Health: Cancer
Earl Howe Excerpts(10 years, 11 months ago)
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Lord Saatchi
To ask Her Majesty’s Government in what proportion of deaths recorded as caused by cancer is the actual cause of death the treatment of cancer.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
The Office for National Statistics publishes national cancer mortality data annually. Data are collected where cancer has been recorded as the cause of death, but not on treatment for cancer as the cause of death. I therefore regret that I am unable to provide this information.
Lord Saatchi
My Lords, I thank my noble friend for that reply. The point of this Question is that there is no answer to it. Since I tabled the Question, I have received an estimate from within the medical profession that last year 15,000 people in Britain were killed by cancer treatment rather than by cancer. We do not know whether 1% or 100% of patients die as result of the treatment; what we do know is that cancer drugs do such damage to the immune system that the patient is helpless to resist fatal infections such as MRSA, E. coli or septicaemia. Does my noble friend agree, as I think he has, that the official statistics for the UK cannot distinguish between cancer death and treatment for cancer death? Is this not because the ONS, under WHO guidelines, records only the single underlying cause of death? In other words, it does not record the sequence of causation, sometimes known as the sequence of conditions, that led to the death. This is supposed to be the era of big data. Will my noble friend review the limitations of cancer mortality statistics in order to assist scientists and doctors to have the information to move forward innovation towards a cure for cancer?
Earl Howe
My Lords, I agree that it is important to have more information on the effect of cancer treatments on mortality. New data collections which will provide more detail in this area are under way. The systemic anti-cancer therapy dataset will enable better information to be collected about deaths after the delivery of chemotherapy, and the cancer outcomes and services data set will provide information in respect of death after surgical treatment. However, it is important to make one point here: it can be hard to identify the precise cause or sequence of progression of factors resulting in death, particularly for those with end-stage cancer or who are particularly frail and are experiencing physical deterioration. I do not think that it can ever be a precise science.
Lord Campbell-Savours
My Lords, what about the circumstances where a person awaiting treatment in a congested cancer clinic is surrounded by patients who are coughing and spluttering? There will be consequential effects on immunity for those being treated. It may well be the drop in immunity that kills the patient, not necessarily the original cancer.
Earl Howe
My Lords, the noble Lord makes a good point. When recording the cause of death on a medical certificate of cause of death, doctors are required to start with the immediate, direct cause of death and then go back through the sequence of events or conditions that led to death until they reach the one that started the fatal sequence. This initiating condition will usually be selected as the underlying cause of death according to the International Classification of Diseases coding. However, that does not mean that someone with a primary cause of death of cancer will not have pneumonia, or whatever it happens to be, recorded somewhere on the death certificate.
Lord Patel
My Lords, does the Minister agree that as we progress with the current research into the molecular tagging of drugs that have the same molecular make-up as the cancer itself and nanomedicine we will be better able to target cancer tissue while leaving normal tissue alone? That will save lives lost to the complications related to treatment.
Baroness Jolly
My Lords, everyone—families, statisticians, managers and, indeed, researchers—wants accurate death certificates. What are the arrangements to monitor the recording of death as part of clinical governance?
Earl Howe
My noble friend has raised a very live issue because consultation will begin shortly on the Government’s plans to reform the governance relating to death certification. The proposed reforms will simplify and strengthen the process for death certification by appointing local medical examiners to provide independent medical scrutiny of the cause of death for all deaths not subject to coronial investigation. The medical examiner will improve the accuracy of information recorded on medical certificates of cause of death because the process will include a review of medical records and consideration of the circumstances leading to death.
Baroness Symons of Vernham Dean
My Lords, does the Minister agree that some forms of cancer, particularly the leukaemias and, within those, acute myeloid leukaemia, need a very aggressive form of chemotherapy in order to maintain life and that that necessarily includes the very high risk of infection through blood poisoning or diseases affecting lung capacity? Where the only alternative to very aggressive forms of chemotherapy is the certainty of death, does not the noble Earl agree that these forms of chemotherapy remain enormously important in the treatment of cancer?
Lord Ribeiro
My Lords, we have 11 cancer registries in the United Kingdom and Public Health England is due to merge eight of the English cancer registries with the National Cancer Intelligence Network this year. The United States and Sweden have national registries, and the benefit of that is that they are able to establish not only the diagnosis and causation but also the impact of treatment on patients and provide much more information to improve the quality of outcomes for patients. Is it not time that we had a national registry, mindful that independence for Scotland may put this at some risk?
Earl Howe
My noble friend raises a very important issue. I agree that it is important to draw together as much information as we can about causes of death from across the country. However, I am advised that the question of whether a cancer-related death can be attributed to the underlying disease or to the treatment cannot be answered comprehensively from information collected as part of the death certification process or the cancer registration process or, indeed, a combination of both. However, as I hope my previous answer indicated, I am sure that this is a developing science.
Baroness Brinton
My Lords, the Minister has kindly explained the tracking of the causes of death. What advice is given to doctors about recording dementia, which is often excluded when somebody has died of cancer? In the case of my late father, it was possible to get it added, but I suspect it may also be one of the reasons why dementia is underrecorded in this country.
Earl Howe
My noble friend asks a very good question. I will write to her on the specific question of dementia. I understand that the completed medical certificate of cause of death is given to the bereaved family which will present it to the registration service to register the death. The registrar will check that the doctor has completed the certificate fully, so it could then be open to the family to question anything that is not quite right on the certificate.
NHS: GP Dispensing
Earl Howe Excerpts(10 years, 11 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the current NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 continue an agreement reached between representatives of pharmacist and GP contractors setting out the circumstances under which patients living in designated rural areas are eligible to receive dispensing services from their GP. To make any significant change in the regulations would mean reopening complex and lengthy discussions. We believe that contractors’ representatives are satisfied with the current regulatory arrangements and would not support an extensive review.
The Countess of Mar
My Lords, does the Minister agree that “no decision about me without me” and the freedom of patient choice have been pivotal to the Government’s NHS reforms? Does he not think it crazy that I, as a patient of a dispensing doctor, can either ask my doctor for a prescription which I can take to a pharmacist in the nearest town or have my prescription dispensed by his staff, whereas my neighbour, who might live just within that 1.6 kilometre boundary, is allowed to get his prescription dispensed only in a pharmacy in the town? Does the Minister agree that the reasons for this rule are now obsolete? It was created in 1911 when there could have been corruption between doctors and patients, and that possibility no longer exists because of the controls.
Earl Howe
My Lords, there is a balance of interests here, not least the interests of the patient. We therefore need a set of rules which reflects those interests. Patients who live in a rural area can be dispensed to by their GP if there is no pharmacy within 1.6 kilometres of where the patient lives, or within 1.6 kilometres of the GP practice. Without these rules, it would rarely be viable for new pharmacies to open to serve rural areas. That would deprive people living in rural areas of the opportunity to benefit from the more comprehensive health service that a combination of a GP practice and a pharmacy can provide.
Baroness Knight of Collingtree
My Lords, can my noble friend say whether all elderly people who have difficulty over this matter are clearly informed that they can ask to have their prescription given by the doctor? For those who have no car and live in areas where buses are not frequent, it is sometimes extremely difficult to manage.
Earl Howe
My noble friend makes a good point. There is a special provision that allows a patient who has serious difficulty in getting to a pharmacy by virtue either of the distance involved or lack of means of communication to receive dispensing services from a doctor. Any patient is eligible to receive these services; they do not have to live in a rural area to do so.
Baroness Masham of Ilton
My Lords, does the Minister agree that some pharmacies do not have wheelchair access? Some have steps, including the one in my own village. However, surely it is the easiest place for a disabled person to receive their prescriptions.
Earl Howe
My Lords, the rules as they stand do not present a major obstacle for disabled patients. Many pharmacies, for example, offer a free prescription collection and delivery service if a patient encounters difficulty in getting into the pharmacy premises. Under that arrangement, the pharmacy collects the prescription from the surgery on behalf of the patient, dispenses it and delivers it to the patient. Patients can contact their local pharmacies to see whether they offer that service.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. I well understand why the noble Earl does not want to reopen the issue, having chaired meetings at the department of the two representative bodies myself. However, I wonder whether the current arrangements are justifiable in 2013. Does the Minister not think that it might warrant his department asking an independent reviewer to look at the situation again, particularly from the point of view of the consumer and patient rather than of either the pharmacist or the dispensing doctors?
Earl Howe
I am sure that the noble Lord is as aware as anyone of the balance that has to be struck here. A GP’s primary purpose is to provide comprehensive medical care and treatment to his or her patients. More than 90% of prescription items are dispensed by pharmacies, which is what most patients expect. However, we must have arrangements to enable patients who live in rural and more remote areas to access medicines more easily. I think the noble Lord will understand that the arrangement for some GPs to provide dispensing services has always been the exception rather than the rule. I do not think there is an appetite on anyone’s part among the professions to reopen these arrangements.
Baroness Jolly
My Lords, these GP-dispensed services come at a cost, but as someone who lives in a rural area I am very glad of it, because it saves me a 12-mile round trip. However, the cost of a practice-based prescription will be apportioned to the CCG in two parts: the actual cost of the medicine itself and disbursement costs. Does my noble friend expect that the disbursement cost mechanism will be looked at again in the light of GPs running CCGs, where, of course, every penny will count towards the care of the patient?
Earl Howe
My Lords, those particular technical matters will always be looked at very carefully to ensure that the right balance is struck. It is open to commissioners to propose a change in the arrangements. If a new pharmacy applies to open, and that could affect GPs dispensing to patients in a rural area, we would fully expect there to be consultation with patient groups and the public. There is a mechanism to ensure that that process can take place.
Emergency Services: Paramedics
Earl Howe Excerpts(10 years, 12 months ago)
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Baroness Gardner of Parkes
To ask Her Majesty’s Government under what circumstances unsupervised, unqualified paramedics may be sent to respond to an emergency call.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, ambulance trusts have a range of staff with different skill levels who are able to respond to patients depending on the severity of their illness or injury. It is the responsibility of individual ambulance trusts to determine how best to deploy those resources, ensuring that suitably qualified, skilled and experienced staff are sent to respond to calls.
Baroness Gardner of Parkes
Will the Minister tell me, therefore, whether he thinks that it was just an individual case or whether a general principle was at fault in the case of Sarah Mulenga, which has been widely publicised? The coroner ruled that neglect contributed to her death and found,
“a gross failure to provide basic medical attention”.
