up on the comments of the noble Baroness, Lady Emerton, and agree with her totally. As chairman of Barnet and Chase Farm Hospitals NHS Trust, I find it bewildering that, never mind any cover-up at the CQC, the board was not aware of those tragic deaths of mothers and babies. Certainly, in my trust that would absolutely be reported, both through the quality and safety committee that deals with what are called SUIs, or serious untoward incidents, and from the board itself. It would be helpful, as has been suggested, that the inquiry goes a bit further than just the CQC.
Earl Howe
I am grateful to the noble Baroness. In fact, the trust has taken significant action in response to the concerns raised by the CQC and Monitor. In addition to responding specifically to the three warning notices issued by the CQC, there have been significant leadership changes at the trust. Sir David Henshaw was appointed as interim chair and Eric Morton as interim chief executive. The trust appointed four new non-executive directors and a new chief operating officer and recruited a new obstetric consultant and additional midwives. There have been other appointments as well. It has established a programme management office, as requested by Monitor, to oversee the implementation of programmes of work to bring about lasting improvements across the trust—and it has recruited a number of posts to the programme office to take that work forward. So I am encouraged that it is taking the position as seriously as it should in the circumstances and that, again, there is a refreshed team at the top of that organisation.
Baroness Cumberlege
Very often, when we have these inquiries, they are initiated not so much by the people who work within the trusts but by members of the public who feel very concerned about the quality of care being given within a hospital or service. Very often, those people who bring up these concerns, who are dubbed colloquially as whistleblowers, get very victimised by other people within the population but also within the hospital. Is there any support or help that we can give those people who bring to the attention of the NHS some of the problems that exist?
Earl Howe
My noble friend raises a key issue, which successive Governments have wrestled with. We all know how life works. Whistleblowers are treated badly because their message is often very uncomfortable. That is why local Healthwatch could potentially be a very important part of the puzzle here, by ensuring that people have a place to go to that they can trust and that can raise concerns without necessarily naming the person who has initiated those concerns.
More and more, we need to encourage providers of care to take ownership of their performance. They have to be candid with themselves and accept criticism where it is laid. Boards of directors have to look systematically and regularly at the complaints made against them—whether rightly or wrongly—to make sure that they are as open as possible with themselves. Only by instilling a culture of that kind can we move forward.
NHS: Accident and Emergency Units
Earl Howe Excerpts(12 years ago)
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Lord Campbell-Savours
To ask Her Majesty’s Government what assessment they have made of the impact of closures of Accident and Emergency units in Buckinghamshire on neighbouring hospitals; and how that compares with the impact of closures of Accident and Emergency units elsewhere in the country.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we know that there have been increasing pressures in A&E across the country. In October 2012, a GP-led 24/7 minor injuries unit was introduced in Wycombe to deal with cuts, bruises, sprains and other minor injuries and illnesses. A modest increase in the number of patients going to neighbouring A&E units was expected as a result of local changes. Commissioners provided £4 million to these hospitals to address that increase.
Lord Campbell-Savours
My Lords, the minutes of the Heatherwood and Wexham Park National Health Service Trust disclose that the downgrading of A&E and medical emergency departments in neighbouring hospitals led to a fivefold increase in the number of people having to wait more than four hours—the national target—in Wexham Park A&E and a dramatic increase in the number of cancelled operations. Indeed, I am told that that number doubled. What is the point of making this national policy of closing these A&E departments when all it is doing is upsetting people all over the country and making them extremely angry?
Earl Howe
My Lords, I have to emphasise to the noble Lord that, although I understand his concerns in relation to Wexham Park and other hospitals, there is no government policy about the closure of A&E departments. The whole thrust of government policy since we were elected to office has been that there should be no top-down direction of this type of decision. Rather, we are clear that any changes to healthcare services should be locally led, clinically driven and involve the local population in a consultation. All patients have the right to high-quality urgent care at whatever time they use the health service. The key for local commissioners and decision-makers is to ensure that that happens. I am aware that the situation at Wexham Park has improved and money is being invested to ensure that there are enough beds for the future.
Baroness Wall of New Barnet
My Lords, I declare an interest as the chair of Barnet and Chase Farm Hospitals NHS Trust. I was in my A&E department at Barnet Hospital this morning for two hours. In addition to the concerns that my noble friend has expressed, the real issue is that people are turning up at A&E who really should not be there, do not need to be there and ought to be able to get treatment elsewhere. Obviously, government policy is to ensure that we have more services outside, but can we make sure that that happens more quickly than is currently the case?
Earl Howe
My Lords, the noble Baroness is absolutely right. There is no doubt from Sir Bruce Keogh’s urgent and emergency care review, published this month, that attendance at an A&E department often reflects the lack of availability or the lack of awareness of alternative sources of help. Some patients may default to A&E departments when they are unsure about which service is most appropriate to their needs. That has to be addressed and is being addressed in Sir Bruce’s review. It will look at the entire system of emergency care and how we can make sure that it provides the right care, in the right place and at the right time.
Baroness Finlay of Llandaff
Will this review include an audit of the number of patients who are in A&E but cannot be sent back to their normal place of residence, whether that is their home or a care home, because of the lack of immediate transport and an absence of immediate referral systems to community services that could monitor and review the patient back in the community?
Lord Brooke of Alverthorpe
My Lords, will the Minister be kind enough to enlighten us as to whether Ministers are under instructions these days to blame the NHS and its different levels for failings but to accept no responsibility for putting it right? I watch with increasing fascination the number of Ministers who are now attacking the way that A&E operates, although they are to blame. I heard a Minister the other day attacking GPs for failing to act in the way they should. At the end of the day, I wonder who is responsible for putting this right. The noble Earl said earlier that this is a not a “top-down” operation now. Who, then, is going to accept responsibility for the failings which are now starting to take place within the health service?
Earl Howe
My Lords, Ministers are responsible to Parliament for the provision of the health service so I do not duck that responsibility for a second. Nevertheless, Ministers do not manage the health service day-to-day and have never done so. We are involved day-to-day in the plans to ensure that we have a health service that is properly configured to meet the needs of patients. My right honourable friend the Secretary of State could not be more assiduous in the work that he is doing to make sure that that happens. Responsibilities are not being ducked; nobody is being blamed. The fact is that demand is going up considerably, and has been for a number of years. We need to address that and we need to do it cleverly. It is not always a question of piling more money in; it is looking at how the services are configured and delivering care in the right place.
Baroness Masham of Ilton
My Lords, does the Minister agree that drunken and aggressive people are putting great pressure on A&E departments across the country, especially at weekends? Can he do something about it?
Earl Howe
The noble Baroness is right. Quite a considerable proportion of people who attend A&E do so at weekends after heavy drinking, and in some areas, that has overloaded the system. I am aware of many hospitals that are working with the local police force and others to keep such people out of hospital if they do not need to go, but to make sure that they do not disrupt the work of an A&E department if they do go.
Autism
Earl Howe Excerpts(12 years ago)
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Lord Touhig
To ask Her Majesty’s Government what assessment they have made of the findings of the campaign by the National Autistic Society, Push for Action, launched on 14 May. I declare an interest as vice-president of the National Autistic Society.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the National Autistic Society’s Push for Action campaign coincides with the Government’s review of the 2010 adult autism strategy. We are already taking forward some of the campaign’s recommendations, and we will consider others that fall to government during the review, the investigative stage of which is due to last until the end of October.
Lord Touhig
I must say that I am encouraged by the Minister’s words. Four years after Parliament passed the groundbreaking Autism Act, this National Autistic Society report reveals that despite some progress far too many autistic adults are missing out on everyday support. A shocking 70% of adults and their carers say they get no help from social services, and this is not always down to money. Indeed, economic modelling by Deloitte shows that every pound invested in services for autistic adults with moderate needs brings a return of £1.30. When the Government review the autism strategy, will they consider providing an innovation fund so that local councils can provide the cost-effective services that all autistic adults need and actually demand?
