South London Healthcare NHS Trust
Earl Howe Excerpts(11 years, 3 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House I shall now repeat a Statement made in another place earlier today by my right honourable friend the Secretary of State for Health on the subject of South London Healthcare NHS Trust. The Statement is as follows:
“With permission, Mr Speaker, I would like to make a Statement on the future of South London Healthcare NHS Trust.
The NHS exists to provide patients with the highest levels of care and compassion and it does so in a way that is more equitable than any other country in the world: comprehensive care, free at the point of need. But to be true to those values, different parts of the NHS need to be financially sustainable. Financial problems left unaddressed become clinical problems, not least because money used to fund deficits cannot be used for patient care.
The South London Healthcare NHS Trust is the most financially challenged in the country, with a deficit of £65 million per annum. It currently spends some £60 million a year, or 16% of its annual income, to service two PFI contracts signed in 1998. For this and other reasons, repeated local attempts to resolve the financial crisis at the trust have failed. As a result, the trust is losing more than £1 million every week. In the three years since it was formed in 2009, it has generated a deficit of £153 million, a figure that will rise to more than £200 million by the end of this financial year—a huge amount money that has to be diverted away from front-line patient care.
So, after consulting the trust, its commissioners and the London Strategic Health Authority, my predecessor as Health Secretary, my right honourable friend the Leader of the House, instituted the special administration process, which includes a period of intense local engagement. Matthew Kershaw, former chief executive of Salisbury NHS Foundation Trust, was appointed as the trust special administrator in July 2012. I would like to put on record my thanks to him and his team for his exceptionally detailed and thorough work.
Mr Kershaw had the extremely difficult task of finding a clinically and financially sustainable way forward for the South London Healthcare NHS Trust. Reluctantly, he concluded that only by looking beyond the boundaries of the trust to the wider health community was he able to put forward a viable solution. I support that analysis.
I received his recommendations on 7 January. Six of his seven recommendations were as follows: first, that over the next three years, all three hospitals within the trust—Queen Elizabeth Hospital in Woolwich, Queen Mary’s in Sidcup and the Princess Royal in Bromley—make the full £74.9 million of efficiencies he has identified; secondly, that Queen Mary’s in Sidcup be transferred to Oxleas NHS Foundation Trust and developed into a hub for the provision of health and social care in Bexley; thirdly, that all vacant or poorly utilised premises be vacated, and sold where possible; fourthly, that the Department of Health pay the additional annual funds to cover the excess costs of the PFI buildings at the Queen Elizabeth and Princess Royal hospitals; and, fifthly, that the South London Healthcare Trust be dissolved, with each of its hospitals taken over by neighbouring NHS and foundation trusts. Sixthly, to aid implementation, he further recommended that the Department of Health write off the accumulated debt of the trust so as not to set the new trusts up to fail; that the Department of Health provide additional funds to cover the implementation of his recommendations; and that a programme board be appointed under an independent chair, reporting to Sir David Nicholson as chief executive of the NHS Commissioning Board, to ensure the changes are effectively delivered. I have accepted each of these recommendations in full.
As a consequence, he also recommended that services be reconfigured beyond the confines of South London NHS Trust, across all of south-east London. This part of his recommendation included reducing the number of A&E departments across the area from five to four; replacing the A&E department at University Hospital Lewisham with a non-admitting urgent care centre; reducing the number of obstetrician-led maternity units from five to four; downgrading the current obstetrician-led maternity unit at University Hospital Lewisham to a stand-alone midwife-led birthing centre—each obstetrician-led maternity unit would also have a midwife-led birthing centre—co-locating paediatric emergency and inpatient services with the four A&E units, with paediatric urgent care provided at Lewisham, Guy’s and Queen Mary’s hospitals; and finally, that University Hospital Lewisham should become a centre for non-complex elective procedures, such as hip and knee replacements, to serve the entire population of south-east London.
The public campaign surrounding services at Lewisham Hospital has highlighted just how important it is to the local community. I respect and recognise the sense of unfairness that people feel because their hospital has been caught up in the financial problems of its neighbour. However, solving the financial crisis next door is also in the interests of the people of Lewisham, because they, too, depend on the services that are currently part of South London Healthcare Trust. None the less, I understand their very real concerns about how any changes could affect their access to vital health services. These concerns are echoed by Lewisham CCG and many clinicians at Lewisham Hospital. I have had in-depth discussions with the honourable Members representing those affected, who have reflected those concerns to me. As a result, I asked the NHS medical director, Professor Sir Bruce Keogh, to review the recommendations and to consider three things: first, whether there was sufficient clinical input into the development of the recommendations; secondly, whether there is a strong case that the recommendations will lead to improved patient care in the local area; and, thirdly, whether they are underpinned by a clear clinical evidence base, as set out in the third of the four tests for reconfigurations.