That was when two unqualified paramedics went to her call and, apparently, did not take her to hospital or even register her normal condition. How often does that sort of thing happen? Is it necessary to change the training system so that there will be more people qualified and trained?
Earl Howe
My Lords, the London Ambulance Service has advised that the article in the Sunday Times was slightly misleading, in that the two members of staff who attended that particular patient were student paramedics in their third and final year of training and so were sufficiently qualified to work unsupervised. It is inaccurate to call them “unqualified”. The issue in this case was that, despite their qualifications and experience, the crew did not act in accordance with their training or the procedures that were laid down. That has been acknowledged by the London Ambulance Service, which has said that it believes that the failings are not reflective of the hundreds of ambulance staff who provide a high level of patient care to Londoners every day.
Lord Harris of Haringey
My Lords, the Minister has suggested that, on the issue raised by the noble Baroness, Lady Gardner of Parkes, it is really down to the management of ambulance trusts to make all those decisions. There is widespread concern around the country about the delays in ambulances reaching emergency cases. For example, I am told that the police now find that they are the first responders and end up having to take people to hospital. Is this a problem with the management of ambulance trusts or is it about the level of resources being made available by commissioners for emergency services and ambulance services?
Earl Howe
The noble Lord is quite right that certain areas of the country have seen unacceptable delays in ambulance response times—I am aware of two trusts in that regard. However, this is not an issue around a lack of trained paramedics. Projections by the Centre for Workforce Intelligence show that there is a secure supply of paramedics until 2016. The College of Paramedics has stated that training posts on courses are always filled and, currently, 900 ambulance technicians are training to become paramedics. We are seeing an increase in paramedic numbers, which is encouraging.
Baroness Masham of Ilton
My Lords, does the noble Earl agree that first aid ought to be taught in all schools mandatorily, so that as many people as possible in the community can learn first aid, help when there is an emergency and save lives?
Lord Davies of Coity
Will the Minister address the question asked by the noble Baroness, Lady Gardner? It has been said quite clearly that there are circumstances in which unqualified paramedics attend an emergency call. Does he believe that any unqualified paramedic should be responding to an emergency call?
Earl Howe
My Lords, the issue here is that they were not unqualified, as I tried to convey. All ambulance trusts in the UK allow student paramedics to work unsupervised, but only after they have had nine months’ operational experience and have passed both a written exam and a clinical practice observation by a qualified assessor. In this case, the London Ambulance Service accepts that, despite their qualifications and experience, the crew did not act in accordance with their training.
Baroness Jolly
My Lords, there are also volunteer first responders, trained with a minimum skill set and working with ambulance trusts across England. Will my noble friend tell the House who keeps the information about their deployment and how they are monitored for quality outcomes?
Earl Howe
I think that my noble friend is referring to first responders, who should be integrated into the clinical governance structure of all ambulance trusts. The outcomes will be assessed for all calls regardless of who attended the calls in the first instance. A first responder is just that—further ambulance staff would always be sent to a call. In rural areas, these staff can often get there first and provide immediate help, so the use of those people is a matter for local decision.
Lord Colwyn
My Lords, how often are fully trained paramedics and those in the training process evaluated as being fit to practise?
Earl Howe
My Lords, it is up to the employer—in this case, the ambulance trust—to ensure that it has a body of suitably trained and experienced staff. That depends on regular monitoring and ensuring that training is kept up to date. Equally, it is up to commissioners to ensure that the service that they are receiving is delivered by suitably experienced and qualified people. The CQC will also have a role in this regard.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. To follow on from the noble Earl’s final comment, is this not an example of staff such as nurses being trained to be practitioners in the health service but finding that they have not been given enough practical training when they come to treat people on the front line? The noble Earl will know that Health Education England is being established as a non-departmental public body in the Care Bill. Can we ensure that that body has much more control over the curriculum of those being trained to fill these very important posts?
Earl Howe
The noble Lord makes a series of very important points about training. The answer to his final question is that, yes, Health Education England will certainly be looking at the degree of training required to fulfil specific professional tasks across the piece in the health service, including the ambulance service. However, I do not think that this case reflects a lack of appropriate training on the part of the individuals involved. They were appropriately trained; they were just incompetent. That is the point.
NHS: 111 Telephone Service
Earl Howe Excerpts(10 years, 12 months ago)
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Lord Hunt of Kings Heath
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer noble Lords to my health interests in the register.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we recognise that the NHS 111 launches in March did not go as smoothly as planned and that a number of providers have delivered an unacceptable service, especially at weekends. NHS England is working closely with clinical commissioning groups to stabilise providers who have failed to deliver an effective service and to ensure that areas yet to go live are in a safe and fit state to do so.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for that response, but on what grounds was the decision made to go ahead with the national rollout in the light of the results from the pilots, which showed problems with the scheme, and the fact that many people in the NHS advised Ministers and NHS England not to roll it out because it was not ready?
Earl Howe
My Lords, the University of Sheffield did work for the department reporting on the first four NHS 111 pilots. That showed that 92% of patients were satisfied with the service and that 93% felt that the advice given was helpful. It also found that, overall, the service was meeting its objective of getting people to the right place first time. On that basis, it was considered safe to go ahead with a rollout. Unfortunately, in particular areas of the country, the resources deployed to meet the demand have not been accurately assessed, but I stress that that is in a minority of locations.
Lord Mawhinney
My Lords, does my noble friend accept that if the Government were to take firm action and turn back the clock to require general practitioners to provide seven days a week, 24 hours a day comprehensive and efficient service, demands on 111 would greatly decrease?
Earl Howe
My noble friend, with his experience, is very wise on these matters. I think it would be quite difficult to turn the clock back completely, but I take his point. There is enormous scope for GPs to contribute to the drive to keep elderly, frail people in particular out of hospital. Too many people are landing up in hospital with chronic diseases who should never have been allowed to get there.
Baroness Wall of New Barnet
My Lords, the Minister has just stolen my thunder in his response to the noble Lord. Does the Minister have any idea when the failings in the system will be sorted? At the Barnet and Chase Farm Hospitals NHS Trust, of which I declare an interest as chair, we see extra people coming into A&E who, as he has just said, are very poorly and should not really be in hospital because they need antibiotics or something like that and would get better much quicker either in their own home or in a nursing home.
Earl Howe
On the issue of A&E, there is no doubt that the NHS has been under very heavy pressure over the past few weeks. I am pleased to say that over the past two weeks the NHS as a whole has met the 95% standard, but obviously that statistic masks difficulties that are still being experienced in particular locations. The challenge now is to ensure that we are ready for next winter, and all the work that is now being done in NHS England, by clinical commissioning groups and within providers is designed to ensure that we are much readier for the pressures to come.
Lord Laming
My Lords, does the Minister accept that, although we refer to “primary care services”, they are not primary in that they are available for the shortest number of hours per week of any part of the health service? Unless things change dramatically, it is inevitable that accident and emergency will be seen as the first point of call for more and more people, especially in out of office hours.
Earl Howe
I take the noble Lord’s point. That is why the 111 service has been created; there is no doubt that there was a very confusing landscape in which people did not know who to call out of hours, and they did not necessarily have the telephone number of the out of hours provider in their area. The 111 service is designed to simplify all that, and across the vast bulk of England people are getting a good, if not fantastic, service. Unfortunately, in two areas of the country, the south-east and the south-west, we are still seeing problems arising, and those are being gripped.
Baroness Jolly
My Lords, the out of hours services, the ambulance services, A&E and these 111 services need to work in a harmonious and co-ordinated way for the good not only of the patient but of the service as a whole. Will the Minister reassure the House that the 111 service will be part of the review of urgent and emergency services being led by Sir Bruce Keogh?
Lord Tomlinson
Does the Minister accept that Sir Bruce looking at these questions is not necessarily a comfort? Sir Bruce looked at accident and emergency services in south London but, based on what the Minister has said today about the pressure on accident and emergency services, Sir Bruce came to the wrong conclusion about Lewisham accident and emergency.
Baroness Masham of Ilton
The Minister said that there had been confusion in the past. There is even more confusion now. Does he not agree that there should be some publicity for the general public so that they know where to go?
Earl Howe
I agree. NHS England and clinical commissioning groups are engaged in that publicity. I think it will be a while before the general public are fully aware of what NHS 111 has to offer, but I have in my brief a series of very complimentary testimonials about 111 that show that many members of the public are already enjoying its benefits.
Baroness McIntosh of Hudnall
My Lords, would the Minister accept that many people who are not directly involved in the health services find it quite hard to understand why NHS Direct was dismantled in favour of the 111 service, which has clearly not been working terribly well? Does he agree that the fact that this change has not succeeded tremendously well does not give one great confidence that other changes that appear to have been relatively unnecessary will go through successfully?
Earl Howe
I agree. It is unfortunate that the launch of this service was not nearly as satisfactory as was planned. The adverse performance in certain areas of the country has rather overshadowed the very good, if not excellent, performance in other areas, so while not belittling the issue the noble Baroness raises, I think we have to get it in proportion.
Health: Tuberculosis
Earl Howe Excerpts(11 years ago)
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Lord Maginnis of Drumglass
To ask Her Majesty’s Government, in the light of the recent findings reported in The Lancet, why the incidence of multidrug-resistant tuberculosis in the United Kingdom is higher than that in other European countries.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the incidence of multidrug-resistant tuberculosis in the United Kingdom is not higher than in the rest of Europe. However, the proportion of TB cases in the UK that are multidrug-resistant has increased from 0.9% to 1.6% over a decade. Ninety-five per cent of multidrug-resistant cases diagnosed in the UK were not born in the UK.
Lord Maginnis of Drumglass
As always, I am grateful to the Minister for his frankness in his response. The reality is that compared with France and Germany, we have probably three times the rate of tuberculosis in the United Kingdom. In comparison with Italy, we have five times the incidence. The Minister made the point about immigration. Given that we are to have an influx of people from Romania, where the rate of tuberculosis is over seven times what it is in the United Kingdom, and is something like 22 times what it is in Germany and 36 times what it is in Italy, is it not important that his department is able to announce some measure that can be applied to ensure that we are not going to face an epidemic of tuberculosis? Is it not true that the cost of dealing with multidrug-resistant TB is about 14 times that of dealing with an ordinary case of TB?