Earl Howe
My Lords, we will certainly consider the idea of an innovation fund during the course of the review. We have allocated some central funding already to support the implementation of the autism strategy, for example in commissioning a range of training products from expert bodies to support local areas and professionals. I hope the noble Lord will agree that the strategy and the statutory guidance that goes with it mark a great step forward for adults with autism in England. We now need to take an honest look at how it is all working and come up with further ideas and actions as necessary.
Lord Clement-Jones
My Lords, I declare an interest as president of Ambitious about Autism. Can my noble friend confirm that the Government’s review of the adult autism strategy will pay close attention to the kind of day support services, such as the NAS’s Horizons service, which the recent Deloitte report, Ending the Other Care Crisis, has demonstrated not only leads to increased quality of life and reduced dependency but has clear economic benefits?
Earl Howe
My noble friend draws attention to a very important strand of support for people with autism. Many people with this condition can benefit from small amounts of advocacy, help and support often through less formal support networks and not necessarily through the local authority. We will certainly be looking at that area.
Baroness Browning
I declare my autism interest in the register to the House. Does my noble friend accept that the Department of Health is the lead department on the Autism Act, but that other departments have responsibilities as part of the strategy? He will be aware of the finding of the Upper Tribunal (Administrative Appeals Chamber) in a case against the Secretary of State for Work and Pensions that the case has to be made that autism is different. Can I ask him to make sure that that case is made by his department to all other government departments involved in the care of people with autism?
Earl Howe
I can give my noble friend that assurance. The autism strategy is, of course, a cross-government strategy. A number of departments will look at their role in supporting it, including the Department for Work and Pensions and the MoJ. I am hopeful that when we come out in October with some considered proposals, my noble friend will take heart from the fact that this has involved all relevant government departments.
Baroness Howarth of Breckland
My Lords, one of the great concerns of people with autism is the transition arrangements between young people and adults, particularly the difficulties created now that education and social care provision are separated in adult education centres for these children and young people. What is intended to ensure that this does not continue to disadvantage these young people?
Earl Howe
My Lords, the Children and Families Bill, which was introduced into Parliament this month, will usher in from next year new joint arrangements for assessing and planning commissioning services for children and young people with special educational needs. We realise the difficulties that young people with autism can face in making that transition to adulthood. Under the autism strategy, my department and the Department for Education funded the social policy research unit at the University of York to examine how statutory services are currently supporting young people on the autistic spectrum. Its report, published in February, points the way to some important lessons that we should take on board during the review.
Lord Collins of Highbury
My Lords, despite the strategy, only 63 out of 152 local authorities have a pathway to diagnosis. Will the Minister give an assurance that the department will produce a clear guide for CCGs on how to commission the right diagnosis and support services?
Earl Howe
My Lords, we are indeed currently supporting, along with NHS England, a practical guide for CCGs to support health professionals and others in implementing the adult autism statutory guidance, as well as the NICE guidelines on recognition, referral and diagnosis, and the management of adults on the autism spectrum. This will be published later in the summer through the Joint Commissioning Panel for Mental Health.
Baroness Greengross
My Lords, I was recently privileged to chair a commission that looked for the first time at the large numbers of people who grow into old age with autism. I would very much like the noble Earl to assure the House that these people will not be ignored, will also receive diagnosis, and that professionals will be trained to ensure that a preventive support system of care is introduced so that it is not always crisis-driven. Can he tell us that?
Earl Howe
I agree with the noble Baroness that the needs of those with autism in older age should not be forgotten. We will meet the National Autistic Society, following the publication next month of its report on autism and ageing, to see how we can support the taking forward of this work, which builds on that done by the autism and ageing commission in this House. We are also looking at the whole issue of the training of health professionals, in particular the core curricula for doctors, nurses and other clinicians.
Lord Campbell-Savours
Is there a connection between the MMR jab and autism?
Health: Children's Heart Services
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House, 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 Safe and Sustainable review of children’s heart services. The Statement is as follows.
“With permission, Mr Speaker, I would like to make a Statement on the Safe and Sustainable review of children’s congenital heart services.
On average, around 3,700 heart procedures are carried out each year on children who have been diagnosed with congenital heart conditions. The mortality rates at Bristol Royal Infirmary, identified as far back as 1989, indicated that we are not as successful as we should be in such operations. The Safe and Sustainable review began in 2008 and set out to make sure that children’s heart services are the best they can be for all children across the country. Whatever the controversy about the location of such services, we all have a responsibility to ensure the best possible outcomes for children and their families, who must always come first in any decision about service provision.
Sir Ian Kennedy, in his Bristol inquiry report in 2001, recommended the concentration of medical and nursing expertise in a smaller number of centres. Subsequent working groups and reports have endorsed that recommendation, including the Royal College of Surgeons in 2007. The public consultation on the Safe and Sustainable review received over 75,000 responses. This was the largest review of its kind, conducted independently of government by the NHS.
In July 2012, the then Joint Committee of Primary Care Trusts—the JCPCT—on behalf of local NHS commissioners, decided that children’s heart surgery networks should be formally structured around specialist surgical centres in Bristol, Birmingham, Liverpool, Newcastle and Southampton, as well as Great Ormond Street and the Evelina Children’s Hospital in London. They recommended that services should no longer be provided in Leicester, Leeds, Oxford and the Royal Brompton and Harefield in London. Following the JCPCT’s announcement, three local health overview and scrutiny committees formally referred the JCPCT’s decision for me to review and I wrote to the Independent Reconfiguration Panel—the IRP—asking them to undertake a full review of the proposals.
On 30 April 2013 I received the report. I would like to thank the IRP for producing such a comprehensive review of such a challenging topic. It strongly agrees with the case for change, specifically that congenital cardiac surgery and interventional cardiology should only be provided by specialist teams large enough to sustain a comprehensive range of interventions, round-the-clock care, specialist training and research. I agree with their analysis.
However, the report also concludes that the outcome of the Safe and Sustainable review was based on a flawed analysis of the impact of incomplete proposals, and leaves too many questions about sustainability and implementation. This is clearly a serious criticism of the Safe and Sustainable process. I therefore accept their recommendation that the proposals cannot go ahead in their current form and am suspending the review today. NHS England will also seek to withdraw its appeal against the judicial review successfully achieved by Save Our Surgery in Leeds.
None the less, the IRP is clear that the clinical case for change remains, and its report is very helpful in setting out the way forward in terms of broadening the scope of the discussion, and looking in detail at the affordability and sustainability of the proposals. The IRP says—and I agree—that this is not a mandate for the status quo or for going back over all the ground already covered during the last five years. The case for change commands widespread support and understanding and we must continue to seek every opportunity to improve services for children.
The recommendations in the report set out what the IRP considers needs to be done to bring about the desired improvements in services in a way that addresses gaps and weaknesses in the original proposals. Specifically, they include: better co-ordination with the review of adult heart surgery services; expanding the detailed work on the clinical model and associated service standards for the whole pathway of care, beyond surgery; services to be fully modelled and their affordability retested; NHS England to establish a systematic, transparent, authoritative and continuous stream of data and information about the performance of congenital heart services; NHS England and the relevant professional associations to put in place the means to continuously review the pattern of activity and optimise outcomes for the more rare, innovative and complex procedures; NHS England to reflect on the criticisms of the JCPCT’s assessment of quality and learn lessons to avoid similar situations in its future commissioning of specialist services; and NHS England to use the lessons from this review to create with its partners a more resource and time-effective process for achieving genuine involvement and engagement in its commissioning of specialist services.
