Health and Social Care
Earl Howe Excerpts(11 years, 8 months ago)
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Baroness Tyler of Enfield
To ask Her Majesty’s Government whether they will consider linking the separate outcomes frameworks for health and social care.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we will improve outcomes only if all parts of the system work together with a common purpose. The three outcomes frameworks have been and continue to be increasingly aligned, reflecting the joint contribution of health, public health and adult social care to improving outcomes. The frameworks form the basis for integrated working locally. They support local partners across the health and care system to identify shared responsibilities, pursue shared goals and improve outcomes for their communities.
Baroness Tyler of Enfield
I thank the Minister for that helpful reply. I certainly welcome the efforts that have been made to align more closely the various outcome frameworks, in particular the sharing of particular outcome indicators on premature mortality. Given the new duties that are now on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups to reduce health inequalities, and indeed the current inequalities in the incidence of conditions such as cancer and survival rates among deprived groups, what evidence is there that using these common outcome indicators will result in more integrated services such as smoking cessation, leading to real reductions in health inequalities?
Earl Howe
The essence of the answer to that is that improved outcomes will be achieved only when all parts of the system work together. If you have shared measures within the outcomes frameworks and measures that are complementary to each other, you will shine a light on areas of inequality and inform local and national action to advance equality. This focus on outcomes rather than processes enables an innovative approach to health and care services that is driven essentially by the needs of the local population. I will just add that local Healthwatch has a role to play in working with partners to make sure that the views of vulnerable and seldom heard groups in the population are heard.
Baroness Pitkeathley
My Lords, is any work being done on the outcomes of preventive work? I speak, for example, of installing a handrail to prevent a fall that results in an unnecessary and expensive hospital admission. These are often overlooked in terms of outcomes. Will the Minister tell the House if any work is being done on preventive work?
Earl Howe
There are a number of indicators in the NHS Outcomes Framework and, indeed, in the public health outcomes framework and the adult social care outcomes framework relating to the vulnerable elderly groups in our population. I shall need to write to the noble Lady with a specific answer to her question. However, her question is extremely pertinent to the issues that have been very high profile recently, the resolution of which depend, in part, on ensuring that we can avoid unplanned admissions to hospital and keep people securely in their own homes.
Lord Laming
My Lords, will the Minister assure the House that when the separate inspectorates are established they will reinforce integrated working rather than operate in separate identities?
Earl Howe
I can indeed, and I can do so with confidence because the three chief inspectors that we propose to create—one of whom, the Chief Inspector of Hospitals, has already been appointed—will be working as part of the Care Quality Commission. They will be senior employees of the CQC and their job will certainly be to align the methodology that they use to assess good and poor care.
Lord Kakkar
My Lords, I declare my interest as professor of surgery and consultant surgery at University College London Hospital. During the passage of the Health and Social Care Act 2012, there was a discussion about the need to ensure that there was an ongoing focus on integrated care between community hospitals and tertiary services. This needed to be attended by a focus on the development of metrics that would describe whole pathways of care outcomes for patients. What progress has been made with regard to the development of those whole pathway metrics?
Earl Howe
The noble Lord hits upon a point of central importance. The outcomes framework clearly sets out where the different parts of the health and care system share responsibility for outcomes and support joint working in the way that I have described. However, we are committed to developing a measure of people’s experience of integrated care for use in the outcomes frameworks. That is a work in progress. Meanwhile, a place holder was included within both the NHS and adult social care outcomes frameworks when they were refreshed in November last year. We have highlighted the development of this measure in the public health outcomes framework, so I hope to give the noble Lord further news in a few months’ time.
Baroness Jolly
My Lords, within local authorities, public health is responsible for reducing local health inequalities, particularly in areas of non-communicable disease. For those, the solutions are often long term, so would my noble friend explain how success can be measured and incentivised in the short term?
Earl Howe
Again, my noble friend asks an extremely good question. The year-on-year success of public health interventions to address non-communicable diseases, for example, will be measured through the public health outcomes framework. The department will incentivise some of the indicators in the public health outcomes framework through the health premium incentive scheme. Some of the indicators that will be selected may contribute to prevention of non-communicable diseases.
Baroness Wheeler
My Lords, on social care, the charity Mind has pointed out that many people with mental health problems are never properly assessed to see if they need social services, such as having somebody to help with admin or household tasks, or with washing, dressing or something meaningful to do during the day. Is the Minister confident that the outcomes framework is robust enough to measure this problem, and how does he think that local councils will be able to address this issue in the light of the £2.7 billion cuts that they will have had to their adult social care budgets by the end of this spending round?
Earl Howe
My Lords, the adult social care outcomes framework was put together with a great deal of help and support from local authorities, so we hope that there will be a great deal of buy-in to it. It has as its focus high-quality care and promoting people’s independence and well-being, and it enables councils to make comparisons, assess scope for improvement and measure progress against their own local priorities in adult social care. Therefore, the virtue of the outcomes frameworks is, above all, transparency and accountability, leading to improved quality of care as defined locally by councils.
Health: Degenerative Brain Diseases
Earl Howe Excerpts(11 years, 8 months ago)
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Lord Soley
To ask Her Majesty’s Government what plans they have to encourage brain donation to assist scientific research, including into degenerative brain diseases.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, as a nation we are deeply indebted to the many individuals who donate brain tissue. This donation enables vital research leading to new treatments for neurodegenerative diseases. The Medical Research Council, the National Institute for Health Research and research charities are all supporting work to encourage brain donation. The MRC network of brain banks is developing a strategy to encourage new donors and plans to hold a workshop in September this year.
Lord Soley
I am grateful for that Answer. I remind the Minister that when we talked originally of heart donation many people found that quite emotionally difficult, but now it is much more common. There is something very similar with brain donation yet it is profoundly important, not only for general research but particularly for degenerative brain disease. The research bodies are very concerned to get people to donate where they do not have a family history of brain degeneration because they need comparative samples. Can the Minister do all he can to promote this? I donated my brain some time ago and so far it has not been returned marked “not fit for purpose”. [Laughter.] In all seriousness, this is a very important issue. It can bring great improvement to people’s lives and to scientific knowledge generally and I ask the Minister and his department to do all they can to promote it.
Earl Howe
I endorse entirely the noble Lord’s ambition in this area. It is an extremely important area of tissue donation and contributes enormously to our understanding, particularly of neurodegenerative diseases. The network of brain banks I referred to has already begun work on its donation strategy, encouraging new donors to sign up for brain donation. Its plan is to target well characterised individuals, for example those in clinical cohorts, as, once donated, the tissue has lots of associated clinical information from life, which is highly useful to researchers. I know that a lot of the major charities are involved in promoting brain donation.
Lord Walton of Detchant
My Lords, does the Minister recognise that, partly as a result of such donations but also as a result of major developments in genomic medicine, the individual genes responsible for a substantial number of degenerative brain diseases have now been identified; the missing or abnormal gene product has been found and, as a result, new treatments are coming on stream? Does he therefore agree that the rare disease advisory group now established under NHS England should be in a position to recommend, in collaboration with NICE, the prescription under the NHS of these so-called orphan or ultra-orphan drugs which are proving to be so effective in some of these conditions and which are now coming on stream in an increasing number?
Earl Howe
My Lords, we are clear that there needs to be a mechanism to assess the clinical and cost-effectiveness of new drugs, particularly those designed to treat rare and very rare conditions. NICE will indeed be the body charged with doing that. It is devising a process by which it can do so that is quite distinct from its normal technology assessment methodology. As the noble Lord will appreciate, the drugs concerned here are of a different kind and order of cost from those which NICE normally assesses. The noble Lord is quite right that that is the broad process which will be adopted.
Baroness Seccombe
My Lords, my husband did not have some rare disease but, following two strokes, he became involved with a research project called OPTIMA. He was then monitored. It gave my family—and me particularly—great satisfaction to know that he left his brain for research, which they found extremely useful.
Earl Howe
My Lords, I am glad to know that. It provides a telling and important example of how this can be done in a sensitive way, and in a way that best meets the requirements of researchers. If there is a possibility of planning in advance the donation of a brain—or, indeed, any organ—it is much easier for the family and gives the patients themselves much satisfaction.
Lord Naseby
Is my noble friend aware that a great deal of work is being done through the EMEA and, through that organisation, by a number of countries in Europe? As one who has raised the issue of orphan drugs before, can we, on this occasion, make sure that NICE co-operates with these other bodies and we do not start duplicating work across the whole of Europe?
Earl Howe
My Lords, I am aware that NICE co-operates with its counterpart bodies not only in Europe but in other parts of the world; its work has an international dimension. As the same time, I say to my noble friend that NICE is seen as a world leader in its field. Many other countries look to NICE for the methodology that it adopts.
Lord Turnberg
I am sure that the noble Earl is aware that Alzheimer’s disease is increasing in frequency as we all age, and is becoming a severe health problem. The Alzheimer’s disease association is certainly anxious for brains to be put into its bank, because it seems that there is the potential for a cure for this disease in a few years’ time. I suspect that the noble Earl is aware that the research that is done on these brains will be extremely helpful in that respect.
Care Bill [HL]
Earl Howe Excerpts(11 years, 8 months ago)
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Baroness Emerton
My Lords, I will add to what the noble Lord, Lord Willis, said. A lot of work is being done on the appraisal system, but without the appraisal system leading into continuing professional development, professional development becomes ad hoc. A lot of work is being done by the noble Baroness, Lady Cumberlege on appraisal, and I believe that some work is being done by the department as well. If we could link this work with continuing professional development, I think that that would be very helpful.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the health service is dependent on having the right numbers of staff, with the right skills and behaviours. Quite rightly, patients expect the people who deliver health services to be well supported and to have the right professional and clinical skills. To achieve this, we need a system that can attract people with the right values, give them the right career advice, support the development of excellent professional and clinical skills, emphasise the centrality of providing care with compassion, kindness and respect, and ensure a workforce that is responsive to changing needs and innovations in services. That, in a nutshell, is why we have established Health Education England and the local education and training boards.
Health Education England is already established as a special health authority and is already working to put in place requirements similar to those placed on it in this legislation. Establishing Health Education England as a non-departmental public body will ensure that it has the independence and impartiality that it requires to plan, commission and quality-assure education and training for the long term. As an NDPB, it will be accountable to the Secretary of State and Parliament for ensuring that there is an effective education and training system in place. The establishment of Health Education England has been welcomed, I am glad to say, by stakeholders across the health and education system. It has the support of the Health Select Committee and the Joint Committee that scrutinised the draft Bill. It is viewed as an important step forward in promoting the development of the healthcare workforce and driving up standards.
Amendments 8 and 10 seek to ensure that Health Education England gives equal consideration to physical and mental health in the delivery of its education and training functions. I have no quarrel with noble Lords bringing us back to that familiar theme, but primary legislation is not required for Health Education England to give equal consideration to the importance of physical and mental health.
To start with what I hope is an obvious point, in establishing Health Education England, the Government are making clear their commitment to the development of the entire health and public health workforce. One of the significant weaknesses of previous workforce planning and education commissioning arrangements has been the fragmented approach, with responsibilities scattered across different bodies and silo approaches taken to considering the development needs of different professions and services. Health Education England will be different. It will be responsible for the planning and development of the whole workforce, whether in primary care, secondary care, public health or mental health. Although it will retain a strong focus on the development of different professions, it will do so with a multiprofessional remit and perspective that promotes multidisciplinary education and training where appropriate.