Earl Howe
My Lords, as regards the very last point made by the noble Lord, he is absolutely right. To treat a multidrug-resistant case of TB typically costs between £50,000 and £100,000, and sometimes more if it is an even more complicated case, in comparison with about £5,000 for an ordinary case of TB.
In fact, to correct the noble Lord, if I may, the proportion of TB cases that were multidrug-resistant in the UK was not high compared with the rest of Europe. The only countries in western Europe with a lower proportion of cases that were multidrug-resistant in 2011 were Ireland, Iceland and Malta. However, I take his point about migrants from eastern Europe. Port health regulations give some powers at the port of entry but this involves knowing quite a lot about the individual, so we are left with what is open to us once the person is in the UK. Once here, health protection regulations can be used to provide local authorities with wider and more flexible powers to deal with incidents or emergencies where infection or contamination present a significant risk to human health, or could present such a risk. I could elaborate on those powers, if the House wished.
Baroness Sharples
My Lords, I had TB in my teens. I know that it often takes years to develop, but why are people not tested in their own countries before they come here?
Earl Howe
My Lords, we are now introducing a system of pre-entry screening. We recognise the contribution that latent TB makes to the overall TB disease burden and that is why we have commissioned NICE to produce a clinical guideline on this. In the countries where TB presents the most significant risk, we shall in future insist that people are screened before they enter the United Kingdom.
Lord Collins of Highbury
My Lords, drug-resistant TB will not subside until the problem is controlled globally. That requires not only intergovernmental co-operation but cross-departmental working. Will the Minister update the House on the Government’s position on the replenishment of the global fund, which will be useful in tackling this problem globally?
Earl Howe
My Lords, the Government fully support the need to scale up efforts to deliver universal access to TB prevention and treatment, and care and support services. Our target date for that is 2015. We have made a long-term commitment of £1 billion between 2007 and 2015 to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and a 20-year commitment to the international drugs purchase facility, UNITAID, which is helping to increase access to and the affordability of TB drugs.
Lord Soulsby of Swaffham Prior
My Lords, if one puts together the high level of drug resistance in the Far East and the high level of migration from the Far East to this country, there is no reason why drug-resistance to tuberculosis should not be more evident than it is at present. If one compares the rate of drug-resistant tuberculosis in the United Kingdom with that of other countries in the European Union, it is fairly clear that we need to do something quite seriously, especially in densely populated areas such as London and Cardiff, before people can come and live in this country. What do the Government have in mind to deal with this issue?
Earl Howe
My Lords, this has to be dealt with nationally and Public Health England is leading a national oversight group for TB that brings together partners from the department, NHS England, local government, NICE, the British Thoracic Society and TB Alert to develop a strategy to reverse the trend of increasing TB rates in the UK. The group recently held its first meeting and the department will continue to support Public Health England in giving national policy leadership in this area.
Baroness McIntosh of Hudnall
My Lords, the Minister will be aware that the problem of multidrug resistance is not confined to TB; there are many other areas where we have every reason to be fearful about the development of drug resistance. Is the noble Earl satisfied that enough is being invested in research into the development of new drugs to be reasonably confident that we are making proper inroads into this problem?
Earl Howe
My Lords, the Government are supporting a range of research programmes to promote the development of new diagnostics, drugs and vaccines for TB. These include £6.5 million for the Foundation for Innovative New Diagnostics, £23.3 million for the Global Alliance for TB Drug Development and £10.5 million for the AERAS Global TB Vaccine Foundation. However, I will look into other areas of disease where there is drug resistance, and if I can supply the noble Baroness with further information I will be happy to do so.
National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013
Earl Howe Excerpts(11 years ago)
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Lord Adebowale
My Lords, I will be brief. I have sat through this debate patiently and I understand the impatience of the House to hear the Minister. I should declare my interest. I have listened to the debate very carefully as a non-executive director of NHS England, the chief executive of a not-for-profit provider of health and social care services in partnership with the NHS and as a board member of a small private company that provides services to the NHS.
I just want to say a couple of things. First, I am absolutely committed to the NHS. My mother was a nurse for 30 years. Listening to the views of the House, it would be possible to slip into a pit of despair having heard the descriptions of the dystopian future that awaits us all if either side of the argument is accepted whole-heartedly. The truth probably lies somewhere in the middle.
However, in reference to the issue of guidance, it might be worth the House hearing that NHS England and Monitor are working in partnership to develop a choice and competition framework. Guidance is important; it is not just the law, but how it is interpreted. The statement that NHS England and Monitor have made points out clearly that: patients and their interest come first and the use of competition must be in patients’ interests; the use of competition must be based on evidence, not ideology, and it is the evidence of what will improve outcomes for patients that matters; commissioners will decide when to introduce competition beyond patients’ rights to choice set out in the NHS constitution—something that not many people have mentioned during the course of this debate, but which has a huge impact on its outcome; where there is poor performance there is an expectation that commissioners will use all the tools available, including competition where that will improve outcomes for patients; and there is a need to strengthen the evidence base further on the potential benefits of introducing competition.
Given that some of the concerns associated with the regulations are about how they will be interpreted and applied in practice, do the Government believe that the regulations are consistent with these principles of how competition should be used in practice and as set out in the agreement between NHS England and Monitor?
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we are debating a set of regulations on which, as we have heard this evening, a great deal of passion and a large quantity of printers’ ink has been expended over recent days and weeks. I would like to begin with three very simple statements, which I hope will be helpful as mental marker posts before I respond to the concerns and questions that have been raised.
First, amid the many changes that the Government have made to NHS commissioning, one area of the law that we have not changed one iota is the law relating to competitive tendering. That law has been in place for a number of years. It has been governed by a European directive, and as regards the rules that govern NHS procurement, these regulations usher in nothing new at all.
Secondly, there is no government agenda to privatise NHS services—quite the contrary. The House may remember that we made it illegal in the Health and Social Care Act for the Secretary of State, Monitor or NHS England to have a policy of deliberately favouring the independent sector.
Thirdly, it is NHS commissioners and no one else who will decide whether, where and how competition in service provision should be introduced. These regulations do not confer any obligation on commissioners to create or promote markets, nor do they require commissioners to unbundle or fragment services against the interests of patients.
I begin with these simple statements because they are key to understanding what the Government are doing and what they are not doing. What we are doing, above all, is having a set of arrangements in place that will protect the interests of patients. The basic purpose of the regulations is to prevent commissioners failing to think about how the needs of their patients can best be met. Equally, their purpose is to ensure that commissioning in the NHS is protected from abuses arising from conflicts of interest or anti-competitive behaviour that works against the interests of patients. There is no encouragement in these regulations, explicit or implicit, to commission services from the independent sector, or indeed any other sector. The regulations enshrine the principle that patients must receive services from the providers, from whichever sector—public, private or voluntary—that are most capable of meeting their needs and improving the quality of services that they receive.
Mechanisms to make sure that this happened were put in place by the previous Administration. These mechanisms consisted of the Principles and Rules for Co-operation and Competition, which were overseen by the Co-operation and Competition Panel. Now that primary care trusts no longer exist, we need to carry over those arrangements so as to apply them to clinical commissioning groups. The Government committed, in their response to the NHS Future Forum report, to maintain the previous rules and place them on a statutory footing in order that they could continue to apply to commissioners. That is exactly what we have done; the panel has been transferred into Monitor, so that there is absolute continuity in how the rules will be applied.
This is a key point for noble Lords to understand. Monitor is now the sector-specific regulator for the NHS. In practice that means that it, not the courts, will be the guardian of patients’ interests and will adjudicate if allegations of anti-competitive conduct arise. In effect, it will act as a firewall between commissioners and the courts. If the House annuls these regulations, that firewall will disappear and I suggest to the House that this could not possibly be in the interests of the health service.
The regulations also make it clear that Monitor has no powers to direct commissioners to go out to tender, which brings me to Regulation 5(1). People who have looked at that regulation have stated that it requires commissioners to go out to tender for just about every NHS service. That is not so. It is not even remotely near the reality. First, the wording of Regulation 5 which refers to “one capable provider” is almost exactly the same as that of the previous Government’s guidance to PCTs. My noble friend Lord Clement-Jones was quite right in pointing this out. I shall now read from that guidance. It said that PCT boards “must act transparently” and without discrimination,
“and be able to demonstrate rationale for decisions on whether or not to competitively tender. In particular, where the commissioner decides to procure through single tender the rationale must demonstrate that there is only one capable provider to deliver the services”.
The circumstances in which a commissioner may therefore award a contract without a competition under the regulations are exactly the same as they have been up to now. There is no daylight between them.
It is worth my making a point about that guidance. It was not guidance that PCTs could take or leave but guidance that was declaratory of public procurement law, which applied to PCTs, so those who think that we are replacing a rather loose arrangement with something more stringent are mistaken. The law was binding before and it is binding now. These regulations are declaratory of the existing legal position, just as the previous Government’s guidance was. However, we also need these regulations to ensure that the various protections for patients and commissioners afforded by Monitor, as agreed during the passage of the 2012 Act, are in place.
We have heard concerns this evening from the noble Lord, Lord Davies, about what might happen to the unbundling of hospital services. I would like to put that misconception to rest. Elective hospital care is not relevant to these regulations. The previous Government brought in a policy known as “any willing provider” for elective hospital services. We have continued with that policy, which means that patients have a free choice between hospital providers who meet NHS quality standards and contractual terms. There is therefore no question of tendering for those services.
In the main, the services where tendering might be relevant are those delivered in the community and certain more specialised services. Again, the overarching principle to guide commissioners is Regulation 2—to do what is in the best interests of their patients. In some circumstances, tendering may be appropriate, but in many cases it will not: for example, where there is only one provider capable of providing the integrated package or pathway of services which the commissioner wishes to secure for its patients. In another situation, they may judge that only one provider is able to meet the clinical quality and safety standards that they require. They may decide not to tender where they conclude that it is necessary for services to be co-located because of the interdependencies between them—a point raised by the noble Lord, Lord Davies, once again—in order, for example, to ensure patient safety.
It is worth looking at the actual wording of Regulation 5(1), which says:
“A relevant body may award a new contract … without advertising … where the relevant body is satisfied that the services to which the contract relates are capable of being provided only by that provider”.