NHS England now must move forward on the basis of these clear recommendations and the Leeds court judgment. I have therefore today written to NHS England, and the local overview and scrutiny committees that originally referred the JCPCT’s decision to me, to explain that the IRP’s report shows that the proposals of the Safe and Sustainable review clearly cannot go ahead in their current form. It is right to give all parties some time to reflect on the best way forward, now that the IRP report is in the public domain, so I have asked NHS England to report back to me by the end of July on how it intends to proceed. In the mean time, it is important to stress that I believe that care for children with congenital heart conditions is safe in the NHS, and that ensuring it continues to be will be the top priority for all involved in this process.
I know that many families have found the Safe and Sustainable review to be a traumatic experience. People are rightly proud of the hospitals and the staff that have saved, or tried their best to save, the lives of their children. However, there is overwhelming consensus that we cannot stick with the model of care that we have now. To do so would be a betrayal of the families who lost loved ones in Bristol and who want nothing more than for the NHS to learn the lessons from their personal tragedies. So it is right we continue with this process, but it is also essential that it is performed correctly so that any decisions, as difficult as they may ultimately be, carry the confidence of the public. I commend the report and this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Hunt, for his measured comments. I agree with many, if not most, of them. I certainly agree that party politics should play no part in this matter. That is one reason why in 2008 his Government decided that the Safe and Sustainable review should be a process set apart from the Department of Health and led by the NHS. We agree with that and still believe that it should be NHS-led. I also agree with what he said about the complexity of this issue being no excuse for not proceeding as fast as is safe and possible with a process designed to see a satisfactory resolution of this issue. That is certainly our view.
I also welcome what the noble Lord said about public confidence. It is clear that parts of the Safe and Sustainable process sadly did not command public confidence, not least in Leeds, but also in Leicester and other places. The noble Lord will no doubt have noticed, in the IRP’s press releases today, the emphasis on openness and transparency in the process going forward. NHS England has also made clear that whatever the process that it recommends going forward, it should involve the maximum amount of consultation with those concerned, not just the clinicians in the centres involved, who are of course very important, but also patients and their families.
The noble Lord referred to the need for greater consideration to be given to access and travel times. I noted an emphasis on that very point in recommendation 4 of the IRP’s report. They clearly matter to families, as was very much picked up by the IRP in its work engaging with stakeholders. In agreeing to address all the recommendations of the IRP report, which NHS England has done, it could not fail to address that part of the recommendation.
With regard to mortality data, I am sure that the noble Lord will understand that when we are dealing with a procedure as complicated and specialist as children’s congenital heart surgery, while transparency of data is certainly an objective, it is important that the data published are not open to misinterpretation. Mortality data are a problem that beset this kind of area because the numbers are small. They must also be presented in a way that is understandable to the public as well as to clinicians. For the most part, clinicians already have this data, but it is important going forward to ensure that when we publish data, there is genuine comparability between the various centres in terms of the outcomes denoted.
The noble Lord rightly said that, by introducing the dimension of adult cardiac surgery, the IRP had added greater complexity to the whole issue. There is no doubt that that is true. All I will say to him is that this was by far the longest and most complicated review that the IRP has undertaken in its 10-year history. It took evidence over 25 full days. That alone should indicate that the opinions that were tapped were very extensive. The IRP did not come up with this recommendation lightly. Although it adds complexity, it behoves NHS England to take that point extremely seriously.
As regards the timetable for the work going forward, my right honourable friend the Secretary of State has asked NHS England to provide him with an interim report by the end of July. NHS England’s press release states:
“We will take the time to listen before coming up with a new proposition, working with patients, clinicians and the providers of services. We intend to announce a new way forward in the autumn, with plans for implementation within 12 months”.
I believe that is an ambitious aim given the added complexity, but it indicates that NHS England is conscious of the need to make progress in this area as rapidly as possible. As soon as I have further information—no doubt at the end of July or shortly after—I will ensure that the House is made aware of it.
I have seen the Royal College of Surgeons’ press release. It is impossible to disagree with it that this is a disappointing state of affairs. Everyone would like to see this issue resolved. Nevertheless, the points the college makes, which were reflected in the noble Lord’s points about the need for expedition in this area, are absolutely right. The noble Lord was also right to say that over the coming months we need to make sure that all the units, which do such a fantastic job in this very complex area of clinical delivery, are supported and feel that their work is appreciated. It is certainly important that we do not see a draining away of expertise. The clinicians in the various centres should now see this as an opportunity to present their case even more fully than they did before. I hope that they will welcome that opportunity.
As regards the tyranny of the electoral cycle, I hope that in my opening remarks I expressed my agreement that that should not play a part in this. In so far as we can divorce decisions of this clinical magnitude from politics, the better it will be. We should achieve that if this process is as consultative and open as possible, as everybody wishes it to be.
Lord Warner
My Lords, I take us back to Sir Ian Kennedy’s review 12 years ago in which he made it crystal clear that unless we significantly reduced the number of these centres, children would continue to die unnecessarily. That was the brutal conclusion of the Bristol inquiry. Has anything come out of the IRP review that fundamentally changes the July 2012 decision of the Joint Committee of Primary Care Trusts that seven centres, with clinical networks built around them, was the right number? As I understand it, the argument is not necessarily that seven was the wrong number of centres, but that the wrong seven were chosen. Are we not now opening up the whole issue of the relationship with adult services, which will take us back to a situation where we start to review from the beginning the appropriateness of the particular centres? Do we not need to get back to where the JCPCT was when there was a good deal of consensus around the idea that seven was the right kind of number? The issue is really about east coast versus west coast, and the danger of this report, thorough though it may be, is that it will now reopen all the issues on which we had actually made a good deal of progress by 2012.
Earl Howe
That is indeed the core of the disappointment felt by the clinical community and noble Lords: that we are little further forward in terms of deciding exactly where these services should be delivered. The noble Lord is also right to say that support for a philosophy of improving children’s heart services by concentrating surgical expertise to provide round-the-clock cover and develop networks of care is as strong as ever. There is a rare consensus on the clinical case for improving services on the pathway of care for children. The IRP has said that its report is not a mandate for going back over the ground of the past five years; indeed, it commends a great deal of the work done by the JCPCT. The IRP says that that work should be built upon. The JCPCT should not necessarily feel bruised by this, although I am sure that it will feel thoroughly disappointed. However, its groundwork has been publicly appreciated, and it is now for NHS England to take that work forward as swiftly as it can.
Baroness Howarth of Breckland
My Lords, I speak as the patron of Little Hearts Matter, the organisation that represents a large number of families who have children with heart conditions, particularly hypoplastic left heart syndrome, which is extremely serious and needs highly skilled intervention. Who does the Minister think is most disappointed about the failure of the review? I probably meet more families and children than most of your Lordships—children who await open heart surgery or extremely complex technical interventions, and whose anxiety is huge; and parents who thought that they were going to have clear answers on where their children would receive treatment and on the quality of those interventions at the end of the safe and sustainable review. I ask the Minister to take back with him all those disappointments and to look not only at safety, which is key to the families. Many of them would travel to wherever you took them if they were sure that the operation would be successful. As a woman from Yorkshire and the east of England, I understand that gap, but what the families want most is quality of service.
As the noble Lord, Lord Warner, pointed out, there is also great disappointment about the link being made with adult services because of where those services are located. Despite the review, there is a lack of understanding of the needs of children. There are certainly transitional difficulties and I ask the Minister whether it is those issues or other issues that have led to children being considered alongside adults. Will he take away with him the disappointment felt by families who are waiting longer for interventions because this has caused delay?
Earl Howe
My Lords, I am accountable to this House for government policy, but it is important for the noble Baroness to understand that this has been an NHS-led review. Many of her questions are for NHS England now to address. Of course there will be huge disappointment and concern among the families of those who require surgery in this area. I want to emphasise that until a decision is reached, the centres now delivering children’s heart services will continue to do so and will be fully supported in doing so.