I would like to take the Committee back to the Health and Social Care Act 2012, which places a clear duty on the Secretary of State to ensure an effective education and training system for,
“persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England”—
which is a very wide scope. That duty is very important. It reflects the importance of education and training in the NHS and public health system, and is a key duty underpinning the Secretary of State’s duty to ensure,
“a comprehensive health service designed to secure improvement … in … physical and mental health”.
The Bill delegates the Secretary of State’s education and training duty to Health Education England, giving it a clear and unambiguous remit for workforce planning, education, training and development across England. I hope that that conveys to the Committee the direct legal linkage between this Bill and the 2012 Act in respect of the parity of esteem issue.
Clause 88 requires Health Education England to have regard to the Government’s mandate to NHS England. It is appropriate that the education and training objectives are aligned to service commissioning objectives in this way. It is especially relevant in the context of this amendment because the NHS England mandate requires mental and physical health conditions to be treated “with equal priority” and to,
“close the health gap between people with mental health problems and the population as a whole”.
The Government’s mandate to the Health Education England Special Health Authority reflects this and requires Health Education England,
“to focus on the mental health workforce”.
I listened with care, as I always do, to the noble Lord, Lord Rix. I simply say to him that Health Education England can support better education, training and development for staff so that they can better support people with learning disabilities and difficulties. The core components of education and training for all staff should be to treat people with kindness and compassion and communicate well with all patients and carers. That, I hope, goes without saying, but it is particularly relevant to those with learning difficulties and disabilities. In saying that, of course I recognise that there are certain specialist skills that people in that field require.
Amendment 12 relates to continuing professional development. I absolutely recognise that the continuing professional development of healthcare workers is important. This is enshrined in the NHS constitution, which places a commitment on all employers that supply NHS-funded services to invest in this area and provide their staff with the support and personal development that they need, as well as access to appropriate training to enable them to fulfil their duties.
Health Education England will play a crucial role in providing leadership in this area. The mandate that the Government published only recently for the Health Education England special health authority sends out a clear message that the staff working in our NHS and public health system are the health service’s most precious resource. We must do all we can to ensure that staff have the right values, training and skills to deliver the very highest quality of care for patients. To support the development of the existing NHS and public health workforce, the mandate sets out that Health Education England will work with Local Education and Training Boards and healthcare providers to ensure professional and personal development continues beyond the end of formal training to enable staff to deliver safe and high quality health and public health services, now and in the future. This will include supporting those staff who may wish to return to training.
I hope that those remarks are helpful to the noble Baroness. To cover a number of questions that were put to me, the noble Baroness, Lady Wheeler, asked about the Royal College of Psychiatrists report. We very much welcome the report. The Minister for Health and Care Services will be attending the report’s launch on 19 June and will be setting out what the Government will do to respond to the challenge that the Royal College has articulated.
The noble Lord, Lord Warner, asked what Health Education England will do to address the issue of reliance on locums and agency staff, a very pertinent question. Health Education England can make a significant contribution in this area. Better workforce planning, linked to service and financial planning, is a key aim of the new system that should ensure less reliance on locum and agency staff.
The noble Baroness, Lady Wall, asked me what Health Education England was doing to support career development for healthcare assistants. The capability of care assistants, and public confidence in that group of workers, is of increasing importance. Health Education England will work with employers to improve the capability of the care assistant workforce, including those in the care sector, as well as the standards of training that they receive. Health Education England will develop a strategy and an implementation plan to achieve that, building on the Cavendish review, which will be published quite soon, and on work by Skills for Health and Skills for Care on minimum training standards. The strategy should cover job roles, recruitment, induction, training standards and transparency, as well as identifying opportunities for career progression. I hope that those comments are helpful to the noble Baroness.
Baroness Wheeler
I thank the Minister for his thorough response and for his reassurances on the Government’s intentions in respect of parity of esteem. The debate as to whether parity of esteem is inferred or assumed in legislation, or should be specifically included, will continue. We will be strongly supporting this issue as we move through the Bill, with the comments of the noble Lord, Lord Rix, on the need to ensure the inclusion of people with learning difficulties. I am disappointed that the Minister is resisting this issue of inclusion. It would underline the importance of parity of esteem as a guiding principle, ensure consistency with the Health and Social Care Act and reinforce the HEE mandate role in this respect.
Amendment 12 received strong support from my noble friend Lord Warner, the noble Lord, Lord Willis, and the noble Baroness, Lady Emerton. I welcome that. My noble friend was right to underline the particular importance of CPD in the light of the current challenges facing the service. I look forward to the fuller debate later on in the Bill on this. With that, I beg leave to withdraw.
Earl Howe
My Lords, Amendments 9, 18 and 34 seek to require Health Education England to seek the advice of regulatory bodies and royal colleges in the exercise of its functions. Similarly, Amendment 36 seeks to amend Clause 89(3) to require Health Education England to seek advice from all the medical royal colleges. Amendment 15 seeks to amend Clause 85 to require HEE to seek representations from relevant organisations to define sufficient workforce numbers and the appropriate skills mix when carrying out its duty.
The education and training landscape is multifaceted. Many organisations have an interest in the development of health professionals, ranging from local employers in the NHS through to national organisations such as the professional regulators, including the Nursing and Midwifery Council, and professional bodies such as the medical royal colleges and those supporting other professions. To carry out its role effectively, Health Education England and the local education and training boards need to tap into all this knowledge and expertise. These bodies have crucial responsibilities in setting professional standards, shaping curricula and driving forward improvements in the quality of education and training. Health Education England simply has to work closely with them to deliver its functions.
The medical royal colleges in particular play an essential role in supporting the development of the medical profession, shaping curricula and the development of training programmes, supervising training, examining trainees to ensure the highest professional standards, promoting and supporting research, supporting audit and evaluation of clinical effectiveness, and generally providing support and advice for doctors at all stages of their careers. So I can reassure the Committee that Health Education England is already required to work with the professional regulators and medical royal colleges to obtain their advice on the exercise of its functions.
Clause 89 requires Health Education England to obtain advice on the exercise of its functions. Clause 89(2) requires HEE to seek to ensure that it receives representations from bodies which regulate healthcare workers and persons who provide, or contribute to the provision of, education and training for healthcare workers. This includes universities, professional bodies and the medical royal colleges.
The noble Lord will be pleased to hear that Health Education England is already working with the professional regulators and medical royal colleges. When he gave evidence to the Joint Committee that scrutinised the draft Bill, Professor Ian Cumming, the Chief Executive of HEE, was very clear that he saw the professional regulators and royal colleges as partners in developing the next generation of staff. Professor Peter Rubin, the chair of the GMC, gave evidence in the same session and reinforced that view, reassuring the committee that the GMC has a very good working relationship with Health Education England.
HEE is not starting from scratch in building these relationships. It is building on the good work previously done by Medical Education England and others to strengthen engagement and partnership-working with the professions. As I mentioned earlier, the HEE special health authority has established profession-specific advisory groups, involving employers and key partners including national regulatory and professional bodies. These will look at profession-specific workforce development across medicine, dentistry, nursing and midwifery, the allied health professions, pharmacy and healthcare science. They will each have a patient representative and be co-chaired by Health Education England and the professional lead in the relevant field.
In addition to having profession-specific advisory groups, Health Education England is establishing a multi-professional advisory group to bring all professions together to look at cross cutting issues. I hope that is a positive piece of information for the noble Baroness, Lady Emerton, in particular. I hope that the noble Lord, Lord Hunt, will be pleased that it is also setting up a patient forum to ensure patients and service users can engage in education and training and inform work in that area.
Lord Hunt of Kings Heath
I am very grateful to the noble Earl on that point. Is there a case for replicating that at local level, through the LETBs?
Earl Howe
Certainly, I do. I am happy to take that idea away, and if I can give him any further information during the course of our debates I will. Equally, the LETBs have strongly established connections with professional regulators and professional bodies. For example, the postgraduate medical and dental deans, who are now an integral part of the LETBs, work very closely with the GMC and medical royal colleges in the management and quality assurance of training for junior doctors. I hope that those remarks will reassure noble Lords sufficiently for them not to press the relevant amendments.
In reply to my noble friend Lord Willis, who expressed concern about the way the Explanatory Notes were framed, it is important to look at the entire context of the passage he quoted. The words “such as” appear in that passage before “the medical Royal Colleges”, so it is not meant to denote an exclusive reference to the medical royal colleges; it is very much trying to say that the professional bodies in general will be relevant here.
Amendment 35, tabled by the noble Lord, Lord Hunt, and the noble Baroness, Lady Wheeler, seeks to amend Clause 89 to require HEE to seek advice from the Care Quality Commission and Monitor. It is very important that Health Education England works closely with those two bodies. The Care Quality Commission plays an important role in assessing the quality of healthcare services, and in so doing it assesses their ability to deliver services safely and effectively. In doing so, it will consider whether healthcare providers have suitably skilled staff and in the right numbers. It will need to work closely with Health Education England to share findings and evidence to support improvements in education and training. Health Education England will also be able to share information on the effectiveness of providers in supporting clinical placements and training programmes to support the Care Quality Commission in its role.
HEE and Monitor will work closely together to ensure the financial stability of the health system. This will include working together on the reform of education and training funding and the development of education and training tariffs. To reflect the importance of these relationships, the Bill places a clear and reciprocal duty on Health Education England to co-operate with both the Care Quality Commission and Monitor. I hope noble Lords will feel reassured by that and will be able to withdraw this amendment.
Baroness Wall of New Barnet
Is the Minister in a position to respond to my points? I understand the importance of the medical royal colleges and the professional bodies, but the noble Earl described earlier how Health Education England has responsibility for the whole workforce. I sought from him the opportunity to describe where Skills for Health and Skills for Care come in. I should point out that I have spoken three times and have not declared an interest as chair of Barnet and Chase Farm NHS Trust. I hope noble Lords will forgive me for that.
Earl Howe
I am grateful to the noble Baroness. I have to go a little further, so if I may I will cover her point in a moment.
Amendments 40 and 42 to 46, tabled by the noble Lord, Lord Hunt, and the noble Baroness Lady Wheeler, focus on the need for expertise on the local education and training board. Specifically they seek to change Clause 91(3) to require a LETB also to have as members persons who deliver education and training to healthcare workers, a registered nurse, persons with experience in staff groups that are not professionally registered, healthcare workers who receive education and training from within the area, patients and carers or their representatives, and a representative of the local health and well-being board.
I fully expect Health Education England and the LETBs to work closely with and seek advice from a range of key stakeholders, including those providing education and training, members of staff, patients and carers. That requirement is clearly set out in Clause 89. I appreciate the position of noble Lords but do not agree that we need to specify all these groups in the governance structure.
In establishing the LETBs, the Government are committed to driving up standards and the quality of education and training provided. I suggest that that can happen only if those directly involved in the provision of education and training are at the heart of the new system. By their very nature, local education and training boards will be representative of local healthcare providers, who play a critical role in educating and training our workforce. They are the health professionals who support and supervise clinical placements and training programmes across the country, providing professional leadership and support to students and trainees.