The relevant body has to be satisfied. This means that a commissioner needs to go through a process to make sure that it is taking sensible decisions that genuinely address the interests of its patients. In other words, it must have a rationale for what it does and be satisfied that it is doing the most appropriate thing. As long as it has that rationale, that is where the matter ends. I repeat: in those circumstances there is no one who can oblige the commissioner to go out to tender.
Those who maintain that these regulations usher in a lawyers’ charter are not looking at the evidence. The evidence to date tells us that only a tiny handful of cases have been referred to the Co-operation and Competition Panel in the space of several years. I can tell the noble Baroness, Lady Hollins, that none has gone to court. Since the rules on NHS procurement are staying exactly the same, I fail to see why we should expect a sudden avalanche of challenges to commissioning decisions.
As I said during the passage of the Health and Social Care Act, there is no requirement in these regulations or anywhere else to create markets. Nor, as I have said, is there any requirement for commissioners to unbundle or to fragment services to facilitate competition: in other words, to separate out individual services so they could be provided by a larger range of providers. The decision whether and when to create these conditions and the services to which they apply remains entirely with commissioners.
One of the arguments produced by the noble Lord for annulling these regulations is that they lack clarity, particularly Regulation 5(1). I suggest that is a specious argument. First, the law has not changed. Secondly, employees of commissioning support units, whose job it is to support CCGs in commissioning decisions, are very largely the same people who did exactly the same jobs in PCTs and are entirely familiar with this area of the law. Thirdly, there is already guidance out there, produced by the NHS Commissioning Board Authority last year. Fourthly, Monitor will be providing further guidance to support commissioners in understanding the circumstances in which single tender is appropriate, including specific case studies. This guidance will be consulted on shortly. Monitor will continue, as the Co-operation and Competition Panel did before it, to provide informal advice to help commissioners understand the regulations. We really do not have to worry about lack of clarity here.
I turn now to one or two of the specific questions that were posed in the debate. The noble Lord, Lord Owen, asked why other countries have not applied these procurement laws. All member states in the European Union have been required to transpose the EU directive on public procurement into their own national legislation. In fact, it has been applied in Wales and Northern Ireland through the Public Contracts Regulations 2006.
The noble Lord, Lord Hunt, maintained that the OFT’s role in mergers is evidence of the Government’s agenda to marketise the NHS. First, that issue is in no way related to the regulations that we are debating tonight. Perhaps I could remind the noble Lord that the OFT is acting independently under the powers conferred on it under the previous Administration through the Enterprise Act 2002.
With regard to the Competition Commission gagging clinicians in the Bournemouth and Poole merger case, I suggest that that is not relevant either. My understanding is that those arrangements are simply to prevent the merger proceeding further while it is being reviewed. They should not get in the way of providers co-operating with each other in the usual way in the interests of patients. The noble Lord said that Monitor is anti-bundling and that it would be policing the regulations at the same time. That is misleading. Decisions about whether or not to bundle services are not for Monitor to make; they are squarely for commissioners to take in the best interests of their patients, and Monitor is under a duty to enable integrated services.
The noble Lord, Lord Owen, raised concerns about charities. I have seen the brief from National Voices, Marie Curie and others in this regard. Those concerns are helpful in illustrating the point that there is no one-size-fits-all approach to the commissioning of services. It is interesting that some stakeholders have raised concerns about unbundling leading to fragmentation, while others are concerned about the effects of bundling too many services together. In practice, it is for clinically led commissioners to take decisions on whether or not services should be bundled in the best interests of patients. That is their job, and these regulations do nothing to require them to bundle or unbundle, as I have said.
The noble Lord, Lord Davies, asked me whether the regulations take into account the financial viability of hospitals and economies of scale. First, I remind the noble Lord that these regulations are not relevant to the vast majority of elective hospital services, so they do not herald the prospect of large numbers of services being hived off. Secondly, it is for commissioners to make decisions about the need for services to be bundled or co-located, as I have said. It is not in their interest to destabilise providers. Thirdly, the NHS tariff is being improved in order to ensure that it is properly reflective of the costs faced by providers. This would mean that profit-making services would no longer need to cross-subsidise other services.
The noble Lord, Lord Hunt, asked me why there is no contract value threshold below which commissioners do not have to go out to tender. Where the value of a contract is such that it would be disproportionate for the commissioner to hold a tendering exercise, there is no requirement under the regulations or the law to do so.
The noble Baroness, Lady Hollins, said that Monitor should publish figures relating to the cases that it considers. Paragraph 21 in Schedule 8 to the Health and Social Care Act 2008 requires Monitor to publish an annual report on the exercise of its functions and lay a copy before Parliament, and to provide the Secretary of State with such other reports and information relating to the exercise of its functions as the Secretary of State may require. We would also expect Monitor to publish reports on cases considered by it, as the Co-operation and Competition Panel has to date.
I of course took due note of the criticisms made by your Lordships’ Scrutiny Committee. However, I would say that there was a formal public consultation on the requirements of the original set of regulations between August and October last year. Engagement events were held up and down the country. The response to the consultation demonstrated broad support for the proposals from a wide range of stakeholders. The revised regulations did not substantially change the policy, and for that reason I suggest to the Scrutiny Committee that further consultation was not necessary.
Let me be clear about what we would lose if the regulations were not in place. The main thing that we would lose is the adjudication role of Monitor as an expert health sector regulator with an overarching statutory duty to protect and promote patients’ interests. That would mean that NHS commissioners would be exposed to the full force of public procurement law, as interpreted by the courts. I firmly believe that in that situation we would be more likely to secure the very kind of risk-averse behaviour by commissioners that some have argued today must be avoided. In addition, without the regulations, patients’ right to choice under the NHS constitution would not be protected; commissioning processes would be much less transparent and accountable; we would lose safeguards to protect against and address conflicts of interest, discrimination and anti-competitive conduct that work against the interests of patients; and requirements to ensure that the objective of procurement must always be in pursuit of meeting the needs of patients and improving quality would not be in place.
Although in one sense, the regulations can be seen as unexceptional, because they largely carry forward existing rules and arrangements; but in another sense they are more than that. They are vital for anyone who believes that the central interest that the NHS should have at its heart is that of the patient. With that observation in particular, I urge the noble Lord to withdraw the Motion.
Lord Hunt of Kings Heath
My Lords, we have had a long debate and I know that the House will want to come to a decision very soon.
I agree with the last comment of the noble Earl, Lord Howe. These are very important regulations, although there is disagreement about what they mean when it comes to practice in the field. The essential test of the regulations is whether they accord with the assurances given by Ministers during a difficult time in getting the Bill through your Lordships’ House and the other place as to whether clinicians would be free to commission services in the way that they considered best.
The noble Earl, Lord Howe, is always reassuring and was so tonight on the content of the regulations. If you read them and the comments of your Lordships’ Scrutiny Committee, you will see that that simple statement—that clinicians will be free to commission services in the way that they wish to—has been hedged in by the product of many statutory rules contained in the regulations. When it comes to Regulation 5, there is a division of opinion between the Government and the Opposition, and between lawyers, as to what the single capable provider test means. It is arguable that the health service will be confused as to whether it can define a local service as one that can be provided only by one provider, or whether, in many parts of the country, similar services will provided by different organisations within the facility of the CCG. There will be considerable doubt whether the CCG will be able to go ahead and award a contract without some competitive tender process. That is at the heart of some of this argument.
I do not accept the idea that Monitor’s involvement will somehow prevent legal action from ending up in the courts. The general confusion about these regulations will inevitably lead to cases coming before the courts. The advice that will be given to many CCGs by their legal advisers is to act defensively and to go out to more competitive tendering than the noble Earl has suggested.
The noble Baroness, Lady Williams, and the noble Lord, Lord Walton, are of course strong supporters of the National Health Service. I say to them that every day, up and down the country, a market is unfolding in the NHS. People in the NHS believe that that is happening. They are seeing contracts already being won by the private sector. They see themselves being undercut, and they worry about the fragmentation of services and about the overall intent of the Government.
Of course the NHS is not perfect but, my goodness, it enjoys tremendous public support. I have worked with the noble Baroness, Lady Cumberlege, over many years. She referred to international comparisons. I end by referring her to the US Commonwealth Fund, which produces an evaluation of the most developed health care systems in the world. Its latest evaluation placed the UK as No. 2 overall. It placed the US, where the system of markets and competition is most to the fore, as No. 7. When people look at the NHS internationally, they see a lot of things that they wish to commend, not least of which is the integration of purpose and the support from the public. My concern is that at the end of the day I think the noble Earl is right: these regulations are vital. The problem is that they hold open the door to a competitive, marketised service in which I am afraid that, despite the wording that has been used tonight, the interests of patients will be not first but last. I wish to test the opinion of the House.
Suicide
Earl Howe Excerpts(11 years ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, my noble friend Lady Buscombe is to be congratulated for bringing forward this emotive and important subject for a debate, which has generated some splendid speeches for which I, for one, am very grateful.
The loss of a loved one to suicide is a tragedy, and yet suicides are not inevitable. There are often opportunities to intervene, and those missed opportunities can highlight systemic failings. Timely access to high-quality mental health services is an essential foundation for suicide prevention. Although good progress has been made in reducing the suicide rate in England over the past 10 years, the recent rise in the number of people dying by suicide to around 4,500 in 2011 is worrying. Suicide continues to be a major public health issue, particularly at a time of economic and employment uncertainty. That is why we set out a new suicide prevention strategy for England in September 2012, which highlights the importance of targeting the groups most at risk by providing the right support at the right time.
My noble friend helpfully set out the key strands of that strategy and I was grateful for her endorsement of them. She is right that success in suicide prevention depends on communities, individuals and organisations working together to tackle the issue. Much of the planning and work to prevent suicides needs to be carried out locally. The right reverend Prelate rightly referred to the role of the new health and well-being boards in planning and co-ordinating local services based on local needs. That role will clearly be a pivotal one in the future. These health and well-being boards will become the forums for determining local needs and priorities, bringing together local authorities, clinical commissioning groups, directors of public health, adult social services and children’s services. I am sure he is right that third sector and voluntary groups will pay a key part in the delivery of local plans in many parts of the country. The concerns expressed by the noble Baroness, Lady Royall, about fragmentation of services are not ones I share. She may recall that in the Health and Social Care Act we laid great emphasis on integration as a key driver of commissioning. The very existence of health and well-being boards acting as the hub for so many key players in the public health and health arena will itself be a driver for that kind of integration.