However, we cannot ignore a series of recommendations from the IRP that has roundly criticised the methodology of the JCPCT. It concluded that the JCPCT’s way forward was flawed because the analysis was insufficiently thorough. If our aim is to improve the quality of outcomes for these children, I do not believe that it is in anyone’s interests to try to say to ourselves that we can make do with a half-good set of solutions. I do not suggest that the noble Baroness is saying that; of course she is not. We need to be thorough about this without spending another 10 years over it. I hope that I have given the sense to the House that NHS England is determined to progress this rapidly but thoroughly and, above all, in a consultative way. The families will have a chance to have their say in that process.
The Lord Bishop of Ripon and Leeds
My Lords, I am grateful to the Minister and I am also grateful to the Leeds group Save our Surgery for persisting with criticisms, at least some of which seem to have been justified, as they pursued this. I am particularly grateful for the affirmation that children and their families must always come first. Will the Minister also accept that nothing about us should be done without us? Therefore, will he ensure that families, local communities and, indeed, the case for keeping cardiac and other children’s services in our hospitals are heard, in addition to the clinical professionals?
Earl Howe
I can readily agree with the right reverend Prelate. I think it is illustrative of the IRP’s approach that in its press release it states:
“The critical factor to consider, in the Panel’s view, is that engagement of all interested parties is the key to achieving improvements for patients and families without unnecessary delay. There is now a real opportunity to involve patients, the public and other stakeholders in taking work forward as set out in the Panel’s recommendations”.
I endorse that view wholeheartedly, and it is a point that has been directly picked up by NHS England in its press release today.
Baroness Eaton
My Lords, will my noble friend give an assurance that when calculating where centres should be located, account is taken not just of population numbers, but of the make-up of that population? He will know, for example, that children of Asian descent have greater need for these services than other communities, making up 23% of cases at Leeds. Their faster growing population must be taken into account.
Earl Howe
I hope that my noble friend will be reassured by the IRP’s recognition that the location and geography of these centres and where they are in the country are material factors in this equation. At the same time, I think it would be wrong to give the impression that one can establish a centre of expertise of this kind in every city; that is clearly not realistic. Merely because there is a certain density of a population in a location does not mean to say that there can be a children’s heart centre very close to the centre of that population. This is a highly specialised service and we must recognise that the centres that will deliver it will be few in number. Nevertheless, I am sure that the message that my noble friend has given will not be lost on NHS England.
Baroness Jolly
My Lords, it is critical that however NHS England proceeds, it does it openly and transparently. I welcome the Minister’s comments on that. Will he also agree that meetings of any review body should be advertised, public and make all necessary papers available to the public?
Lord Woolmer of Leeds
My Lords, does the noble Earl recognise that in Leeds there will be a great sense of justification regarding the criticisms of the process previously followed and a welcoming of the forensic critique by the latest panel of that process? While it is certainly important that collocation of services is not essential to the provision of children’s heart surgery, does the Minister agree that, where there is outstanding and deliberately engineered collocation of high quality, that is an important factor in the future location of children’s heart surgery?
Earl Howe
The noble Lord makes another very good point, and Recommendation 3 of the IRP report focuses on that very issue. It says:
“Before further considering options for change, the detailed work on the clinical model and associated service standards for the whole pathway of care must be completed to demonstrate the benefits for patients and how services will be delivered across each network”.
Therefore, that point has been explicitly recognised.
Lord Walton of Detchant
My Lords, the noble Earl has explained with his customary clarity the reasons for this further delay. However, surely he would agree that, in the ultimate, the decision that is eventually reached must be based on quality of service and quality of outcomes. This must surely be the guiding principle throughout. I fully appreciate the concerns expressed by the people surrounding the units that were originally marked for closure, but I have to express a personal avuncular interest in Freeman Hospital in Newcastle, which, according to all international comparisons, is producing results in paediatric and adult heart surgery that stand comparison with the best cardiac centres in the world. I know that this further delay is going to cause concern and further damage morale in that unit. I only hope that in the long term it does not have any effect on the efficiency of the service. Let us hope that this review is concluded as quickly as possible.
Earl Howe
My Lords, I pay tribute to the work done in Newcastle in this extremely complex area of surgery. The noble Lord knows that hospital better than anyone in this House, and I understand the disappointment felt in Newcastle about this decision. Nevertheless, I would slightly qualify the comment that he made at the beginning. Although I agree that the decision must depend on outcomes and the quality of care, it must also bear in mind the sustainability of the service into the future. While we can recognise good care when we see it now, we must be sure that the service is capable of being sustained on that level into the future.
Baroness Finlay of Llandaff
Is the Minister able to tell us how many vacancies currently exist among highly specialised staff in children’s heart units and what NHS England is doing to monitor vacancies? During a time of uncertainty, when staff do not know what their future will be, recruitment problems can arise, and where vacancies occur at a very senior, highly specialised level, that in itself can threaten the quality of the service and indeed jeopardise long-term sustainability.
Earl Howe
I do not in fact have any statistics on vacancies, although if I can acquire them I shall certainly pass them on to the noble Baroness. However, the central point that she makes is of course right, and the second recommendation made by the IRP relates to the need to have sufficient staff in place to deliver a safe service. It says that patients should receive this service,
“from teams with at least four full-time consultant congenital heart surgeons and appropriate numbers of other specialist staff to sustain a comprehensive range of interventions, round the clock care”,
and, interestingly,
“training and research”.
I think that that sends a signal that will resonate with many noble Lords in the context of debates that we have had in the past about centres of excellence in the NHS.
Care Bill [HL]
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Lord Walton of Detchant
My Lords, I rise briefly to express my strong support for Amendment 58A. I used to teach my medical students and my postgraduates by telling them that today’s discoveries in basic medical science bring about tomorrow’s practical developments in patient care. Surely this is what the amendment is about. If I were to be pedantic, I would prefer a change in the wording to:
“The HRA shall also have the function of,”
promoting
“the translation of research into innovative practice”.
That is preferable to simply “encouraging” it. Again, I am happy to support the amendment.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this amendment takes us to a subject that is dear to my heart—the translation of research—and I agree very much with the tenor of what the noble Lord, Lord Collins, had to say. The Committee will know that our vision is to improve the health and wealth of the nation through research. The Government are committed to cutting the bureaucracy involved in health and social care research. We want to speed up the initiation and delivery of research so that research findings can benefit people more quickly and improve the UK’s competitiveness in the life sciences. At the same time, research involves a degree of risk, and we need to balance a desire for expediency with appropriate safeguards to protect people who participate or who may participate in research.
Clause 97 sets out the Health Research Authority’s four main functions, which are described in more detail in Clauses 98 to 104. It also sets out the authority’s main objective in performing those functions. The Health Research Authority will have functions in four main areas. These will be, first, functions relating to the co-ordination and standardisation of practice relating to the regulation of health and social care research; secondly, functions relating to research ethics committees; thirdly, functions as a member of the UK Ethics Committee Authority; and, lastly, functions relating to approvals for the exceptional processing of confidential patient information. The Health Research Authority’s main objective in carrying out its functions will be to protect participants, potential participants and the general public by encouraging safe and ethical research, and to promote their interests by facilitating the conduct of such research. This objective has been deliberately framed in a way that ensures that the interests of participants and the public are put first.
As I have said, research sometimes involves a degree of risk, so regulation provides participants, potential participants and the public with assurance that there are appropriate safeguards in which they can be confident. The Health Research Authority will meet the first part of its objective through the regulatory functions that this Bill confers on it relating to the regulation of health research and social care research in order to protect the dignity, rights, safety and well-being of research participants. The second part of the Health Research Authority’s overarching objective is to promote the interests of participants, potential participants and the general public in health research and social care research. The Health Research Authority will promote these interests by facilitating high quality and ethical research. This includes co-operating with others to create a unified approval process for research and to promote consistent and proportionate standards for compliance and inspection. To meet its objective of protecting and promoting participants, potential participants and public interest in research, we would expect the HRA to engage patients and the public in its work. For example, Schedule 7 would give it the power to set up committees or sub-committees which may include people from outside the Health Research Authority.