If we mandate a requirement for a nurse, others will ask why there is no requirement for a doctor, a dentist, an allied health professional or any of the many other professions. I completely agree that these professions, and the bodies that represent, regulate and support them, need to be closely engaged in the work of the LETBs, but it is not practical to require all of them to be members of the board. The Bill makes provision in Clause 91 for those involved in the provision of education and training, such as universities, to be eligible to sit on an LETB. We know from the 13 LETBs established by the HEE special health authority that all of them have a university representative on their boards, and many different health professionals are also represented on them.
HEE will appoint independent chairs of the LETBs. These will be people who are not directly involved in the delivery of health services, or education and training, in the geographical area. Having an independent chair will ensure that the local education and training board acts independently and in the interests of all healthcare providers represented.
To be appointed in the first place, local education and training boards will need to demonstrate to HEE that they have the right governance arrangements and the right mix of people on their boards with the necessary capacity and capability. In going through that process it will be for HEE to assess whether the local education and training board has the right mix of skills, knowledge and expertise with which to carry out its functions. However, as the intention is for local decisions on education and training to be made by the LETBs, it is important that we give them the flexibility to determine who sits on their boards.
To sum up the position, I can reassure noble Lords that LETBs are already developing strong partnership arrangements in their patch to engage with all education institutions involved in education provision in their area. The HEE special health authority has reinforced the importance of this in the appointment criteria that it set the LETBs, which have to be approved by the Secretary of State. These demand that LETBs demonstrate meaningful engagement and collaboration with many stakeholders with an interest in education and training, including students and trainees, and patients and carers. As a result, they are putting in place appropriate advisory and partnership arrangements to support the decision-making of the local education and training board.
Lord Willis of Knaresborough
Perhaps I may interrupt the Minister and come back to the important point made by the noble Baroness, Lady Wall. In responding the Minister has yet again constantly referred to what I would call professional organisations. There are nearly 1 million healthcare support workers in the care and the health sectors. Many are untrained. Most are unregulated and unregistered. The two organisations that are providing basic skills, Skills for Health and Skills for Care, were dreamt up within the department. They did not widely consult before they put their forward their proposals for training programmes. The Nursing and Midwifery Council was never asked about the standards for Skills for Health. Will the Minister say who will be consulted about training the people who do so much of our basic social and healthcare—those who are called healthcare support workers?
Earl Howe
I fully recognise the importance of the healthcare support worker sector. I can reassure my noble friend and the noble Baroness, Lady Wall, that Health Education England will be working closely with the sector skills councils, Skills for Health and Skills for Care. I note my noble friend’s scepticism about those bodies, but I do not share it. They have done a pretty fine piece of work and the fruits of it will be apparent over the coming months. HEE will need to do that if it is to perform its role as fully as it should to plan and shape the development of the entire workforce. If by some mischance it were to neglect that aspect of its work and not focus on improving training standards for the health and care support workforce, it would lead to a very unbalanced and unsatisfactory position. Therefore, we are very clear that this should be part of the remit of Health Education England. I hope that that is sufficient reassurance for noble Lords.
The noble Lord, Lord Hunt, asked about health and well-being boards being represented on LETBs. There is a clear commitment in Clause 93 for LETBs to consult health and well-being boards in the development of their plans.
My noble friend Lord Willis asked how Health Education England’s workforce planning will take into account new innovations. Workforce planning is a key focus for Health Education England. It is not about churning out the same old numbers but about working with service commissioners, service providers and other partners such as royal colleges to understand how the workforce needs to respond to service change. This means taking account of technological, pharmaceutical and other advances, and having a flexible workforce that is able to adapt to those innovations.
Lord Touhig
My Lords, time and again in this House the matter of training of health professionals so that they better understand how to support and care for people with autism has been debated. Here, I should declare an interest as a vice-president of the National Autistic Society. We know that key professionals such as GPs and community care assessors still do not have a good enough understanding of autism.
Amendment 24, about which the noble Lord, Lord Rix, has spoken and to which I have added my name in support, if taken on board by the Government would at least ensure that the Secretary of State would be required to consult vulnerable people, including those with autism, their carers and groups such as the National Autistic Society, Mencap and others on matters affecting education and training that will be provided by Health Education England.
Only one in three adults with autism in this country told the National Autistic Society in a survey that in their experience social workers have a good understanding of autism. There is a well established correlation between the professionals’ understanding of autism and the degree of identification of needs among adults in that local authority area with the condition. Autism training can help ensure that adults with autism are correctly identified, and qualify for the support they need.
I recently served on the autism and aging commission, chaired by the noble Baroness, Lady Greengross. Professor Francesca Happé gave evidence about the difficulties of picking up on autistic people’s needs. She said:
“This is a group that doesn’t self-present, doesn’t come and seek services, because of their difficulties of social interaction and communication and we absolutely owe it to them to go and find out what their needs are”.
For that reason, we need well trained people to support them.
The National Autistic Society’s excellent document, Push for Action: We Need to Turn the Autism Act into Action, made a very good case. It includes a very good case study by the mother of an adult with autism. Her name is Chloe, and she says:
“We got to the point where Peter couldn’t live at home, for his own and our safety. After moving around between people he knew and staying in a B&B, eventually he got a flat but he still doesn’t get any support. Social services don’t understand autism and how it affects him. They’re not asking the right questions. They say, ‘How are you?’, and he says, ‘I’m fine’, so they come back to me and say, ‘He’s fine, he doesn’t need any help’. But of course he says he’s fine at that point because he probably is at that point”.
He does not trust them, so he says he is fine in order to make them go away because he does not believe that they understand or are able to help him.
“He had a mental capacity assessment and they asked him about managing his money. He told them that he was saving money for a motorbike but he doesn’t have any money. He can’t manage his money. He gets into all sorts of trouble”.
Chloe concludes:
“I’ve given up asking for support. Me and my husband now do everything ourselves … Now we have no expectations of what ‘services’ should be providing”.
That is just one example of the lack of trained staff having an adverse impact on the life of an autistic person and their family.
I hope the Government will ensure that autism training is included in the core curricula for doctors, nurses and other clinicians, in accordance with the commitments under the Adult Autism Strategy. It is absolutely necessary that vulnerable groups, including people with autism, are consulted about priorities for training so that decision-makers become aware of the gaps in knowledge and understanding among health professionals.
Ultimately, the Government must tackle the issue by including autism training in the core curricula for doctors, nurses and other clinicians, as they committed to do in the 2010 Adult Autism Strategy. People with a learning disability and/or autism have the right to the same quality of healthcare as those without. I believe that Amendment 24 is a good step forward in achieving that.
Earl Howe
My Lords, I will deal briefly with two of the amendments in this group. I will deal first with Amendment 11, which was tabled by the noble Lord, Lord Hunt. The explanation for this provision in the Bill is essentially that it is a safety net to enable an extension of HEE’s activities in future, and to ensure that this has the Secretary of State’s prior consent. HEE can carry out other activities relating to the education and training of healthcare workers, or relating to the provision of information and advice on careers in the health service. However, we believe that to avoid undue mission creep it is perhaps advisable for the Secretary of State to be content that Health Education England is branching out in new directions.
Regarding Amendment 32A and the issue of end-of-life care, Health Education England will indeed support NHS England where it can in implementing its end-of-life care strategy, and the way that it shapes and reforms education and training.
Lord Rix
The Minister appeared to say that most of the people being consulted were professional bodies. He did not mention that people with a learning disability and their families and autistic people and their families were also going to be consulted. He mentioned the list of professional bodies but not the parents, carers and the people themselves.
Earl Howe
My Lords, I understand the point. In view of the hour, if I may, I will write to both noble Lords to flesh out the remarks that I have made. I hope that I can give them some comfort in that area.
Amendments 25 and 27, tabled by the noble Lord, Lord Hunt, focus on the importance of long-term and national approaches to workforce planning in education and training, as does Amendment 26. We have strengthened the Bill, following feedback in consultation and at pre-legislative scrutiny, in Clauses 87 and 93 to reflect the importance of HEE and the LETBs taking a long-term perspective on workforce planning and education and training. It is the Government’s expectation that all workforce planning, be it national level planning by HEE or local planning by the LETBs, should be based on a well informed, long-term workforce strategy that looks at needs over the next five years, 10 years or beyond. Any workforce strategy to be credible and deliverable has to be developed in partnership with those partners and stakeholders who have a stake in it. The very same principle applies to the development of national workforce priorities and outcomes and the Government are committed to working with everyone involved in education and training to shape the education outcomes framework and the mandate for Health Education England.
Health Education England will be expected to develop a national workforce plan, building on the local plans developed across England by local education and training boards. I hope that the noble Lord will feel reassured by those comments.
I turn now to Amendments 33 and 14, which seek to amend the Bill to require HEE to have regard to any official guidance and standards on staffing numbers and skill mix. HEE must work with commissioners and healthcare providers to ensure that workforce plans focus not only on how many staff are required but the breadth of skills required to deliver safe services. These plans need to be integrated with service and financial planning so that the needs of all patients and local communities can be met. Individual healthcare providers are best placed to determine how many staff they need to employ, the skill mix required across the various teams and how they need to deploy them to support services and so on. It is the responsibility of individual healthcare provider boards to be accountable for staffing levels and the skill mix of staff in their organisations. Where changes are planned to the size and shape of the workforce, including the skill mix, healthcare organisations must provide assurance that the safety and quality of patient care is maintained or improved. The process should include clinical involvement, leadership and sign off. I hope that these comments will be reassuring.
The noble Lord, Lord Hunt, asked me about the definition of “sufficient” and whether we were talking about equilibrium or oversupply. I will write to him on that, but in delivering that duty, HEE will seek to match supply and demand so far as that is practically possible. It will also promote the importance of a flexible workforce that can adapt to changing circumstances.
I will also, if I may, write on the issue of staffing ratios. I would just say here and now that staffing is clearly not just about crude numbers and not just about nurses. It is also about how the staff work and ensuring that the right staff are in place to meet the needs of the patients whom they are looking after. Again, it is local healthcare providers that are in the best place to decide how to configure those staff in the right way and to ensure better outcomes and value for money. It really depends on the skill mix, the clinical practice and local factors. I think we would say that it is right that nurse leaders should have the freedom to agree their own staff profiles. But I shall follow up that point.
Amendment 19 seeks to amend Clause 86(2) to add to Health Education England’s main functions the promotion of the importance of practical based training in the education of clinicians. I wholeheartedly agree that practical experience while training is essential to ensure that clinicians have the necessary skills to deliver high-quality and compassionate care and have the correct values and behaviours to practise in the NHS and public health system. It is the responsibility of the professional regulators to ensure that the right standards are in place for professional education and training. Practical experience is already a requirement of the professional regulators. Nursing students, for example, are required by the Nursing and Midwifery Council to undertake half of their training in a practice setting. The GMC also expects every medical student to gain practical experience of working with patients throughout their degree. We have placed a strong duty to secure continuous improvement in the quality of education and training on Health Education England. HEE is already working with the professional regulators, as I have already mentioned, to ensure that the Bill remains clear and simple. However, we have not specified the integral elements of the training programmes to which this duty applies. I would add, though, that the need for practical experience is one of the key priorities that the Government have set for the Health Education England Special Health Authority in the mandate. Health Education England will work with the LETBs and healthcare providers to deliver high-quality clinical and public health placements that provide students and trainees sufficient time working with patients to gain experience.