As well as targeting high-risk groups, improving the mental health of the population is another way to prevent suicide, as has been mentioned. Our mental health outcomes strategy, No Health Without Mental Health, sets out an ambitious vision for improving people’s mental health. The implementation of the measures set out in the strategy will build individual and community resilience, promote mental health and well-being and challenge health inequalities where they exist. Again, the Health and Social Care Act passed last year was the first one to contain an objective in all parts of the health service to drive out health inequalities.
The noble Baroness, Lady Royall, referred to the need for parity of esteem between mental and physical health. Of course, I subscribe wholly to that aim. The Government’s mandate to NHS England explicitly recognises the importance of putting mental health on a par with physical health, and closing the health gap between people with mental health problems and the population as a whole. We expect the NHS to have made measurable progress towards this goal by March 2015. This will include ensuring timely access to the best available treatment through extending and developing open access to the IAPT programme, Improving Access to Psychological Therapies, particularly for those out of work. I think that is an important part of the targeting philosophy.
Alongside the development of the suicide prevention strategy, Samaritans—to whose work I pay special tribute in their anniversary year—have been facilitating a Call to Action for Suicide Prevention in England, supported by a grant from the Department of Health. Over 50 national organisations have signed the Call to Action, committing to work together so fewer lives are lost to suicide and to support those bereaved or affected by suicide. Organisations include public and private sector bodies and a wide range of charities, including those set up specifically to reduce suicide such as Papyrus, a charity dedicated to the prevention of young suicide in the UK. This is the first time that so many organisations have come together to deliver real action to reduce suicide across England.
Most people who take their own lives have not been in touch with mental health services. We know that some people, particularly men, find it difficult to speak to their doctor if they are having mental health problems, and this is partly because of stigma and shame. By tackling the stigma associated with mental health problems, we can remove a barrier to people seeking and receiving the help they need before they get to crisis point.
The department is therefore supporting the anti-stigma campaign, Time to Change, with up to £16 million of funding over four years. The campaign is run by the charities Mind and Rethink Mental Illness, and is an ambitious programme to end mental health stigma and discrimination. It has the potential to reach 29 million members of the public with its vital messages on mental health.
We know that the media have a significant influence on behaviour and attitudes towards suicide. My noble friend Lord Grade was absolutely right to highlight this. A number of organisations have developed guidance for the media on the reporting of suicide and its portrayal. One of these is Samaritans, which plays a key role in supporting sensitive reporting of suicide.
As my noble friend said, the media have a significant influence on behaviour and attitudes. There is already compelling evidence that media reporting and portrayals of suicide can lead to copycat behaviour, especially among young people and those already at risk. The media is aware of its responsibility in the representation of suicide. In 2006 the Press Complaints Commission added a clause to the editors’ code of practice explicitly recommending that the media avoid excessively detailed reporting of suicide methods. The 2009 edition of the PCC Editors’ Codebook highlights, for example, the distress that can be caused by insensitive and inappropriate graphic illustrations accompanying media reports of suicide.
We have made grants to charities directly involved in suicide prevention. In March 2010, Maytree Respite Centre was awarded a three-year grant totalling over £154,000 to support the continued implementation and development of its service. Maytree is a sanctuary for people in suicidal crisis, providing a non-medical alternative to hospitalisation or sectioning. The grant helped the organisation support over 4,000 people, with 300 being supported through a stay at the house. It also helped them to develop outcome-focused relationships with several NHS and private organisations. In March 2011 we awarded a £50,000 one-year grant to Survivors of Bereavement by Suicide, a charity that serves more than 8,000 clients each year. They provide a range of services from a national telephone line to local area support groups.
Early intervention is imperative to suicide prevention and various organisations, including charities, can help highlight and address problems such as bullying, poor body image and lack of self-esteem. The commitment to early intervention is borne out by the Department of Work and Pensions’ expectation that all Jobcentre Plus advisers are trained to enable them to identify and support people who are vulnerable and who may be at risk of suicide and self-harm. This is important, as we know that community locations, such as job centres and young people-friendly venues, are more successful in engaging with young men than more formal health settings such as GP surgeries.
The noble Lord, Lord Giddens, whose speech I listened to with great attention, spoke about statistics. I will certainly go away and reflect on his points on that score. He asked what the Government’s policy was on prevention at popular suicide spots. The suicide prevention strategy recognises that one of the most effective ways of preventing suicide is to reduce the means to access. Suicide risk can be reduced by limiting access to high-risk locations. Much of the planning and work to prevent suicides will, as I have said, be carried out locally; it will be for local agencies, working through health and well-being boards, to decide the best way to achieve the overall aim of reducing the suicide rate. I fully expect that the local agencies will work together to monitor those hotspots.
My noble friend Lord Roberts pointed to the effect of unemployment, a point made effectively by my noble friend Lady Wheatcroft. We know that previous periods of high unemployment or severe economic problems have had an adverse effect on the mental health and well-being of the population and have been associated with higher rates of suicide. Despite the good progress that has been made in reducing the suicide rate, we need to remain vigilant on that particular aspect of the risk.
Faith groups were mentioned by a number of noble Lords, including my noble friend Lord Roberts. I assure the Committee that the department recognises the comfort and support that people receive from their faith and would expect all medical practitioners to treat their patients holistically, taking into account their physical, cultural, social, mental and spiritual needs. The Government’s mental health strategy, No Health Without Mental Health, draws attention to the importance of ensuring that services meets the needs of diverse communities and faith groups. The right reverend Prelate will know that the former Archbishop of Canterbury, Rowan Williams, and Time to Change recently hosted an event for leaders from different faiths to look at ways of tackling the stigma and discrimination faced by people with mental health problems in their communities. That seminar was held at Lambeth Palace and was extremely well received.
The noble Earl, Lord Sandwich, spoke about the risk of prescribed anti-depressants. The suicide prevention strategy highlights the potential increase in suicide risk in the early stages of drug treatment and risks associated with withdrawal where people are dependent on prescribed drugs. The noble Earl has expressed his concerns forcefully in debate and privately to Ministers, and he knows that these messages have not gone unheeded—at least, I hope that he knows that. It is, as he said, for health and well-being boards to build into the joint strategic needs assessment suitable provision for this particular type of suicide risk.
Over the past 10 years, good progress has been made in reducing the suicide rate in England. Voluntary organisations, charities and community and faith groups have all played their part in this reduction. The messages are clear. We need individuals and organisations to support our continued efforts, to join us in our drive to sustain and reduce further the relatively low rates of suicide in England and to respond positively to the challenges that we face over the coming years.
Lord Grade of Yarmouth
Will my noble friend the Minister be kind enough to give us the benefit of his advice on how we might move forward an initiative to roll out the 116 line? I am much taken with the noble Baroness’s view that we might all write a letter, but I wonder if it is an initiative that the department might want to take up and try to co-ordinate to see if we can get a resolution.
NHS: Leeds General Infirmary
Earl Howe Excerpts(11 years ago)
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Baroness Eaton
To ask Her Majesty’s Government what was the extent of their involvement in the decision to suspend surgery at the Leeds General Infirmary Children’s Heart Unit.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government did not play any role in the decision to suspend children’s heart surgery at Leeds. By agreement, this was a local decision taken by the trust, in agreement with Sir Bruce Keogh, NHS England’s medical director, and the Care Quality Commission. The Government strongly believe that it was the right thing to do. It is absolutely right that the NHS should act quickly and decisively if there is any evidence that patient safety may be at risk.
Baroness Eaton
I thank the Minister for his Answer and for the concern that I know he shares for those who have been affected by the decision. We all wish to see the safest surgery possible for our children. The Minister quite rightly understands that specialist doctors and experts, not politicians, should be responsible for asking and answering questions of safety. In the particular circumstances of Leeds, however, a number of the experts—
Baroness Eaton
My question is coming. The experts in Leeds have been causing understandable concern because of their partiality and apparent vested interest. In Bristol and Birmingham, children’s heart units have recently had mortality alerts and 14 NHS trusts are under investigation. Will the Minister explain why surgery has not been suspended at any of those trusts? Will he also explain why NHS England has chosen to spend resources appealing the decision of the High Court judge, who called the Safe and Sustainable review of children’s heart units flawed, when the decision for the Independent Reconfiguration Panel and the Secretary of State is imminent?
Earl Howe
My Lords, my noble friend raises quite a large number of points. I simply say to her that in regard to Leeds, which is the matter on which I have been briefed, the decision to suspend surgery was taken because concerns had been raised from a variety of sources about the safety of surgery at the unit. Mortality data were supplied to the National Institute for Cardiovascular Outcomes Research with significant flaws, and until those flaws had been rectified, it was impossible to be sure that the trust was operating within acceptable mortality thresholds. Those mortality concerns have, I understand, been resolved, which is why low-risk children’s cardiac surgery has been resumed at the hospital. However, NHS England’s appeal on the Safe and Sustainable review—which, I emphasise, is quite separate from the events of late March and early April—has to be a matter for NHS England. The review of children’s heart services was an NHS review, independent of government, and if NHS England wants to appeal the decision and thinks that there are good grounds for doing so, that is a matter for it.
Baroness Howarth of Breckland
My Lords, does the Minister agree that the people most affected by this are the children and many of the families who do not understand and cannot comprehend what is going on at the moment across these services? I declare an interest as the patron and trustee of Little Hearts Matter, which deals with hundreds of children who have half a heart and therefore all have surgery across the country. The Government may not have a direct interest in dealing with this matter but what are they going to do to make sure that the health services reassure these families that wherever they get surgery it will be safe for their children?
Earl Howe
My Lords, children’s heart surgery has been the subject of concern for more than 15 years. Clinical experts and parent groups have repeatedly called for change, and there is an overwhelming feeling in the NHS that the time for change is long overdue. The review that has taken place was about making sure that children’s heart services are as good as they possibly can be, and that has to be the message to the parents involved. It is of course an extremely complex issue but it is generally accepted that concentrating surgical expertise will deliver better outcomes for the children concerned. In view of the legal proceedings, it is very difficult for me to go any further than that at the moment.