On the matter of clinical input, a highly experienced clinical advisory group, led by a local GP, Dr Jane Fryer, and including eight trust medical directors, six clinically qualified CCG chairs, the London Ambulance Service medical director, the local director for trauma and three directors of nursing, supported the trust special administrator.
Further scrutiny and challenge was provided by an external clinical panel, which included representatives from the Royal Colleges of Midwives and of Obstetricians and and Gynaecologists. The panel was chaired by Professor Chris Welsh, SHA medical director for the Midlands and East of England. Both groups included respected national and local clinicians, built on years of previous work in this area and held a series of clinical workshops in August and September of last year. Sir Bruce was satisfied that there had, indeed, been sufficient clinical input.
On the issue of better care and clinical evidence, the recommendations provide for the adoption, for the first time in south-east London, of the 2012 pan-London standards for acute care. These are the standards that all six local CCGs have said they want to commission for both emergency and maternity care. These standards define the best available clinical practice and set the bar higher than that provided by most other acute providers in England.
Sir Bruce agreed with the TSA that the adoption of these standards, which mean improving the level of care available to the residents of south-east London, could not be achieved without a reduction in the number of sites delivering acute in-patient care. Such a reduction will enable the necessary concentration of resources and senior clinical staff. A similar approach has already led to significant improvements in stroke, major trauma and cardiovascular disease services throughout London, saving hundreds of lives.
For both emergency and maternity care, Sir Bruce found no evidence that patients would be put at risk through increased journey times. The whole population of south-east London will continue to be within 30 minutes of a blue light transfer to an A&E department, with the typical journey time being, on average, only one minute longer. Accessing consultant-led maternity services will increase journey times on average by two to three minutes by private or public transport. Sir Bruce concluded, therefore, that there should be no impact on the quality of care from the small increase in travel time.
On the issue of maternity services, the expert clinical panel advising the TSA was not willing to support the increased risk to patients of having an obstetrician-led unit at Lewisham without intensive care services. As achieving the London-wide clinical standards will be possible only with the consolidation of the number of sites with these facilities, Sir Bruce supports the proposal for this unit to be replaced with a free-standing midwife-led unit at Lewisham hospital. This will continue to deal with at least 10% of existing activity and potentially up to 60%. Thirty-six million pounds of additional investment has been earmarked to ensure that there is sufficient capacity at the other sites.
Turning now to the emergency care proposals, Sir Bruce was concerned that the recommendation for a non-admitting urgent care centre at Lewisham may not lead, in all cases, to improved patient care. While those with serious injury or illness would be better served by a concentration of specialist A&E services, this would not be the case for those patients requiring short, relatively uncomplicated treatments or a temporary period of supervision. To better serve these patients, who would often be frail and elderly and arrive by non-blue light ambulances, Sir Bruce recommends that Lewisham hospital should retain a smaller A&E service with 24/7 senior emergency medical cover.
With these additional clinical safeguards, and the impact that this is likely to have on patient and clinician behaviour, Sir Bruce estimates that the new service could continue to see up to three-quarters of those currently attending Lewisham A&E.
Allowing Lewisham to retain its A&E would help to reduce the level of increased demand at hospitals with larger A&E services, while an additional £37 million of investment will further expand services at these hospitals for more serious conditions. Sir Bruce advised that patients with those more serious conditions should now be taken to King’s, Queen Elizabeth, Bromley or St Thomas’s, not for financial reasons but to increase their chances of survival.
On the issue of paediatric care, Sir Bruce recognised the high-quality paediatric services at Lewisham and that any replacement would have to offer even better clinical outcomes and patient experience. His opinion is that this is possible but dependent on very clear protocols for primary ambulance conveyance, a walk-in paediatric urgent care service at Lewisham and rapid transfer protocols for any sick children who would be better treated elsewhere. He is clear that this will require careful pathway planning and need to be a key focus of implementation.
With these caveats, Sir Bruce was content to assert that there is a strong case for saying that the recommendations are likely to lead to improved care for the residents of south-east London and that they are underpinned by clear clinical evidence. He believes that overall these proposals, as amended, could save up to 100 lives every year through higher clinical standards.