On Amendment 29, I can reassure the noble Lord that, where appropriate, Health Education England will take a national lead in the planning and management of education and training activities. The Bill already makes provision for this in Clause 94(2). The HEE Special Health Authority has already taken on responsibility at national level for crucially important arrangements to manage recruitment into foundation and specialty training programmes for junior doctors. Where there are controls on workforce numbers at national level—for example, in medicine or pharmacy—it will work with partners such as the Higher Education Funding Council for England to develop national plans that will deliver the staff needed across England.
Amendment 30 seeks to amend Clause 88 to add a requirement for Health Education England to have regard to the need,
“to co-ordinate its activities with the NHS in Scotland, Wales and Northern Ireland”.
Of course, it is very important that HEE works closely with the other UK nations in developing workforce plans and shaping education and training. It will be important for it to take a UK-wide perspective and, where appropriate, an EU-wide or indeed global perspective in planning for the future and reforming education and training. I refer the Committee to paragraph 17 of Schedule 5, which enables Health Education England to exercise corresponding functions on behalf of the devolved authorities. The special health authority is already working closely with its partners in Scotland, Wales and Northern Ireland, building on previous arrangements.
I sympathise completely with Amendment 28 and I wholeheartedly agree that there should be equality of funding for education and training across England. Moving to a tariff-based system for funding clinical education and training would enable a national approach to the funding of clinical placements and would provide a more level playing field between different providers. It will ensure that providers are reimbursed fairly for the education and training that they deliver and are incentivised to provide high-quality clinical placements to their students and trainees. For consistency of opportunities across the country, Clause 85 places a duty on HEE to ensure that sufficient numbers of health professionals are trained and available to work in the health service throughout England.
I hope that noble Lords will feel reassured by those remarks. Before I close, I will quickly respond to my noble friend Lord Willis, who expressed concern about the mandate containing little on nursing and support workers. There is a clear and strong commitment to supporting the development of the care assistant support workforce. Similarly, there are clear national priorities focusing on development of the nursing and midwifery workforce. Again, if I can elaborate on that in writing, I would be happy to do.
Lord Hunt of Kings Heath
My Lords, I am very grateful to the noble Earl for that comprehensive response. I am sure that we will all want to study it very carefully in Hansard. I will just make two points. One is that I hear what he says about the obvious intention of HEE to undertake long-term planning, but putting something in the Bill might help it with that. Secondly, I realise that my amendment on practical-based training is not very sophisticated but there is a kernel of truth within it that I would like to pursue on Report. But I am most grateful and beg leave to withdraw my Amendment 11.
Care Bill [HL]
Earl Howe Excerpts(11 years, 8 months ago)
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Baroness Masham of Ilton
My Lords, I, too, support having a nurse on the board. It is vital because the nursing workforce is the biggest of all the professions, and training and recruitment is sometimes the problem that has to be faced.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we begin our Committee proceedings with a series of amendments that take us to the heart of the theme that permeates this Bill. The driving principle of reforming the education and training system is to improve care and outcomes for patients. Excellent health and healthcare require a training system that will deliver a highly skilled workforce, working together with compassion and respect for people.
Noble Lords will remember our debates of last year when, recognising the importance of education and training in the NHS and public health, we inserted into the Health and Social Care Act a clear duty on the Secretary of State to ensure that there is an effective education and training system. This Bill delegates that duty to Health Education England. This means that Health Education England will be clearly accountable to the Secretary of State for ensuring that there is an effective education and training system in place for healthcare workers in England. Health Education England will provide national leadership for workforce planning, the commissioning of education, training and development activity, and the quality assurance of the education and training that is delivered.
The backdrop to all that is the changing face of healthcare provision. The way health services are provided is expected to change significantly over the next few decades, with more care provided in the community and an increased emphasis on public health. This cannot happen unless we equip the workforce with the skills and knowledge to do this. To do it successfully, the local and national infrastructure needs to be in place to plan and commission effectively. That is why the creation of Health Education England and the local education and training boards is so important.
It is vital that the board of Health Education England has the necessary skills and experience to oversee the delivery of its important functions. In recognition of this, the Government have already strengthened the Bill, following pre-legislative scrutiny, to place an explicit requirement, in paragraph 2(1) of Schedule 5, on Health Education England to recruit members with clinical expertise. The specific nature and description of the expertise and specified numbers are to be set out in regulations. That amendment has been well received by stakeholders such as the Royal College of Surgeons. A similar requirement has been placed on local education and training boards to have members with clinical expertise.
The noble Lords, Lord Hunt and Lord Turnberg, have tabled a number of amendments relating to clinical expertise on the board of HEE and the LETBs. I realise that Amendment 1 is a probing amendment. It may be helpful to explain our thinking around the Schedule 5 requirement. This sub-paragraph was added to the Bill following pre-legislative scrutiny to place an explicit requirement on Health Education England to ensure that there is clinical expertise on the Health Education England board. It also responds to responses to the consultation on the Bill, which touched on the importance of Health Education England having access to professional leadership. This will give Parliament and bodies representing the professions the necessary assurance that the Health Education England board has access to the appropriate knowledge and understanding in making decisions that impact on professional education and training. It also provides the basis for a clear duty in the Bill for both the Secretary of State and Health Education England to make appointments of clinical experts, which can be developed subject to regulations. For example, the regulations will specify what we mean by “clinical expertise” and allow greater flexibility to specify any detailed requirements. It will also allow changes to be made to those requirements as Health Education England matures, should circumstances demand it.
Amendments 3 and 4 seek to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include in its board membership a registered nurse and someone with experience in staff groups that are not professionally registered. Similarly, Amendment 2, tabled by the noble Lord, Lord Turnberg, seeks to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include one or more members with expertise in research and one or more members with expertise in medical education and training in the Bill.
It is undoubtedly important for Health Education England to have access to professional expertise, but having said that I need to make clear that the Government do not believe that it is appropriate for the Bill to mandate requirements for certain professions or particular areas of expertise. That is better suited to be set out in secondary legislation, as it may change over time, and Health Education England will need greater flexibility to recruit the expertise it requires and to specify any detailed requirements as circumstances demand.
One of the great strengths of Health Education England over previous arrangements is that it has a remit for all the professions, bringing a strengthened approach to multi-professional education and training. Although medical and nurse training, and an understanding of the importance of research, are extremely important elements of its functions, HEE has a much broader focus. It may be helpful to the Committee to have a sense of how the new organisation intends to do justice to that broad remit.
First, HEE will employ a director of education and quality at board level who is responsible for ensuring a co-ordinated multi-professional approach to education and training. Within the Health Education England special health authority, that post is filled by a doctor, and is supported by a medical director, a director of nursing, and other professional advisers for dentistry, pharmacy, healthcare science and the allied health professions.
Secondly, Health Education England has established professional advisory groups, bringing together employers and national stakeholders, to focus on profession-specific education and training issues covering medicine, dentistry, nursing, pharmacy, healthcare science and the allied health professions. These advisory boards will support HEE and its board in the decisions they make that impact on health professional education and training. It should also be remembered that Health Education England employs many health professionals that support the activities of the LETBs. In these ways it has direct access to a wealth of knowledge and expertise on the planning, commissioning, provision and quality assurance of education and training.
The Government understand the importance of considering the support workforce that is not professionally registered. Health Education England, with the networks of employers working through the LETBs, will provide a wider leadership role in the development of the whole workforce engaged in the delivery of healthcare and public health. This is emphasised in the Government’s mandate for the Health Education England special health authority. In making non-executive appointments to the Health Education England board, the Secretary of State will source the skills and expertise that are required to ensure the Health Education England board can function effectively. The chair and non-executive directors will do likewise in making executive appointments to the board. That approach has worked well for the recruitment of the current HEE special health authority board, which has three members with clinical expertise, including a doctor. I should also mention that two non-executive appointments are still to be completed. In recruiting for those, we are looking for a further clinician with experience of equality and diversity issues, and someone who can bring a strengthened focus on the patient perspective to support the development of education and training.
In the light of what I have said, I hope noble Lords will feel reassured that the Health Education England board is suitably clinically informed, and that they will feel able to withdraw those amendments.
I now turn to Amendment 5. The Bill already requires the consent of the Secretary of State to the appointment of the chief executive of Health Education England. That approach is in line with the appointment of other chief executive officers across the health system and seems proportionate for a body of this size and nature. In addition to approving the appointment of the chief executive, the Secretary of State will appoint the chair and non-executive directors of Health Education England. This approach has worked well for the HEE special health authority, which has a board with a good blend of experience and expertise.
As for the role of Parliament, the Bill makes provision for Health Education England to report to Parliament on an annual basis, with the requirement to publish an annual report setting out its achievements and to publish annual accounts. I am sure the Health Select Committee will rightly continue to take a strong interest in education and training and will have the opportunity to discuss progress with Health Education England whenever necessary. I hope that will reassure the noble Lord on this amendment.
Ensuring that non-departmental public bodies have robust governance and accountability arrangements in place is clearly essential. Schedule 5 to the Bill makes provision for the constitution of Health Education England and deals with the exercise of its functions and its financial and accounting obligations. A number of amendments in this group fall under that broad heading.
Amendment 6, which again I realise is a probing amendment, poses a question about the terms of remuneration of HEE’s employees. In establishing HEE as a non-departmental public body, it is important that it is given the appropriate levels of autonomy and independence to carry out its important education and training functions without day-to-day interference from Ministers or the Department of Health. Yes, it needs to be held accountable for the use of its resources, and the Government are committed to holding it to account in an open and transparent way, but I hope noble Lords would agree that it is important for a body of this nature to have the ability to determine the pay and remuneration rates for the people it recruits and employs, including its executives. That does not mean that it will not be subject to any constraints. I can reassure the Committee that as an arm’s-length body of the Department of Health, HEE will be subject to the rules and controls covering the use of its budget, and to procedures applicable to senior appointments and levels of remuneration. These are the very same rules that apply to other arm’s-length bodies and to all government departments.
The noble Lord, Lord Hunt, asked me whether HEE employees will be engaged on NHS terms and conditions. In fact, HEE employees are currently employed on NHS terms and conditions and there are no plans to change that when HEE becomes an NDPB.
Amendment 7 is another probing amendment. The provision which the noble Lord has questioned is important. It clarifies that Health Education England’s property is not to be regarded as property of, or held on behalf of, the Crown. This is a standard provision that applies to other arm’s-length bodies in the health system. It allows Health Education England to make arrangements for its own property and office needs. It needs to do so to support the staff it employs nationally and across the local education and training boards. It would not be practical for any other body to hold this responsibility. Of course, Health Education England will work with other bodies to look for savings on estates, information technology, human resources and in other areas. It is already doing that as part of the shared services programme which the Department of Health and all its arm’s-length bodies are signed up to.