Lord Warner
My Lords, if NHS England decides, under its new responsibilities, to undertake and control the specialised commissioning functions within the NHS, and if it chooses to implement the McKay panel’s recommendations on paediatric surgery, can the Minister say whether they would accept that judgment by NHS England or whether they would seek to overturn it?
Earl Howe
I take the noble Lord’s question to mean: would the Government accept that decision? Yes. This is a matter for the health service to determine. As I mentioned earlier, the Safe and Sustainable review was an NHS review. The Government and Ministers were not in any way involved in it, and that is appropriate. Therefore, the answer to the noble Lord’s question is that the Government would stand back from any such decision.
Lord Shutt of Greetland
My Lords, it is clear that murky internal health politicking has been going on here. However, the underlying question is: why are the Government determined to deny the people of Yorkshire a children’s heart unit when Yorkshire’s population of 5.3 million is similar to that of Scotland, Denmark and Finland, and is larger than Norway and Ireland? Yorkshire is double the size of the north-east of England, and the Government are happy to see that region locally served.
Earl Howe
I say to my noble friend with great respect that the premise of his question is incorrect. The Government have not taken a role in this matter. As I said to the noble Baroness, Lady Howarth, and to the noble Lord, Lord Warner, this is a matter that the NHS itself has led. There is no agenda by the Government at all, apart from our desire to see the best possible children’s cardiac services provided in this country.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests. Would the noble Earl accept that Sir Bruce Keogh has an outstanding record in the health service in improving outcomes from heart surgery, and therefore he has to be listened to with a great deal of respect?
On the more general issue of the reconfiguration of services, on which NHS England has promised to become much more assertive—which, I am sure, is welcome—is the noble Earl concerned that the Office of Fair Trading and the Co-operation and Competition Panel seem to be intervening in sensible reconfiguration decisions on the spurious basis that they impact on competition? Will he tell these bodies to desist?
Earl Howe
My Lords, if the noble Lord can supply me with some examples, of course I will look into them. I remind him that tomorrow we are debating a set of regulations that bear on this very question and I shall have plenty to say on that occasion, which I hope will assuage his concerns.
Baroness Masham of Ilton
My Lords, is the Minister aware that it has been really splendid to witness the Members of Parliament from all over Yorkshire supporting their constituents? Will the Government listen to them?
NHS: ECMO Machines
Earl Howe Excerpts(11 years ago)
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Baroness Gardner of Parkes
To ask Her Majesty’s Government whether extra-corporal membrane oxygenation (ECMO) machines that are capable of restoring heart functions some hours after an apparently fatal heart attack are in use in any NHS hospitals; and, if not, what consideration is being given to their installation.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the equipment and facilities to undertake cardiac ECMO support are available in all five NHS adult cardiothoracic transplant centres in England and in the five national respiratory ECMO centres, three of which share a location. Provision of cardiac ECMO support is a complex intervention with significant risks attached to it. A cardiac ECMO service requires a fully trained team to be available around the clock and does not consist of simply purchasing the medical equipment.
Baroness Gardner of Parkes
That is very good news and I thank the Minister for it. It is desirable to have these facilities available. Does he agree that the group which would benefit most of all from this would be young people who die suddenly and unexpectedly, often in the sporting field? This is a much greater tragedy for families than the more usual cardiac attack at a later age. Should not more publicity be given so that people involved in those activities know that such facilities are available? You could get a young person by helicopter to one of those centres within the number of hours that your life would be prolonged for.
Earl Howe
My Lords, there is, I understand, no intervention capable of restoring heart function some hours after a heart attack. The only exception is not applicable to heart attacks but to people who have had circulatory arrest due to hypothermia—for example, people who have been buried in avalanches or immersed in very cold water. That area is currently being researched. It is only in a very limited number of circumstances that ECMO support can improve a patient’s chances of survival following cardiac arrest—usually in patients who suffer in-hospital cardiac arrest following surgery.
Lord Patel
My Lords, as the noble Earl indicated in his opening remarks, a typical facility required in the provision of a service such as ECMO for adults who suffer acute myocardial infarction would include a perfusionist, intensive care facilities, an intervention cardiologist, a cardiologist expert in cardiac failure, a cardiac surgeon, together with specialist nurses. Preliminary results of studies suggest that the survival rate might be less than 30%. Does the noble Earl agree that more research is needed before such a treatment can be made available routinely?
Earl Howe
I fully agree. The noble Lord is quite right. ECMO cannot be provided by just any ICU team. It is a highly specialised treatment with significant potential for serious complications, and considerable expertise is therefore required, including having a multidisciplinary team of the kind that he outlined. In general, capacity has much more to do with having suitably trained staff than with having the equipment itself.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests. On the question raised by the noble Lord, Lord Patel, about evidence, would the noble Earl consider referring this to NICE for its expert advice?
Earl Howe
I shall certainly take that idea away with me, but I think that there is broad consensus among the medical community that the key to success with ECMO is getting the patients connected to the equipment quickly. Although it is a moving scenario, all the evidence so far suggests that ECMO confers no benefit if some hours have elapsed since the cardiac arrest.
Baroness Jolly
My Lords, services that need ECMO machines would currently, in the new world, be commissioned by NHS England. Will my noble friend explain to the House what role, if any, the department now has in commissioning such services?
Earl Howe
My Lords, the department itself no longer has a role in commissioning highly specialised services. NHS England is implementing a single operating model for the commissioning of 143 specialised services. That replaces the previous arrangement whereby 10 regional organisations were responsible for commissioning specialised services and, to be frank, there were wide variations in the standard of those services. The new operating model represents a significant change to the previous system and should result in better outcomes.
Baroness Masham of Ilton
My Lords, is the Minister aware that Glenfield Hospital in Leicester, which has ECMO, saved many lives in the swine flu epidemic last year and does more than just hearts?
Earl Howe
I am fully aware of that. Glenfield has been leading the development of ECMO services. It is one of the biggest ECMO centres in Europe. It is currently the largest provider of children’s ECMO in the country, treating about 70 paediatric ECMO patients a year, and now provides an adult service.
Baroness Knight of Collingtree
My Lords, can my noble friend clear up a point of confusion that may have arisen about his first Answer to this Question? It was reported in the Times newspaper by the science editor that people could be brought back from the dead up to seven hours after their hearts had stopped. Is that a report on which we can lay much credence?
Earl Howe
My Lords, my advice is that in most cases of cardiac arrest that is not possible. Where there has been circulatory arrest in the particular conditions that I described, such as immersion in very cold water, the heart can in some circumstances be restarted, but I would not wish to excite noble Lords’ interest in this technique without proper evidence. I am afraid that the article, which I did see, raises people’s hopes perhaps unfairly.
Earl Howe
My Lords, as the noble Lord knows, that decision is interdependent with the decision around the Safe and Sustainable review of children’s cardiac services. Until that issue is determined, it is not possible for me to say what will happen to the children’s ECMO service at Glenfield.
Mid Staffordshire Foundation Trust Inquiry
Earl Howe Excerpts(11 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall now repeat a Statement made earlier today in another place by my right honourable friend the Secretary of State for Health on the Government’s response to the Francis report. The Statement is as follows:
“With permission, Mr Speaker, I would like to make a Statement on the Government’s response to the Mid Staffordshire NHS Foundation Trust Public Inquiry. I congratulate my right honourable friend and predecessor on setting up the public inquiry, and on the many changes that he made foreseeing its likely recommendations. I would also like to pay tribute to Robert Francis QC for his work in producing a seminal report which I believe will mark a turning point in the history of the NHS.
Many terrible things happened at Mid Staffs in what has rightly been described as the NHS’s darkest hour. Both the current and former Prime Minister have apologised, but when people have suffered on this scale, and died unnecessarily, our greatest responsibility lies not in our words but in our actions—actions that must ensure the NHS is what every health professional and patient wants: a service that is true to the NHS values, that puts patients first and treats people with dignity, respect and compassion.
The Government accept the essence of the inquiry’s recommendations and we shall respond to them in full in due course. However, given the urgency of the need for change, I am today announcing the key elements of our response so that we can proceed to implementation as quickly as possible. I have divided our response into five areas: preventing problems arising by putting the needs of patients first; detecting problems early; taking action promptly; ensuring robust accountability; and leadership. Let me take each in turn.
To prevent problems arising in the first place, we need to embed a culture of zero harm and compassionate care throughout our NHS, a culture in which the needs of patients are central, whatever the pressures of a busy, modern health service. As Robert Francis said, ‘The system as a whole failed in its most essential duty: to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment that should never be tolerated in any hospital’.
At the heart of this problem, the current definitions of success for hospitals fail to prioritise the needs of patients. Too often, the focus has been on compliance with regulation rather than on what those regulations aim to achieve. Furthermore, the way that hospitals are inspected is fundamentally flawed, with the same generalist inspectors looking at slimming clinics, care homes and major teaching hospitals—sometimes in the same month. So we will set up a new regulatory model under a strong, independent chief inspector of hospitals, working for the CQC. Inspections will move to a new specialist model based on rigorous and challenging peer review. Assessments will include judgments about hospitals’ overall performance, including whether patients are listened to and treated with dignity and respect, the safety of services, responsiveness, clinical standards and governance.
The Nuffield Trust has reported on the feasibility of assessments and Ofsted-style ratings, and I am very grateful for its thorough work. I agree with its conclusion that there is a serious gap in the provision of clear, comprehensive and trusted information on the quality of care. So in order to expose failure, recognise excellence and incentivise improvement, the chief inspector will produce a single aggregated rating for every NHS trust. Because the patient experience will be central to the inspection, it will not be possible for hospitals to get a good inspection result without the highest standards of patient care.
However, the Nuffield rightly says that in organisations as large and complex as hospitals, a single rating on its own would be misleading, so the chief inspector will also assess hospital performance at speciality or department level. This will mean that cancer patients will be told of the quality of cancer services, and prospective mothers the quality of maternity services. We will also introduce a chief inspector of social care and look into the merits of a chief inspector of primary care in order to ensure that the same rigour is applied across the health and care system.
We must also build a culture of zero harm throughout the NHS. This does not mean that there will never be mistakes, just as a safety-first culture in the airline industry does not mean that there are no plane crashes, but it does mean an attitude to harm which treats it as totally unacceptable and takes enormous trouble to learn from mistakes. We await the report on how to achieve this in the NHS from Professor Don Berwick.