I turn now to the specifics of Amendment 58A, which seeks to make encouraging the translation of research into innovative practice a function of the Health Research Authority. First, I should like to reassure the noble Lord, Lord Collins, and the Committee that we are fully committed to encouraging the translation of research into practice. The Health and Social Care Act 2012 recognises the need to promote research and the use of research evidence and has created unprecedented powers and duties at all levels to meet that need. When it was passing through your Lordships’ House, we debated the duties that the Act places on the Secretary of State. Noble Lords will remember that the Act places a duty on the Secretary of State to promote the use within the health service of evidence obtained from research when exercising his functions in relation to the health service. The 2012 Act also places equivalent duties on the NHS Commissioning Board, now known as NHS England, and clinical commissioning groups when they are exercising their functions under the 2012 Act.
Lord Turnberg
My Lords, I am sorry to rise again, but I have a very brief question. In a clause dealing with promoting regulatory practice, why is the Secretary of State No. 1?
Earl Howe
My Lords, a great many points have been raised in this debate, so I may take a little time to respond. I hope that the Committee will bear with me. Amendments 58B to 62 seek to give the Health Research Authority a stronger role in streamlining the management of research, particularly in the NHS. I am the first to recognise that delays in obtaining research approvals in the NHS remain a problem for many researchers and that there is an expectation that the Health Research Authority will help to improve this situation through its relationship with the NHS.
I also appreciate that noble Lords, particularly in relation to Amendments 61 and 62, seek reassurance that all providers of NHS services will be required to pay attention to the guidance that the authority is required to produce under Clause 98(6). This issue was highlighted by both the Academy of Medical Sciences and the Wellcome Trust during pre-legislative scrutiny of the Bill. The clauses in the Care Bill would give the Health Research Authority a unique, free-standing duty to promote the co-ordination and standardisation of practice in the UK relating to the regulation of health and social care research. At this point I reassure the noble Lord, Lord Turnberg, that the duty of co-ordination and standardisation necessarily involves co-ordinating and standardising the practice of NHS trust research and development committees.
In addition, the Health Research Authority will have a reciprocal duty to co-operate with other regulatory bodies or individuals that have statutory functions in the regulation of health and social care research. Statutory functions are an important point. I take this opportunity to address the three amendments listed here that are concerned with this duty. In doing so, it is important to explain why Clause 98(1) would place a duty of co-operation on the HRA and in particular the Chief Medical Officer of the Department of Health. The reason is that the Chief Medical Officer holds functions relating to research under the Abortion Regulations 1991. These require notice to be given to the Chief Medical Officer of any abortion and any information relevant to it.
The disclosure of such information is restricted, except in specific circumstances, which include disclosure for the purposes of scientific research. The Chief Medical Officer is responsible for determining whether disclosure can be made. It is because of the Chief Medical Officer’s functions in approving the disclosure of information about abortions for the purposes of scientific research that the authority, the Chief Medical Officer and the bodies and individuals listed must co-operate with one another with a view to standardising and co-ordinating practice relating to the regulation of health and social care research. Similarly, other bodies and individuals listed have functions relating to the regulation of health or social care research. So it links in those statutory functions.
I listened with great care and a great deal of understanding to the noble Lord, Lord MacKenzie, my noble friend Lady Cumberlege, the noble Baroness, Lady Emerton, and others on their wish to expand the duty of co-operation to include the Chief Nursing Officer. The Chief Nursing Officer is an NHS England role, while the Department of Health has a director of nursing. Neither of these posts has any statutory functions relating to the regulation of health or social care research. That is the key point. For this reason, Clause 98(1) does not create a duty of co-operation on the HRA either with the Chief Nursing Officer of NHS England or with the Department of Health’s director of nursing and the bodies and individuals listed in Clause 98(1). I hope that this explanation is helpful.
On Amendments 58B and 58C, the medical royal colleges, the General Medical Council, the General Dental Council and the Nursing and Midwifery Council do not have such statutory functions in this context either. The noble Lord, Lord Walton, made an important and powerful point about the GMC. However, the Health Research Authority would have powers, under paragraph 13 of Schedule 7, to work with the GMC and the other medical regulators to help and advise them in their work. That, I hope, will reassure the noble Lord that that aspect of the HRA’s work has not been forgotten about.
Amendment 60A would require the Health Research Authority to assess the impact of proposed changes to the system for setting pharmaceutical prices on health and social care research. I pay tribute to the noble Lord, Lord Hunt, for introducing this extremely interesting topic to our debates. I believe that this function is best undertaken by the National Institute for Health and Care Excellence rather than making it part of the authority’s role in promoting the co-ordination and standardisation of regulatory practice. As he will know, we have already announced that NICE will play a central role in the pharmacoeconomic evaluation of new medicines in the context of the framework for value-based pricing, once that is announced.
The noble Lord made a point about value-based pricing, in that it is important for the Government—I agree with him—to take account of the need to attract investment into this country. As set out in our plan for growth and our Strategy for UK Life Sciences, the Government are absolutely committed to ensuring that the UK continues to offer an environment that supports and encourages investment and innovation by the life sciences sector, and where the NHS is a world leader in clinical trials. However, there are some legitimate points of debate here about the impact of medicine prices on companies’ decisions on where to locate investments or conduct research. As highlighted in the 2007 NERA study, Key Factors in Attracting Internationally Mobile Investments by the Research-Based Pharmaceutical Industry, this is a global market. Companies locate where they can find the best science base at reasonable cost, taking into account other factors such as taxation, flexible labour markets and economic stability. It is not self-evident that the pricing of medicines drives decisions of this kind. It is an interesting debate to have, but perhaps it is one for another occasion.
The noble Lord also asked about the cancer drugs fund. It is very heartening that more than 30,000 patients in England have now benefited from that fund, which in total amounts to £650 million over three and a half years. We are committed to building on that success. In the context of developing new pricing arrangements for branded medicines, I can reassure the noble Lord by saying that we are exploring ways in which new patients can benefit from innovative cancer drugs at a cost that represents value to the NHS. NHS England is very much included in that discussion, and we well appreciate how important it is for patients.
To meet the duty of co-operation in this whole area, the Health Research Authority will be required to take the lead in actively identifying ways in which to remove duplication, streamlining the regulation of health and social care research and seeking to ensure that regulation is proportionate. At this point, I reassure noble Lords that the authority must facilitate all types of high-quality ethical research, including research that is multidisciplinary in nature and research by multiprofessionals. In keeping under review matters relating to the regulation of health or social care research, the authority may provide advice to the Secretary of State and must do so on request. Such advice could include recommendations to improve the regulatory landscape for research.
The existing Health Research Authority, the Special Health Authority, has already begun an ambitious programme of work to speed up the research journey in the UK, including the creation of a unified approval process and consistent, proportionate standards for compliance and inspection. I hope that will be welcome news to the noble Lord, Lord Patel, in particular. In doing so, it is working closely with other bodies, including representation from the NHS, to identify and implement effective solutions to make it faster and easier to initiate research.
Baroness Emerton
I return to Amendment 59 and thank the Minister for explaining that there is no statutory requirement in this regard relating to the Chief Nursing Officer or the director of nursing. In the light of the comments that have been made about research and nursing this afternoon, will the Minister look at how we can take forward nursing research? If the structure is wrong for NHS England and the director of nursing for public health, where can we fit in a statutory requirement for research to be included? We cannot go on without having a means of recognising the importance of evidence-based practice based on research.