Part 2 of Schedule 5 imposes a very clear duty on Health Education England to exercise its functions effectively, efficiently and economically. Part 3 of Schedule 5 sets out how the Secretary of State will fund Health Education England and includes restrictions on the use of resources. These are consistent with provisions made for other bodies in the healthcare system such as NHS England.
I make the same point as I did a minute ago—that HEE needs to be held accountable for the use of its resources—but it is right to give it direct responsibility for how it operates and manages its day-to-day business, including the ability to make arrangements for its own property and accommodation. In the light of that, I hope the noble Lord will feel sufficiently reassured to not press his amendment.
Baroness Cumberlege
Perhaps I may comment on what my noble friend has said in reply to the debate. I understand that under secondary legislation he is considering putting a registered nurse on the board. Some assurance on that would be very helpful. In my experience working with clinical commissioning groups, when they were appointed there had to be a nurse on the board, and the last person to be appointed in many cases was the nurse. There was a feeling that it was hard to find a nurse who would make such a contribution. Some very talented young nurses are coming on-stream, but when one talks about a clinical presence on a board, so often, it is interpreted as a medical person on the board. We seek to ensure that a working nurse will be on those boards. If my noble friend can reassure me that he will consider that very carefully when drawing up the regulations, I will be very pleased.
I am so sorry. I should have declared an interest. My interests are on the Lords’ Register.
Earl Howe
My Lords, I listened with care to my noble friend, whose experience we respect greatly. I can tell her that Health Education England’s board will need to have access to a cross-section of clinical expertise, as it does at the moment. Nursing representation will of course be very important. I assure her that we will prioritise that issue in developing the supporting regulations on membership. That is probably as far as I can go, but I recognise the force of everything that my noble friend said.
Baroness Emerton
On a point of clarification, the Minister used the term multi-professional education in relation to integrated services. We have concentrated on medicine, nursing and clinical expertise. Because we are going to be looking across the boundaries into social care, is Health Education England going to have anything to do with the social care aspect of the training of clinical specialists? We have not mentioned social care, and I wondered whether we should.
Earl Howe
My Lords, Health Education England will have responsibility for the NHS workforce, but not for the social care workforce. We will reach a group of amendments that bear closely on the issue of integration, where I am sure that we can explore the relationship that Health Education England will have with those bodies charged with delivering the social care workforce. The noble Baroness is absolutely right: there needs to be co-ordination and joined-up thinking in those areas. If she will allow, we can wait until we reach that group of amendments before debating the issue further.
Lord Warner
Let me assure the noble Baroness that I shall be in good voice on the subject of social care on Amendment 13.
It was helpful to hear what the Minister had to say about advisory committees and advisers. I listened carefully. I did not note anything about those advisory committees or an adviser for what I might call the sub-professional group. I am sure that the professions will be extremely well looked after in HEE, but the groups which we often have the most problem recruiting and ensuring are properly trained are those below the professional level. Can the noble Earl say a little more about those unsung heroes working at the sub-professional level and what kind of advisory capacity HEE might have in that area?
Earl Howe
It will certainly be open to the board of HEE to establish an advisory committee that specialises in unregulated professions. Although, again, I cannot make a firm commitment about that, the very fact that we are dealing with a workforce of substantial size on which the NHS crucially depends—I am now talking about healthcare support workers—means that it would be very surprising indeed if the board were not to have some form of specialist advisory service to inform its decisions.
Lord Willis of Knaresborough
Before we finish debating this group of amendments, will my noble friend reflect on what he has just said about regulation? One of the traps we fell into with the Health and Social Care Bill—I do not think that it was intentional, it just happened—was that so much was promised in regulation that it was not until we started discussing the regulations that we saw what we had not done in the Bill. Perhaps it would be helpful to produce draft regulations as we go along before Report, so that we know what we are including in the regulations.
Earl Howe
It may not surprise my noble friend to know that I asked my officials the self-same question, because I anticipated an appetite for draft regulations. I am, unfortunately, not in a position to make that promise, much as I would like to do so, because there may not be the necessary time available for the regulations to be drawn up in draft. However, I will take back the strength of my noble friend’s request and see whether there can be any reconsideration of that point.
Lord Hunt of Kings Heath
My Lords, it has been a very good debate, and I am grateful to the noble Earl and other noble Lords for taking part. It is the role of noble Lords always to ask the Government for draft regulations but, alas, I fear that we may not see them. If we cannot, perhaps we could at least get a sense of instructions that might be given on policy direction.
First, let me say that the Government’s reflection on the Joint Committee’s recommendation with regard to clinical expertise, and the change that has been made, is welcome. I listened with care to the noble Earl when he said that the needs of Health Education England and the education and training of staff may change over time, which is why that is best left to regulation. That makes sense, but I cannot believe that there will ever be a time when research and nurse representation will not be important. I ask the noble Earl to give that further consideration.
I will just reflect on the comment of the noble Baroness, Lady Emerton, that this has been a consistent theme of restructurings over the years. The noble Baroness, Lady Cumberlege, and I have lived through many restructurings and they always start with the premise that there will not be a nurse on the board. Then, after argument and sometimes experience, it is discovered that you need to have a nurse. I would have thought that the Francis report, at its heart, focused a lot on nursing experience and leadership. I ask the noble Earl to give this further consideration. It would be a very visible sign that the Government are listening to this point and that they actually set out in primary legislation that a registered nurse should be appointed.
I am glad that the noble Earl picked up the point about non-registered staff and managerial staff. It is not just in the health service. In the further education sector there is a similar problem, with only a limited number of people applying to be college principals. We need to think very hard about what we can do to give greater support and encouragement to bright young people coming through so that they aspire to take on these top jobs. No one should underestimate the pressures that those leaders are under, but we really want good people. I endorse the noble Earl’s reference to clinicians. We need to encourage more clinicians to take on leadership roles.
I was very interested in the contrast between the desires of the noble Earl not to give autonomy to the board to appoint its own chief executive, but to give it autonomy when it came to the salaries of its staff. I ask for some consistency here. If the Secretary of State appoints the chair and the non-executives—which is absolutely right—he or she should then have confidence in their judgment to allow the board to appoint a chief executive.
Finally, on the intervention of the noble Baroness on integration, it might help our future debate if the noble Earl could confirm that Clause 88, on matters to which HEE must have regard and in which subsection (1)(h) refers to,
“the desirability of promoting the integration of health provision with health-related provision and care and support provision”,
answers the point that the noble Baroness raised—that in effect HEE does have to have an understanding of the needs of those providing social care because of the contribution that they can make to integrated services.
Lord Hunt of Kings Heath
My Lords, I am very grateful. Having said that, I beg leave to withdraw my amendment.
Care Bill [HL]
Earl Howe Excerpts(11 years, 8 months ago)
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Earl Howe
That it be an instruction to the Committee of the Whole House to which the Care Bill [HL] has been committed that they consider the bill in the following order:
Clause 83, Schedule 5, Clauses 84 to 91, Schedule 6, Clauses 92 to 96, Schedule 7, Clauses 97 to 100, Schedule 8, Clauses 101 to 106, Clauses 74 to 82, Clauses 1 to 38, Schedule 1, Clauses 39 to 42, Schedule 2, Clauses 43 to 67, Schedule 3, Clause 68, Schedule 4, Clauses 69 to 73, Clauses 107 to 113.
Care Bill [HL]
Earl Howe Excerpts(11 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is a privilege to open this debate. Care and support are things that everyone will experience at some point in their lives, whether they need it themselves, know a family member or a friend who does, or provide care themselves. Yet today’s care and support system often fails to live up to the expectations of those who rely on it. While many have good experiences, the system can often be confusing, disempowering and not flexible enough to fit around individuals’ lives.
The Bill represents the most significant reform of care and support legislation in more than 60 years. The foundations of social law are based on principles that are no longer relevant in today’s society. This long-awaited Bill implements the recommendations of the Law Commission’s excellent three-year review, begun under the previous Administration, to pull together over a dozen different Acts into a single, modern framework.
The Care Bill also takes forward our commitments to reform social care. Through the Bill, we are clarifying entitlements to care and support to give people a better understanding of what is available, help them to plan for the future and ensure that they know where to go for help when they need it. The Bill will make a reality our vision for a system that promotes people’s well-being and focuses on the person, not the service. It makes preventing and reducing needs a priority, and empowers people to take control over their care and support. It introduces national eligibility criteria, bringing greater consistency and transparency of access to care across the country.
The Bill includes historic reforms to strengthen the rights for carers to access support, putting them on the same legal footing as those they care for. It emphasises the importance of integration and co-operation between care and support and other services, providing the flexibility for local authorities and care professionals to innovate and achieve better outcomes for people.
A new adult safeguarding framework will ensure that arrangements are in place to protect people from abuse and neglect. There are new guarantees for people receiving care whereby if they move from one area to another they will not go without the care they need. For the first time, the Bill clearly sets out that local authorities are responsible for the care and support of people in prison.
I am pleased that public consultation and pre-legislative scrutiny have demonstrated widespread support for the principles and approach to law reform in adult care and support. Indeed, I am very grateful to those present who have already provided helpful and detailed scrutiny in draft through a Joint Committee of both Houses. The Government have accepted the majority of the recommendations of the Joint Committee on the draft Care and Support Bill. The Bill now reflects the importance of financial advice as part of the care and support information service; there is a stronger focus on prevention in assessments and care planning; and we have extended the powers to assess children for transition before the age of 18.
We have accepted the recommendations of the Commission on the Funding of Care and Support, chaired by Andrew Dilnot. The current care and support system offers little financial protection for the cost of care, which for one in 10 people will be in excess of £100,000. Critically, the Bill will reform care and support funding by creating a cap on care costs, giving people peace of mind by protecting them from catastrophic costs. By introducing universal deferred payments, it will also ensure that people do not have to sell their home in their lifetime to pay for residential care. Following the failure of Southern Cross, the Bill clarifies local authorities’ duties to protect people’s interest in the event of the failure of a provider, and creates a new regime for financial oversight of larger care providers.
In the debate on the gracious Speech, a number of noble Lords expressed concern about levels of funding for care and support. This is of course a very important matter. As a nation we are living longer, which I am sure all noble Lords welcome. Managing the fiscal consequences of this will be a key challenge in the coming years.
We must recognise that for the foreseeable future government spending will be constrained. However, we are also aware that in many areas local authorities are finding new and innovative ways of spending their available funding to secure better outcomes. The Bill will help to ensure that the care and support system works as effectively as possible to make best use of the resources available. To draw an analogy, the legislation changes not the amount of fuel available but rather the efficiency of the engine. I look forward to hearing noble Lords’ views about how the framework set out in the Bill can do this even more successfully.
The report of the Mid Staffordshire NHS Foundation Trust public inquiry, led by Robert Francis QC, identified inexcusable failures in care that must never happen again. Between 2005 and 2009 many patients received appalling care, and the wider health system failed to identify and act on the warning signs. The Government’s initial response set out our commitment to ensuring that patients are,
“the first and foremost consideration of the system and everyone who works in it”.
It set out a five-point plan to ensure safe, compassionate care.
Most of the steps we need to take are about increasing cohesion and bringing about a change in culture across health and care. This is not about fundamental changes to the structure of our healthcare system. However, there are a number of limited but significant changes we need to make which require primary legislation. These are changes primarily to the way health and social care information is used to assess performance, and to the way poor performance is tackled.