Yesterday, 30 January, as no viable alternative plan has been put forward, and in the light of Sir Bruce’s opinion I decided to accept the recommendations of the trust special administrator, subject to the amendments suggested by Sir Bruce. It is important to be clear that my acceptance of these recommendations is conditional on Monitor approving the proposals relating to foundation trusts and on my department negotiating an appropriate level of transitional funding with organisations such as King’s partners.
Due to the size of the task, there is a significant level of risk associated with achieving the identified savings. I recognise that the additional clinical safeguards I have put in place will marginally increase these financial risks but, on balance, I have made the judgment that this is worth it if it means that local patients are reassured they will gain from an additional better service, rather than losing their A&E.
I believe the amended proposals meet the four tests required for local reconfigurations. I am therefore content for the process to now proceed to implementation and I expect the South London Healthcare NHS Trust to be dissolved by no later than 1 October 2013.
The implementation of these recommendations will be challenging and complex. It needs to be planned for carefully and will not happen overnight. I call on all organisations, hospitals and commissioners to offer their full support during the coming years to achieve the ambition of these proposals for the benefit of the people of south-east London. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, the noble Baroness’s comments echo very closely those made in another place by her right honourable friend the Shadow Secretary of State. I am disappointed that they do, because she seems not to have taken account of anything that the Statement contained. First, I heard no recognition that there is a serious problem to be addressed in south London. A deficit of £1 million a week is a serious matter in any terms. The deficit means that resources, whether people or money but mostly both, are being applied inefficiently. That plays into concerns about equity, which is one of the fundamental principles of the NHS. Not to acknowledge that we had a major problem there and that funds were being diverted into servicing debt that should have been applied to patient care was regrettable.
Secondly, there was no acknowledgement that the process that we had adopted was that laid down by the then Government—of whom she was a distinguished member—in the 2009 Act that amended the 2006 Act. That process is quite deliberately couched in a way designed to bring a rapid conclusion to what, by definition, is bound to be a serious if not intractable situation such as this—a curtailed process that involves public consultation but not the kind of consultation that flows from reconfiguration decisions, which are locally led.
In this case, it was our judgment that only the unsustainable provider regime was applicable, after repeated attempts by local clinicians, both commissioners and providers, to find a way of resolving the problem by looking at the difficulties faced by the trust. In the judgment of the TSA, it was a necessary and consequential part of the solution to look more widely than the trust itself, and that is what we did.
I heard a grudging recognition that the decision to retain an A&E department at Lewisham was welcome. I am glad that the noble Baroness welcomed that. We took that decision, which was not one that the trust special administrator recommended, because we listened to local opinion and to Sir Bruce Keogh’s advice. It was clear that, in some cases, it would not serve the best interests of those presenting at A&E to have to be moved to another hospital. Therefore, we took the decision that there should now be 24/7 cover in an A&E department and the capacity to admit patients from A&E. Neither of those things was recommended by the TSA, but this is what we now propose.
The noble Baroness said that this decision clearly reflected that finance took precedence over patient safety and care. I simply do not agree. Finance is, of course, a major consideration, but the fundamental thing we wanted to assure ourselves of—and this is one of the four tests that my right honourable friend Andrew Lansley put in place—was that there should be clear evidence of clinical benefit. Not only have we had two expert panels advising the TSA about this, we have had reassurance from Sir Bruce Keogh as well. I suggest to the noble Baroness that these are not people whom Ministers have somehow nobbled or interfered with. We have stayed absolutely separate from the process, as is right and proper. This has been an independent process and the results are as I have indicated.
The clinical justification for these proposals is there. All four tests that we put in place—the four tests for any change of services—have been passed, not only in terms of local consultation but also in terms of support from clinicians and of patient choice. On one level, one could argue that any service change that seeks to drive up clinical quality by consolidating clinical skills on fewer sites diminishes choice. Nevertheless, choice is not just about being able to choose a provider; it is about choosing the right care in the right place. At the moment, the London-wide clinical standard that was mentioned in the Statement is not being adhered to in any of the hospitals in that part of the world, so one could argue that the choice of provider is very limited when it comes to choosing the right quality care. It is from the fact that commissioners want to commission that higher standard that all the rest flows. To say that this is being driven purely by finance is incorrect.
By their nature, these decisions are very difficult. The job of a Secretary of State—and I believe that my right honourable friend has performed it admirably, both dispassionately and conscientiously—is to look at the best interests of the population in a region. He has done that and taken independent advice, and I hope that noble Lords will recognise that when they look more carefully at these recommendations.