Earl Howe
My Lords, I heard very clearly a strong message from noble Lords on that point. Indeed, I recognised the noble Baroness’s strength of feeling in our earlier debates on Health Education England. Having noted that strength of feeling, I would like to engage with noble Lords between now and Report to see what avenues we can pursue in this area. I cannot make a specific commitment now, but I am very happy to talk further about these issues.
Lord Turnberg
I bring the noble Earl back to Amendment 60 on the research and development committees of NHS trusts. He made some very reassuring comments about the work that is going on in the HRA to try to unify this area. One of the difficulties at the moment is that the foundation trusts are a law unto themselves to a large extent and jealously guard their independence. I wonder whether we need to strengthen the HRA’s arm by including something about this area in the Bill.
Earl Howe
I understand the issue that the noble Lord has raised. There are a number of ways of exercising leverage on foundation trusts, if I can put it in that rather impolite way. One of them relates to the funding from the National Institute for Health Research. The noble Lord may well be aware that as from 1 April that funding is conditional on the 70-day timeline for the recruitment of the first patient into a trial. If that timeline is not met, the funding does not follow. I can tell the noble Lord that that has concentrated minds rather effectively across the health service, including in foundation trusts, towards achieving a much more efficient and effective decision-making process.
I am aware that I did not answer a question from the noble Lord, Lord Patel, about rationalising the number of research ethics committees, which may well bear upon this issue in another sense. The HRA and its predecessor have made good progress in reducing the timelines for ethical approval, something that stakeholders have recognised. The current special health authority feasibility study is looking at how to address other delays whereby trust decisions can be made based on their capacity and capability to take part in research. This is ongoing work. I come back to my point about the core function of the HRA, which is, above anything else, to protect the interests of patients and the public. It might not be advisable to load on to it too many other roles that could detract from that core function.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for that comprehensive response. I cannot help thinking that in order to protect the patient and the public there must be recognition that high-quality research is one of the best ways to enhance the quality of patient care. I remain concerned that bodies in the NHS still do not understand the importance of getting their act together in research approval. That does not mean that they do not have to go through a thorough process, because there clearly has to be a rigorous process to protect the public. I would like to see stronger language in the Bill that essentially allows the HRA to intervene if undue delays take place. I hope that we can return to that on Report.
I am grateful for the noble Earl’s comments on value-based pricing. All I would say to him is that I have been disappointed that there has been a great lack of public debate on this matter. I know that the department is shortly to publish further work. It is essential that these ideas are tested, and I am concerned that this is going to be simply a matter of negotiation between his department and the industry without there being a wider discussion of the implications. I appeal to the noble Earl for some opportunity on that.
Finally, the Minister has made it clear that the list in the clause represents bodies concerned with regulation, and that is now well understood. I come back to the question raised by the noble Baroness, Lady Emerton: is there not a case for another clause stating that there is a general duty of co-operation? There is an argument that while, of course, you have your statutory regulators which need to co-ordinate their efforts, you also want a lot of organisations and people to be involved, including the Chief Nursing Officer and the Director of Nursing at the department. I put that forward as a suggestion and beg leave to withdraw the amendment.
Baroness Thornton
My Lords, it is a great pleasure to be back on the Front Bench as part of my noble friend’s health team, even if it is for a short time. I join other noble Lords in sending best wishes to the noble Lord, Lord Willis, for a speedy recovery.
As noble Lords will know, I have been interested in the future of the HFEA and HTA both as a Minister and during the course, in the early days of this Government, of the slash and burn Public Bodies Act, which both these bodies survived. The idea of merging the HFEA and HTA is not new, as my noble friend Lord Warner said, and has been rejected on more than one occasion. I am puzzled by the noble Lord, Lord Patel, raising it now, especially in the middle of yet another review. What I waited to hear, particularly from noble Lords with scientific and research backgrounds, was what the public thought. The right reverend Prelate was right when he said that this is also about how people feel about these issues, not just how the great doctors and scientists think things should be done. In fact, that was how we started out with all these issues.
As my noble friend Lord Warner said, this was first raised by my Government. We proposed establishing a new arm’s-length body called RATE—the regulatory authority for tissue and embryos. According to my research, in 2007 the Government wisely decided not to proceed with that following criticism from a Joint Committee set up to scrutinise that draft Bill. The arguments advanced against RATE then were just as persuasive as they are today. Many of us have held that there is little overlap in the work of the two bodies and that the specialist expertise each provides should be maintained to ensure that regulation remains effective and public confidence is maintained. The discussion we have had so far today has not convinced me that this proposal is the best way forward at the moment. The independence of the HTA and HFEA is important for a number of reasons, not least because of the public confidence needed in both the areas they cover.
In 2010, the Government proposed as part of their bonfire of the quangos that the functions of the HFEA and the HTA should be transferred largely to the CQC. Noble Lords will remember the debate about that during the passage of the Public Bodies Act. Following an extensive public consultation, that proposal was also rejected by the Government in January this year. Once more, a clear majority of those who responded thought that the risks involved in such sensitive areas of medicine were just too great. Instead, the Government decided that an independent review of the way the HFEA and HTA carry out their functions should be undertaken by Justin McCracken. I understand that Mr McCracken’s review is complete and Ministers have yet to decide what to do. Perhaps we will have a sneak preview of that today.
Is there new evidence that there is an advantage in merging these two distinct and expert organisations? As I said, they have different roles. According to the brief I was sent, there are fewer than 10 organisations jointly regulated by both organisations. As context, around 130 organisations are regulated by the HFEA and 800 by the HTA across diverse sectors. On these Benches we are nervous that the amendment tabled by the noble Lord, Lord Patel, to merge the boards of both these organisations risks losing specialist expertise held by the HTA and HFEA and the unique roles in law that their respective boards have.
During the committee scrutiny of the Bill in its draft form—as the Care and Support Bill—the committee advised against a full merger of the boards. In its call for evidence, the committee asked for views on precisely this question. As far as I know, respondents unanimously opposed the abolition of either body or the transfer of their functions. The Academy of Medical Sciences replied:
“There is a great deal of support among our community for the HFEA and the HTA; both are perceived as having developed the experience to respond in a balanced, practical way to the changing landscape that reflects the evolving risks and benefits of research. The relatively small savings to be made through disbanding the HFEA and the HTA need to be balanced against the inevitable period of disruption and uncertainty, and any potential risk of loss of expertise, efficiency, effectiveness and coherence that could hinder research and practice and result in the loss of public and professional confidence … We therefore support retaining both the HFEA and the HTA, providing they work closely with the HRA and other regulators to further streamline the regulation, inspection and governance process for patient and public benefit”.
I accept precisely the point made by my noble friend Lord Winston and others that there are unnecessary delays and that there are clearly issues to be addressed in the way that these bodies operate.
The committee concluded that Ministers should not have the power to abolish the HFEA or HTA and recommended that the relevant clause should be deleted. While its conclusions were about abolition, these same points apply to the merger of the boards: expertise would be lost, there would be huge disruption and all for relatively tiny cost savings at the moment. The work of the HTA and HFEA is of enormous scientific and ethical importance. We accept entirely that there is always room for improvement and we should never be complacent. The review led by Justin McCracken will no doubt make recommendations for further efficiencies. We would be jumping ahead of his proposals by agreeing this amendment at this time.
Earl Howe
My Lords, this has been a very instructive debate and one to which I have listened with enormous care and interest. It takes us back to a well-worn area, as noble Lords have been keen to point out. The amendment proposed by the noble Lord, Lord Patel, would abolish the HFEA and HTA and replace them with a new regulatory body, the human tissue and embryo authority. It would also transfer responsibility for the regulation of infertility treatment involving embryos, sperm and eggs to the CQC.
I listened with great care, as I always do, to the noble Lord, Lord Patel, when he moved the amendment. As has been amply demonstrated in the course of this debate, the prospect of the merger of the HFEA and HTA, or of the transfer of their functions elsewhere and the subsequent abolition of the two bodies, is by no means a new one. It has been considered carefully and consulted on on a number of occasions over recent years, including by Members of this House.