Zero harm means listening to and acting on complaints, so I will ask the chief inspector to assess hospital complaints procedures, drawing on the work being done by the Member for Cynon Valley and Professor Tricia Hart to look at best practice.
Given that one of the central complaints of nurses is that they are required to do too much paperwork and thus spend less time with patients, I have asked the NHS Confederation to review how we can reduce the bureaucratic burden on front-line staff and NHS providers by a third. I will also be requiring the new Health and Social Care Information Centre to use its statutory powers to eliminate duplication and reduce bureaucratic burdens.
Secondly, we must have a clear picture of what is happening within the NHS and social care system so that, where problems exist, they are detected more quickly. As Francis recognised, the disjointed system of regulation and inspection smothered the NHS, collecting too much information but producing too little intelligence. We will therefore introduce a new statutory duty of candour for providers to ensure that honesty and transparency are the norm in every organisation, and the new chief inspector of hospitals will be the nation’s whistleblower in chief.
To ensure that there is no conflict in that role, the CQC will no longer be responsible for putting right any problems identified in hospitals. Its enforcement powers will be delegated to Monitor and the NHS Trust Development Authority, which it will be able to ask to act when necessary.
We know that publishing survival results improves standards, as has been shown in heart surgery. So, I am very pleased that we will be doing the same for a further 10 disciplines: cardiology, vascular, upper gastro-intestinal, colorectal, orthopaedic, bariatric, urological, head and neck, thyroid and endocrine surgery.
The third part of our response is to ensure that any concerns are followed by swift action. The problem with Mid Staffs was not that the problems were unknown; it was that nothing was done. The Francis report sets out a timeline of around 50 warning signs between 2001 and 2009. Ministers and managers in the wider system failed to act on these warnings. Some were not aware of them; others dodged responsibility. This must change. No hospital will be rated as good or outstanding if fundamental standards are breached. Trusts will be given a strictly limited period of time to rectify any such breaches. If they fail to do this, they will be put into a failure regime which could ultimately lead to special administration and the automatic suspension of the board.
The fourth part of our response concerns accountability for wrongdoers. It is important to say that what went wrong at Mid Staffs was not typical of our NHS and that the vast majority of doctors and nurses give excellent care day in, day out. We must make sure that the system does not crush the innate sense of decency and compassion that drives people to give their lives to the NHS. Francis said that primary responsibility for what went wrong at Mid Staffs lies with the board. So, we will look at new legal sanctions at a corporate level for organisations that wilfully generate misleading information or withhold information that they are required to provide. We will also consult on a barring scheme to prevent managers found guilty of gross misconduct finding a job in another part of the system. In addition, we intend to change the practices around severance payments, which have caused great public disquiet. In addition, the General Medical Council, the Nursing and Midwifery Council and the other professional regulators have been asked to tighten their procedures for breaches of professional standards. I will wait to hear how they intend to do this, and for Don Berwick’s conclusions on zero harm before deciding whether it is necessary to take further action. The chief inspector will also ensure that hospitals are meeting their existing legal obligations to ensure that unsuitable healthcare support workers are barred.
The final part of our response will be to ensure that NHS staff are properly led and motivated. As Francis said:
“All who work in the system, regardless of their qualifications or role, must recognise that they are part of a very large team who all have but one objective, the proper care and treatment of their patients”.
Today I am announcing some important changes in training for nurses. I want NHS-funded student nurses to spend up to a year working on the front line as support workers or healthcare assistants, as a prerequisite for receiving funding for their degree. This will ensure that people who become nurses have the right values and understand their role. Healthcare support workers and adult social care workers will now have a code of conduct and minimum training standards, both of which are being published today. I will also ask the chief inspector to ensure that hospitals are properly recruiting, training and supporting healthcare assistants, drawing on the recommendations being produced by Camilla Cavendish. The Department of Health will learn from the criticisms of its own role by becoming the first department where every civil servant will have real and extensive experience of the front line.
The events at Stafford Hospital were a betrayal of the worst kind—a betrayal of the patients, the families, and of the vast majority of NHS staff who do everything in their power to give their patients the high-quality, compassionate care that they deserve. However, I want Mid Staffs to be not a byword for failure but a catalyst for change: to create an NHS where everyone can be confident of safe, high quality, compassionate care; where best practice becomes common practice; and where the way in which a person is made to feel as a human being is every bit as important as the treatment they receive. That must be our mission and I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Hunt, for his comments, and for the support that he was able to give to a number of the proposals that the Government have made. I will attempt to answer as many of his questions as possible. First, he asked why the Government’s response does not address all 290 of Francis’s recommendations. This report, which comes seven weeks on, is not and I think could not be a full response to each and every one of those recommendations. Francis himself notes in his report that:
“Some recommendations are of necessity high level and will require considerable further detailed work to enable them to be implemented”.
That work we will most certainly do. We accept most of the recommendations in Robert Francis’s report, either in principle or in their entirety, but I emphasise that there is much more to do. To rush ahead would mean that we would not give the full and collective consideration to the report that is clearly needed. It would also limit the clinical engagement and the patient and public involvement that is so important. Our response today is designed to be an overarching one, setting out our key early priorities.
The noble Lord asked me about the duty of candour. We recognise that attaching criminal sanctions to key areas of public service delivery can send an important message to the public about the expected standards of care and duty. That is why we will consider the introduction of additional legal sanctions at a corporate level where organisations wilfully generate misleading information, or withhold information that they are required to provide. I cannot be more specific about the extent and scope of that, but we do think there is an issue to be addressed there. I will take the noble Lord’s points on board as to how widely that should go.
However, we are concerned that the introduction of criminal sanctions on individual staff who provide NHS services could run counter to the creation of an open and transparent culture. It could instead create a culture of fear that could lead to the cover-up of mistakes, which is the very opposite of what we seek to achieve. That of course could in turn prevent lessons being learnt and could make services less safe. However, we agree that where staff are obstructively dishonest action will need to be taken to ensure that the quality of patient care is not jeopardised. We are asking the NMC and the GMC to look at how they might be able to strengthen professional standards and disciplinary measures to address those kinds of case. Registered clinical staff are, of course, already placed under a duty to be open through their professional regulators, but we will consider whether is a need to add to that duty in the light of the Berwick review on safety.
Turning to healthcare support workers, as I have frequently said in your Lordships’ House, the Government’s mind is not closed to statutory regulation, but regulation as such is no substitute for a culture of compassion and effective supervision. Putting people on a national register does not guarantee protection for patients, as was sadly seen at Mid Staffs. Instead, we have decided to tackle this issue at its root, focusing on making sure that healthcare support workers have the right training and values and, most importantly, support and leadership to provide high-quality care.
As I repeated in the Statement, we are today publishing minimum training standards and a code of conduct for healthcare and care assistants. In addition, all healthcare support workers work under registered professionals who are responsible for the care provided to their patients. Camilla Cavendish has been asked to conduct an independent study of healthcare and care assistants to ensure that they have not just the right training but the right support to provide services to the highest of standards. She is due to report in May. We will consider further action following that review. Health Education England is working with employers to improve the capability and training standards of the care assistant workforce. Its strategy will feed into the Camilla Cavendish review.
As regards nurse training and the idea that every prospective nurse should have bedside experience before undertaking formal training, we believe that that idea should be piloted. The charge that we have heard for so many years that some nurses are too posh to wash must be got rid of. We must ensure that we are training nurses who have an aptitude for the role and who know what it is like to have hands-on experience as a healthcare assistant before committing themselves to training. Starting with pilots, every student seeking NHS funding for nursing degrees should, we believe, first serve for up to a year as a healthcare assistant to promote front-line caring experience and values, as well as academic strength. The current first-year dropout rate for nurses alone is 25%. For that reason also, it is important to ensure that we have the right sort of man and woman as a nurse trainee. We recognise that the scheme will need to be tested and implemented carefully to ensure that it is cost-neutral. Of course that is a consideration and the noble Lord was right to raise it. We will explore whether there is merit in extending the principle to other NHS trainees.
The noble Lord asked me a number of questions about the chief inspector. We think that having a chief inspector as part of the senior team of the CQC will provide us all with an expert judgment on the part of those who have walked the wards, spoken to patients and staff, looked the board of directors in the eye and made a rounded judgment of an organisation’s health, and thereby give true quality assurance, as opposed to what I fear that we have seen all too frequently, which is a tick-box approach. It will be a powerful role and it is very important that the data on which the chief inspector relies are representative of quality. That is a job of work that needs to be done.
The noble Lord also asked me about the National Patient Safety Agency. We continue to believe that it is absolutely right to place the national reporting and learning service within the Commissioning Board if we are to learn from safety incidents and near misses and to enable that information to be fed directly into commissioning behaviour. It is obviously important that we do not lose the expertise that the NPSA has built up. I hope and believe that we will not and that this is the right model. Nevertheless, the noble Lord is right to flag up that we need to learn from experience and we will do that.
As regards the CQC’s responsibilities, the noble Lord may be aware that the Health Select Committee of another place recently reported on the role of Monitor. One of the key criticisms that it levelled against the current system was that it is, in many senses, ambiguous. Sometime the roles of Monitor and the CQC appear to overlap and sometimes there appears to be a gap as to exactly who is responsible for what. Having thought very carefully about this issue, our judgment is that it is important to be crystal clear about who is responsible for what. The CQC’s powers, in terms of warning notices and improvement notices, will remain, but should the CQC find that there is an intractable case of quality failure in a provider organisation, it should not be the CQC’s job to sort that out. There should be a single failure regime triggered by Monitor, which is the body currently responsible for triggering the financial failure regime. The details are yet to be worked out, but clarity of roles is vital in this area.
I am aware that there are one or two questions that I have not covered, but I undertake to write to the noble Lord on those.
Baroness Jolly
My Lords, I thank my noble friend the Minister for repeating the Statement. I am sure that many noble Lords will welcome, in due course, a full and spirited debate on this issue. Will my noble friend clarify which of the recommendations that are being adopted will require primary legislation, what the timescale might be and what the mechanism might be for that?
We welcome my noble friend’s remarks on the duty of candour but, as with all these things, the devil is in the detail. My question is about the chief inspector regime in general. We are going to have a chief inspector of hospitals so it would seem sensible to have a chief inspector of social care. Will we then need a chief inspector for public health and another one for mental health? Is that the way to have all the bases covered?