Through the Care Bill we will introduce a ratings system for hospitals and care homes to give a single version of performance so that organisations and the services they provide can be compared like for like in a way that is meaningful to patients and the wider public. For while there is considerable information available on organisations providing health and care in England, there is currently no consolidated summary of how well they are doing. Aggregated ratings will help people choose the right services, and encourage organisations purchasing or providing services to improve them.
We will create powers so that the new Chief Inspector of Hospitals can instigate a single failure regime. A key finding of the Francis report was that the focus at Mid Staffordshire was on financial and organisational issues rather than the protection of patients and ensuring quality of care. A new failure regime, in which quality of care is as important as financial performance, will ensure that where quality of care is below an acceptable standard, firm action is taken to resolve it properly and promptly.
Robert Francis made a number of recommendations to promote openness in the health system. We will improve transparency and accountability by making it a criminal offence for providers of NHS secondary care to supply or publish false or misleading information about their own performance and outcomes. This will ensure that regulators, commissioners and the public have an accurate picture of the organisation’s performance, and enable the Care Quality Commission to detect quickly any signs of poor quality or safety and trigger the appropriate interventions.
The Care Bill also closes a loophole in the regulatory powers of the CQC. At the moment, if the CQC finds that a care home that is part of a large provider is not complying with registration requirements, the provider could close down the care home voluntarily in order to evade enforcement action by the CQC. In order to guarantee transparency of the regulatory system, the Bill will address this gap in the law to ensure that large providers operating a non-compliant service cannot avoid a record of poor care in this way.
These measures make limited but important adjustments to facilitate our response to the Francis inquiry. Together with changes we are making that do not require primary legislation, they will help bring about a revolution in the care that patients experience, rooting out unacceptable care, tackling failure promptly and effectively, and ensuring that the inspectorate and ratings framework inspires all hospitals to drive for continuous improvement.
Health Education England provides national leadership for the education and training of healthcare professionals. It supports a network of local education and training boards to enable local healthcare providers and professionals to take responsibility for planning and commissioning education and training in their area. The Health Research Authority was formed to protect and promote the interests of patients and the public in health research, and to streamline the regulation of research. The Care Bill establishes both HEE and the HRA as statutory bodies independent of the Department of Health, giving them the impartiality and stability they need to carry out their vital roles free from political interference.
I am grateful to noble Lords from all parties for their support for this Bill in the debates on the gracious Speech. I look forward to debates about the detail of the measures it introduces, and I am sure that improvements can be made. Fundamentally, the Bill delivers much needed and long overdue reforms that can and should be widely supported. The Care Bill demonstrates the Government’s commitment to ensuring a compassionate, integrated and sustainable system of health and care, built around the needs of individuals and the outcomes they want to see, for now and the years to come. I commend it to the House. I beg to move.
Earl Howe
I begin by thanking everyone who has spoken today. There have been some excellent and highly informed contributions from all sides of the House. Health and care matter to us all throughout our lives; the quality of the contributions today demonstrates how important the issues are in this Bill. I am grateful in particular for the welcome given to Part 1 of the Bill by many noble Lords. A large number of questions have been raised during the debate and I will endeavour to cover as many of them as possible in the time that I have. Unfortunately, there is unlikely to be time to address all of these issues but I will, of course, write to follow up on any unanswered questions.
I listened with care, as I always do, to the speech of the noble Baroness, Lady Wheeler, but I must confess that I was disappointed by the somewhat negative tone that characterised her remarks. Anyone listening to her could be forgiven for thinking that the Labour Party opposed the principles set out in the Bill. I was very glad to hear the noble Lord, Lord Hunt, correcting that impression. I hope that, at the very least, we can look forward to a constructive approach in Committee from all noble Lords opposite. As ever, I stand ready to work with the noble Baroness and the noble Lord, Lord Hunt, and indeed all noble Lords to ensure that we explore the Bill thoroughly so that we can, in due course, send it to another place in a form of which we can be collectively proud.
A number of noble Lords referred, unsurprisingly, to the funding envelope for adult social care. We recognise that the last spending review provided local government with a challenging settlement and that is why we took the decision to prioritise adult social care and provide extra funding to help local authorities maintain access to services. In the White Paper, we committed to additional support for social care over the next two years. However, it has to be remembered that local authorities ultimately have discretion over how they use their resources. Of course we agree that the level of funding available in future will have an impact on how far the reforms are realised, but noble Lords should appreciate that we have committed to funding the reforms set out in the Bill in full.
For example, as the noble Lord, Lord Lipsey, pointed out, funding reform will cost the Exchequer £1 billion a year by April 2019 and there will be an additional £175 million a year to fund the new legal rights for carers in 2015-16. I assure the noble Baroness, Lady Wilkins, that the needs of social care will be at the front of Ministers’ minds as we approach the spending review. However, noble Lords will understand the realities facing us. We cannot improve care and support by simply putting more and more money into the system, and in this financial climate it is therefore more important than ever that councils review their practices, drawing on the work of the sector’s efficiency programmes, to ensure that they are using their resources in the most effective and efficient way possible.
The noble Baroness, Lady Wheeler, and others criticised the level of the cap on care costs. It is surely to be welcomed that, for the first time, there will be a cap to protect people from spiralling costs, and that people will no longer have to live in fear that their home will be sold while they are in a care home or that all their life savings will disappear. The level of the cap is not set in the Bill, but will be set in regulations. Why do we propose to set it at £72,000? We want to strike the right balance between supporting people in paying for care and managing the public purse in a sensible, sustainable way. We believe that a cap of £72,000, which is equivalent to around £60,000 in Dilnot terms, along with the increase in the means test threshold to £118,000, achieves this balance. I was grateful for the broad support provided by the noble Lord, Lord Lipsey, in that context.
The noble Baroness, Lady Bakewell, in her characteristically eloquent and powerful speech, contended that the formula we have arrived at protects the wealthiest. The current system, as she knows, exposes those with few savings or modest housing wealth to the greatest risk of losing everything to pay for their social care. That is unfair and it needs to change. Yes, we are expanding the scope of the means test benefit so that more people will get help, but the vast majority of state support will be provided to the 40% of older people with the lowest incomes and wealth. This is about protecting people with the greatest lifetime care needs, not the greatest wealth.
The noble Baroness, Lady Wheeler, asked me to confirm the details of the sliding scale of contribution towards care costs. People with assets above the lower capital limit, which will be £17,000 from April 2016, will have to make some contribution to the costs of residential care. The sliding scale determines the amount they must contribute. Individuals are deemed to be able to contribute £1 for every £250 of assets above the lower capital limit. We are extending the upper capital limit to £118,000 in residential care, which removes the cliff edge in the current assessment and will result in a gradual increase in support towards an adult’s care costs.
I have noted the hopes and concerns of a number of noble Lords, including the noble Lords, Lord Rix and Lord Warner, and the noble Baroness, Lady Bakewell, around the eligibility threshold. There has been widespread support for a national eligibility threshold and noble Lords are understandably keen to see the regulations that set it. In determining the threshold, we must consider the funding settlement to local authorities; the national minimum eligibility threshold will be announced as part of the spending review on 26 June, and the regulations will follow. Indeed, in answer to the noble Baroness, Lady Campbell, and the noble Lord, Lord Hunt, we will make available a draft of the regulations under Clause 13 to provide for the national eligibility criteria in order to support debate of the Bill in Committee.
The noble Baroness, Lady Uddin, said in her powerful speech that care and support was harder to access for minority ethnic people. I would say to her in that context that information is central to ensuring equality of access to care and support, a point rightly made by the noble Lord, Lord Hunt. Clause 4 sets out clearly and places the duty on local authorities to provide information which is accessible to people needing care and support in the local community. The information must be accessible to those for whom it is provided. So, for example, it should be translated into the languages that are used in the area. The noble Baroness also said that a disabled person should be involved in decisions about how their needs are met and their personal budget is settled. Clause 25 sets out important new duties for the local authority to involve the adult in care planning and to take all reasonable steps to reach agreement with the adult or carer on how their needs are to be met.
My noble friend Lord Sharkey and the noble Lord, Lord Warner, expressed their concern that the Bill contains no provision for a right of appeal against eligibility decisions. The Bill sets out, for the first time in primary legislation, how eligibility decisions will be made by local authorities and the new right to a written record of the decision and the reasons for it. These are important new rights, which will promote transparency and aid decision-making. Where people are unhappy about a decision, there is an established right to make a complaint, which is set out in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. There is no need to set out another system in the Bill. I say to the noble Lord, Lord Hunt, that we will look at the existing complaints arrangements, including considering how best to provide for effective challenge to local authority decisions, in the light of the findings of the review of NHS complaints led by Ann Clwyd and Professor Tricia Hart and our consultation on the capped-cost scheme.
The noble Lord, Lord Patel of Bradford, drew attention to Clause 2(3) and the power to charge for prevention services. He was concerned about how people will pay for this. Local authorities already have the power to charge for preventive services. We do not expect this to be the norm for lots of simple preventive services but we think it important to retain the ability to do so. We intend to use regulations to ensure that services which must currently be provided free, including intermediate care and minor aids or adaptations, remain provided free of charge.
The noble Lord, Lord Sutherland, drew attention to the cross-subsidisation issue. Local authorities and individuals can pay different prices for care, as he well knows, and this can be because individuals have chosen premium facilities or because the local authority has negotiated a lower price in exchange for buying care for a large number of people. The Bill places new duties on local authorities to promote an efficient and effective market for high-quality care services. The local authority must ensure that it has regard to factors such as the sustainability of the market.
The noble Baroness, Lady Wheeler, asked how the Bill interacts with benefit changes. My department is in regular contact with the Department for Work and Pensions on the relationship between welfare reform and our proposals for care and support in order to understand the interaction and impact on people who use care and support, carers and families.
My noble friend Lady Barker asked whether the development of the deferred payment scheme would take into account existing case law. The answer is yes. We have committed to a universal scheme for deferred payments for people who need residential care. In designing this scheme we will of course take into account all relevant case law.
The noble Baroness, Lady Wilkins, spoke about the Independent Living Fund. Following the closure of that fund, we have committed to passing funding to local authorities in order to allow for ILF recipients to be brought into the mainstream care and support system. Final details will be announced as part of the spending round on 26 June.
The noble Lord, Lord Hunt, and the noble Baroness, Lady Wilkins, stated their view that the Bill does not do enough to reference the importance of housing to care and support. In actual fact, the Bill does a lot to recognise housing as a determinant of health and well-being. In response to comments during consultation and pre-legislative scrutiny, we have included “suitability of living accommodation” within the list of matters which well-being relates to in Clause 1. Clause 3 requires local authorities to integrate the provision of healthcare and support and health-related services, which includes housing, while Clauses 6 and 7 require local authorities to ensure the co-operation of their housing officers, both internally and with the authority’s “relevant partners”, in care and support.
The noble Baroness, Lady Donaghy, stated her view that Clause 8 should include transport as a way of meeting needs. I agree that the provision of transport is an important way of meeting people’s needs but we do not believe that there is any requirement to set this out in Clause 8. That clause provides high-level examples of ways of meeting needs so as to leave maximum flexibility to the local authority and the adult to agree on how their needs should be met. Of course, that could encompass transport.