In 2007, as we were reminded, a Joint Committee of both Houses of Parliament, chaired by my noble friend Lord Willis, considered a proposal to replace the HFEA and HTA by the regulatory authority for tissue and embryos—RATE. The committee roundly rejected that proposal. It recognised concerns expressed by stakeholders about the risk of losing the specialist expertise that the HFEA and HTA individually hold and the small extent to which the two bodies actually cover common ground. That point was made very powerfully by the noble Lord, Lord Walton, today.
The Government are as keen as anybody to minimise the number of arm’s-length bodies when we possibly can. A substantial exercise was undertaken across government when the coalition was new to do exactly that and a great number of bodies were abolished. Within that framework, last year the Department of Health undertook a public consultation on a proposal to transfer the functions of the HFEA and HTA to the Care Quality Commission and the Health Research Authority, as part of our review of the arm’s-length bodies. Across the full range of respondents, a majority of three-quarters disagreed with the proposal. The main reason cited was that the HFEA and the HTA have developed considerable expertise in their highly specialised fields. They were said to be trusted and respected by the regulated sectors. Respondents believed that this expertise and trust would be lost were a transfer of functions to take place. That point was well made by the noble Baroness, Lady Thornton, who I am delighted to see on the Front Bench opposite. The noble Lord, Lord Patel, indicated that in his view it was unnecessary to have two separate organisations, but that was not the view of those who responded to the consultation.
Respondents also said that they did not believe that the CQC was well-placed at the time to take on the functions of the two bodies and they feared that those functions would be subsumed by the CQC’s other responsibilities. Another strong message from the consultation was that the small size of the two bodies and the small overall anticipated savings did not warrant the risks involved in abolishing them and transferring their functions. I recall that the noble Lord, Lord Warner, made that very point when we debated these issues during the passage of the Public Bodies Bill. The Government listened to the responses and decided not to proceed with the transfer and abolition. However, we also recognised the clear message from the consultation that there is scope for the HFEA and the HTA to achieve further efficiencies in the way that they operate. That much, I hope, all noble Lords agree on.
The noble Baroness, Lady Thornton, asked whether there was any new evidence about the value of a merger. It was with that very question in mind that we commissioned an independent review of the two bodies by Justin McCracken, former chief executive of the Health Protection Agency, in January this year. The review included looking at the scope for shared membership and leadership of the HFEA and HTA and for their merger. The report of the review was submitted to Ministers in April and is currently under consideration, so I am afraid that I am not in a position to share any conclusions quite yet. I will give way.
Earl Howe
I sincerely hope and anticipate that we will, but I am afraid I do not have a particular date in my brief. If I am able to supply the noble Baroness with that information, I will be happy to do so. The noble Lords, Lord Winston and Lord Patel, cited the number of different regulators involved in the organisational arrangements and the regulation of regenerative medicine in the UK and pointed to the complexity of these arrangements. I understand that point of view, but we are now in a world where the regulators in this area work very closely together to provide regulatory clarity to the sector and to ensure that the system actually works. I know, for example, that the MHRA and the HTA work closely together and have carried out joint inspections.
The department, along with the UK regulators, worked together to produce a regulatory map for stem cell research and manufacture, and I think that too has been helpful. I fully understand and appreciate the interest of noble Lords in this matter and their desire to streamline regulation. We all welcome that aim. I hope that noble Lords will appreciate that the Government have given this matter consideration in some depth, including through public consultations. The strong message we have consistently received from stakeholders is that the HFEA and the HTA should not be abolished or merged or their functions transferred elsewhere. Our latest consideration of this is the scope for regulatory streamlining that the McCracken review looked at, including the scope for regulators to work closely together. That consideration is currently taking place. As soon as the Government’s position on it is determined I will ensure that noble Lords are informed. I am additionally told by a most reliable source that we do not yet have a confirmed date for that announcement.
I am always loath to disappoint the noble Lord, Lord Patel, but I hope he will understand that we did not reach this position without due deliberation and indeed without taking extensive soundings among the stakeholders who are most concerned in this area. I hope he will feel, if not exactly comfortable in withdrawing his amendment, at least satisfied that the matter has been fully debated.
Lord Campbell-Savours
My Lords, I will intervene only briefly, unlike yesterday when I went on at length on a couple of the amendments. My noble friend Lord Warner referred to the absence of a new force in town. I suspect that in some ways he is referring in part to the confusion referred to by my noble friend Lord Hunt. I will deal with paragraphs 60 and 61 of the Francis report, where two recommendations are made. Will the Minister, in his response to this debate, just tell us why the Government are refusing to implement those recommendations? I will not read those paragraphs in their entirety, but just the key points. The report states:
“The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission. A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning”.
I would have thought that the Bill was the opportunity to do that. If that is the case, will the Minister tell us precisely what the objection is, and why we are not taking up that particular recommendation from the Francis report?
Earl Howe
My Lords, in addressing this complex and very important topic, I begin by thanking all noble Lords who have spoken in this debate, not least those who have introduced the amendments they have tabled. I welcome the opportunity to debate these clauses as they form a key part of our response to the issues raised by Robert Francis QC. They deal with difficult issues and I recognise the critical importance of getting this right. I particularly welcome the support of the noble Lord, Lord Hunt, for the principles, which I can assure him have governed the Government’s work in this area.
The intention of the changes we are making is to deliver a strong but flexible process for tackling quality failures to ensure that all NHS trusts adopt a rigorous approach to maintaining high quality care. I hope that noble Lords have had an opportunity to familiarise themselves with the document my department published, in collaboration with CQC, Monitor, the Trust Development Authority and NHS England, copies of which can be found in the Library. In my response to the amendments, it may help if I summarise the key elements of our proposals and why we feel that the approach we have taken is appropriate.
The Francis report made a strong case that the regulation of NHS trusts and foundation trusts needed to change so that greater emphasis is placed on addressing failures of quality. We agree. In future, roles within the regulatory system will be simpler and clearer. The Care Quality Commission will focus on assessing and reporting on quality, and Monitor and the NHS Trust Development Authority—the TDA—will be responsible for using their enforcement powers to address quality problems. To free up time to care, the overall regulatory burden on providers will be radically reduced. I remember that that concern was raised from the Benches opposite when I made a Statement to your Lordships on the Francis report. However, where there are failings in the quality of care, there will be a stronger response.
The CQC, through its new Chief Inspector of Hospitals, will become the authoritative voice on the quality of care provided. It will take the lead in developing a methodology for assessing the overall performance of organisations in meeting the needs of patients and the public. In doing so, the CQC will consult a range of bodies, including Monitor, the TDA and NHS England, to ensure that national organisations are working to a common definition of quality. The idea here is to arrive at, if I can put it this way, a single version of the truth: a single, national definition of quality that brings together information and intelligence from commissioners, regulators and local Healthwatch, as well as from the other bodies I mentioned. This new approach to assessment and inspection will form the basis of a new system of ratings to provide a fair, balanced and easy to understand assessment of how each provider is performing relative to its peers. It will also provide the basis for identifying where improvements are needed. We will, of course, debate the provisions on ratings later on.
The noble Lord, Lord Hunt, has tabled a number of amendments—Amendments 64A, 66ZB, 66ZD and 66ZF—relating to the consistency of CQC’s judgment. I understand the concern to ensure that there is transparency and consistency over how decisions to intervene are reached, but I am not sure that it can be defined through legislation. In part, it will be for the CQC, Monitor and the TDA to agree and set out in guidance—something, incidentally, they have all committed to doing. However, ultimately they must be matters of judgment rather than the tick-box mentality that allowed the failures uncovered in Mid Staffordshire to go unnoticed for so long.