Earl Howe
My Lords, it is a little early to say what legislation we will need, but I can tell my noble friend that we can deal with the duty of candour by secondary legislation. It may be that many of the follow-up actions to Francis can be done without any legislation at all. However, primary legislation would appear to be the obvious route when statutory roles are to be changed.
With regard to the chief inspectors, the only firm decisions we have taken so far are to appoint a chief inspector of hospitals and a chief inspector of social care. We are looking at the merits of a chief inspector of primary care but we need to make sure that there is a genuine issue that needs to be addressed by way of a chief inspector role rather than leaving the CQC to perform its role in the normal way. Further details will be forthcoming at an appropriate time.
Baroness Emerton
My Lords, I would like to mention nurse education. The suggestion of having some front-line experience before entering university is, philosophically and practically, very good if it can be worked, but it raises all sorts of questions. I spoke to a healthcare support worker a few weeks ago who said that all the students who come on to her ward tell her, “I wish we had had this experience that you are getting before going into training”, so there is evidence that many of them would like to have that kind of experience. However, this raises the question of their supervision during that time. Will there be adequate numbers of trained staff to supervise the continuing support workers as well as those who are pre-nursing apprentices, or whatever?
The logistics of this are going to be important to work on. We need to know whether the Government will look at minimum staffing levels. Where there are enough registered nurses and the minimum is stated, there should be means whereby registered nurses will be available whenever demands on patient care escalate, such as during a time of winter problems, rather than abusing and misusing the support workers. There is a tremendous amount of work to be done on that.
There is also the role of the Nursing and Midwifery Council, which has responsibility for regulating the pre-nursing standards. I hope the Government will ensure that the council takes an active part in this pre-nursing experience, because that will be important. I urge Ministers to have this minimum staffing looked at, if that is possible. I am extremely disappointed that the Government are not prepared to take on the regulation of these support workers because I fear that we may find ourselves having similar problems as in the past, unless we have some regulatory system.
Baroness Northover
My Lords, I remind noble Lords that brief questions only are called for after Statements, and that the briefer they are, the more colleagues will be able to get in.
Earl Howe
I reassure the noble Baroness that all the concerns that she rightly raised are very much in our sights, not least the need for proper supervision of nurse trainees and the practical aspects of having the right level of support on the ward. This is why we believe that this idea should be piloted first, so that lessons can be learnt. Yes, we will involve the NMC, and indeed the Royal College of Nursing, in these plans. As regards ratios, having the right staffing in terms of numbers and skills is clearly vital for good care, but minimum staffing numbers and ratios, if laid down in a rigid way, risk leading to a lack of flexibility or organisations seeking to achieve staffing levels only at the minimum level. Neither of those is good for patients. However, I do not dismiss the general concept. It is ultimately up to local organisations to have the freedom to decide the skill mix of their workforce, based on the health needs of those on the wards.
Baroness Pitkeathley
My Lords, the principle of putting the needs of patients first will be welcomed by every Member of this House. However, does the Minister agree that this means looking at care in an integrated way, since the patient experience is very rarely one of either hospital or social care but a mixture—sometimes a very haphazard mixture—of the two? Can the Minister therefore give the House more detail about how the government proposals will facilitate the integration of care services across health and social care, particularly as there will be two separate inspectors and as the ability of the CQC to put the shortcomings right is apparently going to be passed to Monitor?
Earl Howe
My Lords, the main drivers and levers for increased integration will come from other directions, such as: the systems we are putting in place at local authority level and health and well-being board level; more sophisticated tariffs; better commissioning arrangements between the NHS and social care; and the financial imperative that all commissioners and providers now face. That will mean an imperative to ensure that resources are not wasted and are deployed to the best effect of patients.
We must also remember that the NHS outcomes framework will be the benchmark by which the success of the service is judged, just as the social care outcomes framework will act in that sphere in an equivalent way. The major domain in both areas is the patient experience. If we believe that integration is above all to be defined by reference to the patient’s experience, we can expect commissioners across the piece to address commissioning in a way that avoids disjointed care.
Lord Cormack
My Lords, is my noble friend aware that many people in Staffordshire will welcome this report but will wonder whether the present chief executive is the best person to oversee the implementation of the many recommendations to which my noble friend has referred?
Earl Howe
My Lords, it was a signal feature of the Francis report that he consciously avoided pointing the finger at individuals. The chief executive of the NHS did not have the finger of blame pointed at him. The House may be interested to know that I regard Sir David Nicholson as a truly outstanding public servant who has done an enormous amount of good for the NHS since becoming chief executive.
The benefit of hindsight is wonderful but we must remember that in the years in which these dreadful events took place the National Health Service was held to account by reference to two main indicators: access to care and waiting times, and finance. Above all, it was the arrival of the noble Lord, Lord Darzi, as a Minister and the Secretaries of State whom he served that saw the transformation of the NHS from an organisation that was concerned just about numbers into one that really appreciated that quality matters. Therefore, to accuse those with positions of responsibility with regard to Mid Staffs of overlooking the fact that quality was poor is to place a wholly unfair retrospective expectation on them.
Lord Patel
My Lords, a great deal of importance and emphasis is being placed on introducing zero harm with regard to patient safety. I am delighted that the Government have asked Don Berwick to advise them how to do this. Do the Government intend to have zero harm in the NHS as a concept or as a requirement? If it is the latter, what legal framework will make that happen?
Earl Howe
It is much more a question of culture than anything else. However, the noble Lord will be aware that Robert Francis recommended that we look at the concept of fundamental standards below which care should never fall. We are determined to do that. Defining a fundamental standard is something for wide discussion. However, we take this recommendation very seriously. Robert Francis was clear that if individuals or an organisation were found guilty of breaching fundamental standards, serious consequences should ensue.
On a more general level, it is impossible to expect human beings never to make a mistake or never to fall down on the job. The point here is to create an attitude of mind in all those who work for and with the NHS that puts the patient’s well-being at the centre of their daily lives and thinking. That is where we want to be.
Lord Bilston
The recent pronouncements of Monitor seem to ignore the vast majority of the people of Stafford, who, as my noble friend Lord Hunt indicated, require a range of safe, sustainable and comprehensive health services rather than the delegation of a range of services, including elective surgery, to other hospitals such as New Cross in Wolverhampton. That hospital is already under considerable pressure and has inadequate facilities in many areas, including a very restricted site with inadequate car parking. Will my noble friend comment on that, because there is great concern and anxiety in Wolverhampton that many thousands of people will be allocated to New Cross and that it will be unable to respond that heavy need? As always in these cases, the balloon will burst and we will quickly find that New Cross Hospital itself sinks into the abyss and then has difficulty responding to the health needs of the people of Wolverhampton.
Earl Howe
I understand the noble Lord’s concerns and those of the people of Stafford. Unfortunately, this trust is losing a substantial amount of money. That is not a situation that anybody can be relaxed about, which is why Monitor has taken the action that it has. One of the tests by which any trust administrator’s report will be judged will be whether the solution offered delivers high-quality care and the prospect of good health outcomes to the patients of the area. This is not just a pounds, shillings and pence exercise; it is an exercise that is necessarily looking at services across the piece to see how they can be better and more cost-effectively configured to ensure that high-quality care is maintained.
Baroness Browning
My noble friend will be aware that the Mental Capacity Act was not mentioned or used at Winterbourne View and that we have seen one too many reports from Mencap about the deaths on hospital wards of young people who have a learning disability or autism. In the next 12 months, this House will carry out post-legislative scrutiny of the Mental Capacity Act. Will my noble friend ensure that his department is not just a passive observer of that process but communicates with those on that committee to ensure that people on hospital wards who lack capacity, albeit a fluctuating or temporary lack of capacity, are not only spoken to but treated like any other patient?
Earl Howe
My noble friend is right to raise this issue, and I pay tribute to the work that she has so consistently done to improve the lot of those with autism. I undertake to write to her about this, but I can give her the general reassurance that the Department of Health will certainly be involved in the scrutiny of these measures, as will the NHS Commissioning Board. I want to ensure that we learn the right lessons from the actions already taken.
Baroness Masham of Ilton
My Lords, does the Minister not think that, with the duty of candour, those who make mistakes should take responsibility and be accountable for them? Otherwise people will not learn from those mistakes and they will continue. I also want to ask about the 10 disciplines. I was very surprised that respiratory conditions are not included as nearly all death certificates have pneumonia on them.
Earl Howe
I undertake to look at the latter point made by the noble Baroness. The 10 disciplines were selected as ones that could reasonably and readily be subject to the kind of assessment process that we are looking to achieve. I will come back to her on that.
As regards the duty of candour, individuals should certainly take responsibility for their actions and be encouraged to do so. We fear, however, that criminalising individuals’ behaviour within an NHS organisation could risk doing the opposite of what we all want to see: a much more open culture, one that has made the NPSA and its work so successful; a no-blame culture, where people take responsibility for when things go wrong but do not feel that the heavy hand of authority is going to descend upon them at the merest mistake. However, it is important that people are held to account if they are dishonest or deliberately withhold information, and that is a different set of issues.
Lord Walton of Detchant
The appalling failings highlighted in the Francis report clearly demonstrated that the managerial virus—an obsession with meeting targets—infected many of the medical and nursing staff in Mid Staffs and diverted them from their primary standards of providing a high quality of patient care. Many of the proposals set out in the Statement are essentially welcome.
I learnt only last week of the new assessment method, PLACE, and I would love to hear where that fits in to the programme. Having said that, will the Government take note of the fact that there is a danger in creating a superfluity of regulatory authorities that would divert doctors and nurses from their primary bedside responsibilities? Is it not better to make certain that regulatory authorities function much more efficiently and effectively in controlling standards?
Earl Howe
I wholeheartedly agree with the noble Lord. One of the concerns at the back of our minds as we have considered Robert Francis’s report is the need to ensure that we do not create oppressive additional regulation to cure the problems that Francis has identified. Indeed, we need to look at doing the opposite: how can we lift regulatory burdens and ensure that the culture Francis spoke about can thrive? The NHS Confederation is advising us on this. It is looking specifically at burdens placed on NHS providers and organisations, and we shall take its recommendations to heart.