The noble Baroness, Lady Wheeler, and the noble Lord, Lord Hunt, asked whether we had been talking to the insurance industry about the reforms. It is encouraging that many companies support the change. We have been talking to the industry. The Association of British Insurers has welcomed the announcement as a,
“positive step forward in tackling the challenges of an ageing society”.
My noble friend Lord Sharkey asked why the Bill does not implement Dilnot’s recommendations for an awareness campaign. Legislation is not required for that but the Government agree on the need to raise public awareness. The Government will adopt a strategic approach to maximising the public’s understanding of the new care and support system, and that is a crucial part of our plans to implement Dilnot.
My noble friend Lady Jolly and the noble Lord, Lord Patel, spoke about the proposal to legislate for free end-of-life care. The palliative care funding review recommended that social care should be provided free at the end of life. The Government are funding eight pilot sites to test this and other recommendations, which are gathering evidence over two years until 2014. Before making any decisions we want to consider the evidence collected from the pilots. I can, however, confirm that primary legislation will not be required to enable social care to be provided free at the end of life.
My noble friend Lady Browning spoke about autism and people with Asperger’s. The autism strategy and its statutory guidance mark a great step forward for adults with autism in England, as I know she acknowledges. What it does not do, however, is guarantee that everyone with a diagnosis of autism will receive support or services from local authorities. If your needs do not meet the eligibility criteria set out by your local authority you will not receive social care services. The Bill will ensure that you are given information about what other support is available in your local area. As local areas gain a better understanding of autism needs locally and develop autism commissioning plans, we expect local authorities to look more at the cost benefits of more low-level and preventive services such as befriending services or social skills training.
A number of noble Lords, including the noble Baronesses, Lady Pitkeathley and Lady Wheeler, my noble friends Lady Jolly and Lady Tyler, and my noble and learned friend Lord Mackay, referred to young carers. The boundaries between children and adult legislation ensure appropriate distinctions between what can reasonably be expected of adults and children. It is of course crucial that adult and children’s services work together to ensure that young people are not carrying out inappropriate caring roles or are disadvantaged in their education and losing their childhood because of caring. First and foremost, however, young carers should be seen as children and assessed in that context.
Several amendments to the Children and Families Bill on support for young carers were debated in the other place. My honourable friend the Parliamentary Under-Secretary of State for Children and Families, Mr Timpson, recognised that the effective identification of young carers and assessment of their needs for support are best achieved by children’s social care, health and education services working together and considering the whole family’s needs. He explained that he would reflect on the arguments put forward and the evidence from the National Young Carers Coalition. Ministers in his department are very happy to meet noble Lords who are interested in this area as the Children and Families Bill moves to this House. Officials are in contact with the National Young Carers Coalition and other key stakeholders as part of the consideration of the evidence that they have provided. I should say, however, that the Care Bill encourages local authorities to take a whole-family approach in assessing an adult, which means that adults’ needs for care and support are not seen in isolation from their family circumstances, including the contribution of young carers. Regulations about assessment procedures to be made under Clause 12 will put a duty on councils to have regard to the family of the adult to whom the assessment relates.
The noble Lord, Lord Rix, spoke about the transition into adulthood, and I completely agree that transition between childhood and adulthood is an important time when young people and their families are thinking about their goals and aspirations for the future. The Bill gives young people and child carers the right to request an assessment before they turn 18 in order to help them to plan for the transition to adult care and support in order for them to have the information that they need to prepare for their future. The Bill will ensure that no child reaching the age of 18 should go without the care and support that they need around the point of transition. It will require local authorities to maintain children’s services until a decision has been taken about whether they require adult care and support in place for there to be no gap. The Bill will therefore incentivise local authorities to focus more closely on the relationship between these services to improve the experience of transition for all.
The noble Lord, Lord Patel, said that care plans should be in place from the age of 14, and for five years thereafter. As he well knows, the difficulties that some young people and their families face as they move into adult care and support are well documented. The Care Bill aims to smooth the transition. It sets no restrictions about whether the child is already receiving a specific service under children’s legislation in order to request this assessment, nor does it contain any restriction or stipulation about the age of the child for whom the request may be made, or their proximity to their 18th birthday. Instead, the local authority must consider whether the individual child is likely to have needs for care and support after they turn 18 and whether there would be significant benefit in undertaking the assessment.
My noble friend Lady Barker said that Clause 9(4) needs to be clear that people’s needs are assessed on the basis of what their family can provide and not what they are expected to provide, so that there is no pressure on them. I completely agree with what she said. The assessment is to include whether any carer is able, and is likely to continue to be able, to provide care. The intention is also that the regulation supporting assessment will require the local authority to have regard to the needs of the whole family, as I have just mentioned.
The noble Lord, Lord Low, stated his view that Clause 12(1)(f) is weaker than it was in the draft Bill. I will write to him about that, but that is not our intention and we will look at that point. My noble friend Lord Sharkey referred to the Clause 9 duty to assess where it appears to the local authority that a person may have needs. He thought that might be too passive. The duty is worded on the basis of the existing duty that it will replace, Section 47 of the National Health Service and Community Care Act 1990. It implements the Law Commission’s recommendations on what should trigger the duty to assess, and it is not intended to be passive. In fact, we do not think that it is.
The noble Baroness, Lady Campbell, spoke powerfully about the portability provisions in the Bill. The Bill will ensure that no one should face discontinuity in their care and support when they move local authority area. This is an important reform which will improve well-being for many people who use care and support. The Care Bill will place duties on local authorities that will ensure continuity of care. This will provide clarity on which local authority is responsible, and should ensure that there is no disagreement between authorities which might result in disruption to a person’s care.
The noble Baroness asked why there was no requirement for equivalent services when somebody moves. We believe that when people move local authority area their circumstances are in many cases likely to change. They may be moving to be nearer family support or to take up employment, and their needs for care and support may also change. After the move it will not always be appropriate for them to have services that are equivalent to those that they had before. Moreover, equivalent services may not be available in the new area. The assessment process we are putting into legislation is very much focused on these needs, rather than service provision.
With the leave of the House I would like to continue for a little longer, because there are a number of questions which I hope noble Lords would be glad if I answer while I am on my feet. If that is not the wish of noble Lords, I will race through the rest of my remarks. My noble and learned friend Lord Mackay of Clashfern, my noble friend Lady Tyler and the noble Lord, Lord Warner, all referred to the duty in Clause 1 to promote individual well-being, and asked why the Secretary of State was not bound into that duty. I am sure that we will have debates in Committee on that point, but I only say now that the well-being principle in Clause 1 is intended to apply at an individual level, when a local authority makes a decision. This individual focus on the specific well-being and outcomes for that person is at the heart of the way that the Bill has been drafted. It is not intended to apply in a more general way. Given that we do not think it would be appropriate for the Secretary of State to be subject to the same duty, the Secretary of State does not make decisions at the individual level.
The noble Lord, Lord Patel of Bradford, and the noble Baroness, Lady Pitkeathley, asked why there was no mention of advocacy in Clause 24(2)(b). The Bill specifies that the information and advice service provided by local authorities,
“must be accessible to, and proportionate to the needs of, those for whom it is being provided”.
This allows for information and advice to be provided in a variety of ways, as is appropriate to the needs of the people who use the service. Information and advice provided by an explanation in a leaflet or on a website may be a sensible way of providing this service for many people, but other people may require individual discussion through their assessment and care support planning process, in a variety of depths from independent brokerage to advocacy.
The noble Lords, Lord Bichard and Lord Warner, and the noble Baroness, Lady Pitkeathley, referred to the key issue of integration, which again I am sure we will debate in Committee. Integration is about more than legislation. That is why my department has been working with national partners—NHS England, Monitor, the Local Government Association, ADASS and others—to empower local health and care communities to improve integrated care and support for their populations and to tackle the barriers to achieving this. This is described in detail in Integrated Care and Support: Our Shared Commitment, which was published last week and which I commend to noble Lords.
The noble Lord, Lord Wigley, asked about cross-border issues and whether a legislative consent Motion was required for issues to do with Wales. We do not anticipate any issues in this area. Legislative consent on matters applying to Wales has been sought from and agreed in principle by Welsh Ministers. Of course, this is subject to the tabling and agreement of a legislative consent Motion by the Welsh Assembly. The issue of cross-border placements is complex due to diverse charging systems and regulatory requirements across the UK. The exact details of cross-border residential placements will be tailored to the wishes of each Administration and we will create a bespoke set of regulations for each Administration to meet those diverse operational requirements.
The noble Lord, Lord Rix, expressed concern that, in relation to the safeguarding duty, there is no duty to assess based on the appearance of risk. He suggested that that was an oversight. It is not an oversight. The adult safeguarding duty to make inquiries in Clause 41 arises where the local authority suspects that an adult with needs for care and support,
“is experiencing or is at risk of abuse or neglect”.
The local authority duty is to make inquiries to decide what action should be taken. One such form of action is to assess the adult’s needs under Clause 9. The duty to assess needs arises where it appears,
“that an adult may have needs for care and support”,
and that would cover an adult who is at risk of abuse or neglect.
My noble and learned friend Lord Mackay said that social workers should not have to rely on bits of paper to know what they have to do and that there should be a code of practice. I totally agree that social workers should not have to look at lots of bits of paper. Guidance should be set out in single, clear, accessible volumes. The only issue is whether it has to be laid before Parliament each time it is changed. We do not think that that is necessary. Equivalent guidance to social workers on children’s social services is not laid before Parliament but is set out in accessible volumes and we plan to do the same. Our proposals will look and feel just like a code of practice and will have the same legal effect.
The noble Lord, Lord Patel of Bradford, drew attention to Clause 68 and the proposed definition of Section 117 aftercare. We noted that several mental health organisations were concerned that the consultation definition of aftercare was drawn too tightly. We therefore changed the wording to clarify that Section 117 services address needs “related to” as well as “arising from” the person’s mental disorder. We have also clarified that the purpose of Section 117 aftercare is to reduce,
“the risk of a deterioration of the person’s mental condition (and, accordingly, to reduce the risk of the person requiring admission to a hospital again for treatment for the disorder)”.
Various noble Lords, including the noble Lord, Lord Low, and the noble Baroness, Lady Greengross, asked about Clause 22. The boundary between the NHS and local authorities is critical to the way in which the law impacts on the services people receive. This needs to be as clear as possible so that the division between local authority care and support and healthcare, particularly continuing healthcare, is more easily understood. The current law is especially complex and dates back to 1948. It was not designed for setting out the boundary between modern care and support and the reformed NHS. It has been subject to much case law and dispute over many years. The clause establishes the boundary between the responsibilities of local authorities and the NHS and includes a regulation-making power to enable clarification in the event of uncertainty. It is not intended to alter the current boundary, but instead to express it in a more transparent way which fits with the new framework.
I shall cover rapidly the rest of the points made, if I may. My noble friend Lady Jolly asked about the timescales for introducing ratings. We are currently considering the Nuffield review; we will respond in due course with our plans for implementation. We want to proceed quickly, but it is important that the CQC has the time to develop ratings properly in consultation with the wider health and care system. The CQC will begin the discussion on ratings with the publication of a consultation document in June.