Lord Warner
My Lords, I am sorry to interrupt, but I have here a document that the noble Earl’s department sent out in May, signed up to by the TDA, Monitor and the CQC. I want to direct his attention to paragraph 27 of that document, which I mentioned in my remarks. As I understand it, this sets out the Government’s policy on the relative difference between TDA and Monitor. It makes it very clear. I shall quote from it, because this is absolutely the nub of the issue:
“Monitor can also place a foundation trust into special administration directly, following consultation with the Secretary of State and the CQC, on the grounds that it has, or is likely to become, financially unsustainable. The changes proposed in the Care Bill will enable it also to do this where it is apparent that a provider is clinically unsustainable”.
The initiative lies with Monitor. It can do this in relation to the trust of my noble friend Lord Hunt or to any other foundation trust when it has had a warning notice from the CQC and thinks change has not taken place. Hold that thought in the head and look at what the document says about NHS trusts that are in the maw of the TDA. It states:
“Managing the process of reconfiguring local services to provide sustainable, high quality healthcare that meets patient expectations and needs is primarily a role for local commissioners, supported by NHS England. In the event that an NHS trust or foundation trust has failed to make improvements and commissioner-led efforts to resolve the issue have not succeeded, special administration may, as a last resort, provide a mechanism for dealing with NHS trusts and foundation trusts which have become either clinically and/or financially unsustainable. Where the TDA considers it is in the interests of the health service, it can already advise the Secretary of State to place an NHS trust which it considers to be either clinically and/or financially unsustainable into special administration”.
Monitor can simply take that decision itself when it has the evidence. The TDA has to go through a series of hoops with commissioners before it can advise the Secretary of State. That is what this document seems to say. If it is wrong we need to be clear that it does not say what the Government mean it to say.
Earl Howe
I think the noble Lord has misled himself. The way in which we envisage the system working for both trusts and foundation trusts, where we have a provider that looks as though it might be clinically unsustainable, is to encourage commissioners and the provider concerned to come together and have a grown-up conversation about the configuration of services. That is the first resort and it is the normal course of action that we would expect, whether it is an NHS trust or an NHS foundation trust. In either case, trust special administration is going to be a last resort.
The noble Lord is right that, while we envisage the process of trust special administration to be broadly the same in both instances, there has to be a difference. The difference arises from the fact that foundation trusts are, in statute, much more autonomous bodies than NHS trusts. NHS trusts are still subject to directions from the Secretary of State. What the TDA does is act as the Secretary of State’s proxy in overseeing their quality, sustainability and governance. That is why there is a process around referral to the Secretary of State before a trust special administration can take place for an NHS trust, whereas that is not the case with a foundation trust. That is because Monitor is the independent regulator for FTs charged with doing that.
The noble Lord does not need to make too much of the differences that he has purported to identify in that document, which I will, of course, re-read in case we have inadvertently misled the Committee. The point I sought to make was that in no way do we envisage a material difference in the process which will ensue from a clinically unsustainable provider, or one whose quality is in question.
The noble Lord, Lord Warner, asked what will happen to NHS trusts that do not meet expectations of the accountability framework published last December. The accountability framework covers clinical and operational metrics, governance, leadership and finance. If the TDA judges that a trust is failing the accountability framework, it has a number of options. It can request recovery plans—Monitor is also in a position to do that with FTs; it will increase the frequency of its engagement with the trust; it can commission an independent investigation; it can review the skills and competence of board members. Again that is something that Monitor can do with FTs. It can commission interim support to provide additional management capacity—again that is something that in theory Monitor could do under its licensing arrangements. Ultimately, the TDA can exercise the Secretary of State’s functions and terminate appointments. Monitor has similar powers. I want to reassure the noble Lord, Lord Warner, that there is not such a gap as he has made out in this area.
Incidentally, the noble Lord called into question the speed of progress of the foundation trust pipeline. I can assure him that the pipeline is moving. It may look rather glacial from his perspective, and I can understand why. However, even though the TDA was established only on 1 April, two foundation trusts have been authorised since then—Kingston on 1 May and Western Sussex, which was announced today.
The noble Lord, Lord Warner, sounded a warning that this kind of arrangement posed a risk that money could end up being taken away from successful trusts to bolster poorer performers. It is precisely to avoid that that we need to grasp the nettle in some cases as we had to do in south London to ensure that one part of the NHS did not drain the resources that should be shared out more equitably among the rest of the health service. Certainly, this is not the intention of our policy. In fact, the purpose of special administration, if it is deemed necessary, is to ensure both clinical and financial sustainability. When it is clear that a hospital cannot resolve quality failures in its current form, we will no longer have to wait until a trust fails financially before action is taken. That is why I shall talk about special administration in more detail in a second.
In future, issuing a warning notice to a trust or foundation trust will be a sign that there is a serious quality issue at that trust and that significant improvements are required. I fully agree with the noble Lord, Lord Hunt, that it will be important to determine what significant improvements could encompass, as proposed by Amendment 64A. We have been clear that the new warning notices are designed to highlight serious failings, such as a systematic failure to meet fundamental standards. As noble Lords will remember, the fundamental standards are a concept that Robert Francis put forward, whereby treatment or practices in a trust could be said to be absolutely unacceptable by anyone’s measure. The fundamental standards themselves have not yet been defined; that process will be taken forward in the coming months with full consultation with the public, and we need to get that right. That is the issue underlying the provision around significant improvements. Under the 2008 Act, the CQC is already required to publish guidance to detail its approach to issuing warning notices. This will be revised in light of this Bill to include its interpretation of “significant improvement”. That is a flexible and proportionate approach.
When a trust receives a warning notice, just as happens now, it will be published and the CQC will send a copy either to the TDA or to Monitor, depending upon whether they relate to an NHS trust or foundation trust, as proposed by Amendment 65. Clause 74 amends Section 39 of the 2008 Act, which requires that a copy of the notice be sent to Monitor and any other persons whom the CQC considers appropriate. When the notice relates to an NHS trust, this would include the TDA.
I have listened carefully to the noble Lord’s arguments in favour of Amendment 66ZB regarding large providers spread over many sites. This is not a new issue; having a regulatory system that is flexible enough to cope with such organisations has always been critical. At present, the CQC has to ensure that they can take a differentiated approach and can deal appropriately with providers, ranging from large multisite hospital trusts to care homes. This will continue to be the case, so I feel that this amendment, while I sympathise with its intent, is unnecessary.
Clause 75 introduces changes to ensure that when failures are identified, there is a prompt and firm response. We have been clear that when a provider receives a warning notice, the responsibility to resolve problems will remain with the provider in conjunction with the local commissioners, as I referred to earlier. However, serious failures in the quality of care must not be allowed to be endure, so Clause 75 makes changes to ensure that, when quality of care at a foundation trust requires significant improvement, Monitor can take timely action to make changes to leadership or governance to secure improvements in those services. It amends Monitor’s powers under Section 111 of the 2012 Act to enable it to impose additional licence conditions on foundation trusts when the Care Quality Commission has issued a warning notice to that trust. At present, Monitor can make use of these powers only if there is a failure in governance. If the foundation trust breaches those additional licence conditions, Monitor will be able to use its powers to suspend or remove directors or governors. The NHS Trust Development Authority already has powers to intervene in NHS trusts or to remove or suspend boards, as appropriate.
“( ) In subsection (4) of that section, for “the reference in subsection (1) to the Secretary of State is to be read as a reference” substitute “the references in subsections (1) and (3A) to the Secretary of State are to be read as references”.
( ) In paragraph 24 of Schedule 14 to the Health and Social Care Act 2012 (abolition of NHS trusts in England: consequential amendments to section 65N of the National Health Service Act 2006), after sub-paragraph (2) insert—
“(2A) In subsection (3A), for “the Secretary of State” substitute “the regulator”.””