The noble Lord, Lord Patel, emphasised that the domains of effectiveness, patient experience and safety should form an important part of the CQC’s ratings of hospitals. In accordance with the Nuffield Trust’s recommendations, it will be for the CQC, working with key stakeholders, to design and develop the rating system. However, the ratings are likely to include information on safety, effectiveness and user experience, as well as some measures of the quality of governance.
The noble Baronesses, Lady Wheeler and Lady Masham, asked why the duty of candour was missing from the Bill. We will introduce a statutory duty of candour on health and care providers to inform people if they believe that treatment or care has caused death or serious injury and to provide an explanation. That will be introduced in secondary legislation as a requirement for registration with the CQC.
The noble Lord, Lord Sutherland, asked about the role of the chief inspector. The Chief Inspector of Hospitals will oversee CQC inspections, assessment and ratings of providers, identifying both good and poor performance. Ratings will be part of the information used to establish a single version of the truth. The chief inspector will be a CQC post, which does not need to be established in statute.
The noble Lord also asked why the CQC is the right body to oversee market failure. The CQC is the independent regulator of care and support providers in England. It already has significant experience of the care and support sector and longstanding relationships with all registered providers, on which it can build to assess financial sustainability. In our view, the CQC is the body best placed to take on that important role.
The noble Lord, Lord Warner, asked why the NTDA is not included in Clauses 76 and 77. Where the TDA considers that it is in the interests of the health service, it can already advise the Secretary of State to place an NHS trust which it considers to be a clinically and/or financially unsustainable into special administration. An equivalent provision for the CQC to trigger similar action in respect of NHS trusts will be made through directions to the TDA; it does not require primary legislation.
I was struck by the fact the noble Baroness, Lady Wheeler, asked me why the Bill was a partial response to Francis. The short answer to her question is that we can do a lot without primary legislation, but we will be producing a further response in the autumn which will include action resulting from the range of reviews currently under way—for example, on complaints, safety, bureaucratic burdens and training and support for healthcare assistants.
I turn briefly to Health Education England. My noble friend Lord Willis asked how it will ensure sufficient workforce supply. I have a lengthy answer, which I hope that he will allow me to entrust to paper and which I shall copy to all noble Lords. I will write similarly in answer to the noble Baroness, Lady Emerton, on the role of the Centre for Workforce Intelligence and the action being taken by Health Education England to support the development of care assistants and to ensure that there is a sufficient number of nurses and the right ratio of nurses to healthcare assistants.
The noble Lord, Lord Turnberg, asked how Health Education England could ensure continuous improvement in the quality of education and training. Again, I have a good answer for him. In short, I can say that as commissioners with responsibility for the investment of around £5 billion, Health Education England and the LETBs will have considerable influence over the education that is commissioned from education institutions and the training that is delivered by employers through clinical placement and training programmes. They will work together with providers to deliver high-quality clinical and public health placements. I can assure the noble Lord that Health Education England must seek advice widely. The Bill requires that the body obtains the necessary advice needed to carry out its functions, which includes professional regulators and organisations involved in the provision of education and training—royal colleges and universities, for example.
The noble Lord, Lord Rix, asked me what Health Education England will do in terms of improving education and training for people who care for those with learning disabilities. The answer is that it will work with employers, commissioners, education providers and professional bodies so that education and training evolves better to support people in that category.
My noble friend Lord Willis and the noble Lord, Lord Patel, asked why local education and training boards do not have a duty to promote research. Health Education England has the primary duty to promote research. As committees of Health Education England the LETBs will support the national body in delivering this duty through their workforce planning and education and training functions. Health Education England will work with the National Institute for Health Research to ensure appropriate investment in education and training to develop clinical academic careers.
I will respond to the noble Baroness, Lady Emerton, on her question of representatives of the professions on the board of the HRA, and that there should be more investment in multi-professional research and not just clinical research. In my letter, I shall also cover transparency of research, which was rightly raised by the noble Lord, Lord Turnberg, and others.
To my noble friend Lord Willis, I can say on his question about the HRA’s responsibility for co-ordinating and standardising regulatory practice that that is precisely what is envisaged for the HRA. That is why the clauses give the HRA a unique freestanding duty to do just that, relating to the regulation of health and social care research, in addition to the duty to co-operate with other regulatory bodies. I am happy to expand on that when I write to him, along with the question posed by the noble Lord, Lord Wigley, about the HRA’s duty to co-operate with the devolved Administrations.
The noble Baroness, Lady Pitkeathley, observed that this Bill does not provide all the answers to the challenges facing us in meeting the needs of those adults who require social care. I would never claim that it does. However, I have discerned that she and other noble Lords regard the Bill as a landmark measure, representing an essential and major advance in the law relating to care and support. Later stages of our debates will provide an opportunity to consider the detailed issues that noble Lords have raised today and the Government’s mind is open to making further improvements to clauses. I look forward to those debates, and to engaging with noble Lords outside this Chamber to clarify and discuss the Bill’s provisions. Meanwhile, I repeat my thanks to all noble Lords who have spoken today in a debate that has been fully worthy of the vital and pressing issues now before us. I commend the Bill to the House.
NHS: GP Services
Earl Howe Excerpts(11 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall now repeat, as a Statement, the Answer given in another place to an Urgent Question earlier today by my right honourable friend the Secretary of State for Health. The Statement is as follows:
“I have been clear that we have not been satisfied with the performance of A&E over the winter period. On 13 May, I announced to Parliament my intention to launch a new plan for vulnerable older people and publish this in the autumn. As I said in that announcement, there is short-term work under way to address the issues in A&E. However, the plan will look at all aspects of the way we look after those older people most in need of support from the NHS and social care system. In many cases, we could be offering better alternatives outside of hospital. The Primary Care Foundation has estimated that 10% to 30% of A&E cases could be treated elsewhere. The plan is being developed jointly by NHS England and my department, and we will be looking to engage with patient and professional groups over the summer so that the plan can be informed by their views”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, we know that A&E departments are under pressure, and the noble Lord is absolutely right to emphasise that. Over 1 million more people are visiting A&E departments compared with three years ago. However, we also know that, on the whole, the NHS is performing well. The latest weekly figures for emergency services show that 96.3% of patients visiting A&E are being seen within four hours and that people are waiting, on average, 55 minutes for treatment. That is a testament to the hard work of many staff throughout the health and care system.
It is not just about the GP contract; it is about making sure that we have a much more joined-up system in which hospitals communicate better with care homes and GP surgeries so that information about a patient’s needs is shared between the professionals who need it. GPs have an important role to play in this, which is why changes were made to the 2013-14 GP contract as a first step. Any future changes to general practice and the contract will of course be made in negotiation with GPs, and it is too early for me to go into detail on what those proposals might be. As regards NHS 111, I do not agree with the noble Lord. I am sure that he will be aware that the pilots we conducted on the NHS 111 service were extremely encouraging and showed a high rate of patient satisfaction.
Baroness Williams of Crosby
My Lords, I am sure that the noble Lord, Lord Hunt, would not disagree that the GP contract, although it was some time ago now, was a factor in what has gone wrong with A&E. Does the Minister believe that we can move towards a situation where the responsibility for out-of-hours medicine once again becomes part of what GPs accept as their CCG responsibility? Can he also say whether steps might be taken in the short term to ease the situation in A&E, while in the long term we move towards a more satisfactory answer involving the reintegration of GPs into the care of patients going into A&E situations?
Earl Howe
My Lords, I think that the GP contract is but one element of a more complicated picture. It is not the only issue or, indeed, is it the only solution. It is true that access to out-of-hours care in some parts of England is simply not good enough. We are not saying that family doctors should necessarily go back to being on call in the evenings and at weekends. They work hard and have families, and they need a life too, but we must take a serious look at how out-of-hours NHS care is provided. My right honourable friend the Secretary of State will be talking to GP leaders about how we can do that over the coming weeks.
Lord Laming
My Lords, the noble Earl has indicated that there is a need to look again at the availability of community-based services. Hospital-based services are available seven days a week but community ones for much less, and that includes social care services. While not wanting staff to work all hours, is it not possible to move towards a situation where the services will be available at all hours while we protect staff working time?
Earl Howe
The noble Lord, Lord Laming, has summed up the situation extremely well. I am sure he knows that Sir Bruce Keogh, the NHS medical director, is currently looking at how NHS services across the piece can be provided seven days a week in a much fuller way than they are at the moment. Access to GPs out of hours is part of that wider consideration and NHS England is working with the royal colleges and professional organisations to develop a set of standards that will apply to seven-day services. Some trusts are already thinking about treating patients at weekends for non-urgent operations and procedures. We want to encourage that trend.
Lord Reid of Cardowan
My Lords, can I correct a serious misrepresentation and misconception that is constantly made regarding the GPs’ contract, and which has been made in the past few moments? The GPs’ contract for 2003-04 did not remove the requirement of a doctor to work out of hours. That was removed a decade earlier under the previous Conservative Government; indeed, by 2000 a huge percentage of doctors had already opted out. The GPs’ contract was to try to make sure that GPs were not spending part of their normal day bureaucratically chasing up a replacement doctor to take their place. It removed that bureaucratic imperative but it did not remove the right of a doctor to refuse to work out of hours. That was the case with some 70% to 80% by the end of the previous Conservative Government, before the GPs’ contract. That is a very important distinction.
Earl Howe
My Lords, I certainly did not mean to mislead the House and if I have done so in any way I apologise. The summary given by the noble Lord is broadly right. Under the old general medical services contract, GPs had a 24-hour responsibility for their patients, although most GPs delegated responsibility to GP co-operatives or commercial providers. At the beginning of 2004, as I recall, only a small proportion of GPs actually provided out-of-hours services themselves. However, 24-hour responsibility continued to be unpopular with GPs as they felt it was discriminatory, which is why the contract was renegotiated at that time. It has brought about a growth in GP co-ops, with more use of telephone triage and more patients offered emergency consultation with a primary care centre. But that has resulted in fewer home visits and I think that point in particular is one that is exercising many people.
Lord Mawhinney
My Lords, does my noble friend understand that while he is telling the truth in saying that the contract is only one of a number of aspects that have to be addressed, the problem is that Ministers have said that so frequently from this Dispatch Box and the one in the other Chamber that it is now in danger of being understood as a reason why Ministers will not tackle contract issues? If my noble friend and his colleagues would start by addressing the contract issues, they would be doing us all a great favour. He would thereby be creating a lot more credibility when the other issues, which have to be addressed simultaneously, are turned to.
Earl Howe
My Lords, my noble friend makes an extremely important point. He may know that my right honourable friend the Secretary of State is very concerned to look carefully at the current contract to make sure that it does not include too many perverse incentives to tie GPs’ time up too much. If we can work towards a contract with the agreement of the profession that enables GPs to take a more holistic look at their patients’ health and adopt a more preventative approach, which I think everybody agrees is desirable, that is thoroughly to be wished for. However, this is work in progress.
Health: Cancer
Earl Howe Excerpts(11 years, 8 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(11 years, 9 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(11 years, 9 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.