Lord Tomlinson
My Lords, I join in the thanks offered to the noble Earl for repeating the Statement. One has the feeling that, for someone so highly respected in this House, his heart was not really in the repetition.
Lewisham hospital is a local hospital which produces excellent local care—and I declare an interest as someone who uses its services. What the Minister has announced today is that he is not going to make the cuts quite as bad as they were—not quite as extensive. But, in effect, we are still having a very good service penalised in order to provide resources for the failures. Can I ask two specific questions arising from the Statement? At one point it states that,
“a non-admitting Urgent Care Centre at Lewisham may not lead, in all cases, to improved patient care”.
How does the Minister square that with some of the other statements made about the principles on which this reorganisation is based? With two further tranches of money—£36 million and £37 million—provided to the other sites which need to be improved, I ask him to comment on what the Secretary of State said at the end, namely that,
“there is a significant level of risk associated with achieving the identified savings. I recognise that the additional clinical safeguards I have put in place will marginally increase these financial risks but on balance”—
basically, “I think it might be all right”. Is this not another example of wishing being given a higher priority than factual decision-making?
Earl Howe
My Lords, perhaps I may put on the record my own recognition that Lewisham hospital is an excellent hospital. There is no question about that and there has never been any question about it. The hospital provides good care for local people and it is highly valued. Only this afternoon I had one noble Lord from my own Benches telephoning me to tell me of his personal experience of Lewisham hospital and its excellent maternity care.
The noble Lord asked me two specific questions. He quoted the Statement where at one point it was made clear that a non-admitting urgent care unit at Lewisham would not improve patient care. That is the precise reason why Sir Bruce Keogh recommended something different; namely, an admitting A&E unit with 24/7 cover. He looked at the recommendation and was not satisfied with it in terms of risks to patients. I hope that that is helpful to the noble Lord because I think he misconstrued what I was saying.
On the question of risk, any set of assumptions that relies on hypotheses around patient flows in the future and clinical referral decisions has to be, by its very nature, uncertain. It is the view of the trust special administrator and the review of my right honourable friend that the assumptions underpinning these decisions are reasonable, and that was backed up by Sir Bruce Keogh. But the noble Lord has a point because the implementation of these recommendations is going to be key, and that is why the TSA has recommended a programme board to oversee the implementation of these recommendations over the next few years. It is absolutely essential that commissioners and the providers in that area buy in to these proposals. We believe that they will, but it is important that if the financial risk is to be minimised, we get as close as possible to the forecast and predictions that the TSA has set out.
Lord Kennedy of Southwark
My Lords, I want to draw the attention of noble Lords to my declaration of interests in respect of Lewisham hospital. I would like to pay tribute to the staff of the hospital who serve the community so well, and the local residents involved in the save Lewisham A&E campaign for the fantastic campaign they have run. It is supported by local GPs, local businesses and Millwall Football Club. We have a great hospital that is supported and valued locally. In the past two years the ConDem Government have spent £12 million on funding the refurbishment of the Lewisham A&E unit. We have a fantastic children’s A&E unit. That refurbishment was finished only in April last year, yet today they have downgraded our maternity and A&E services to pay for the failings of a neighbouring trust. Will the noble Earl agree to publish all of the legal advice the Government have received in respect of the decision they have taken today? Can he also tell the House if he has ever visited Lewisham Hospital? I am glad he agrees that it is actually a great hospital. If he has not visited it, will he confirm that he is willing to do so at the earliest opportunity, in the light of his responsibilities for quality and urgent care? Further, can he tell the House what he would have spent the £5 million on?
Earl Howe
My Lords, the facilities at Lewisham A&E are indeed very good, and a lot of money has been spent on them. I would hope that the noble Lord will therefore welcome the fact that we are keeping an A&E department open. That department will be comparable with many other A&E departments around the country. It will be a fully functioning department other than for those difficult and critical cases which, by common clinical agreement, need more specialist care where clinical resources can be concentrated. That is increasingly the view of senior clinicians in the royal colleges around London.
The other point that the noble Lord may need to factor in is that many of the services in an area of the country, whether it is London or anywhere else, depend on networks. What we envisage for Lewisham and Woolwich, taken together, is that they will be part of an active network, with staff rotating between the two. There will be an understanding of what each hospital is capable or incapable of doing, and an understanding on the part of ambulance trusts as to where best to take patients. We have already seen the results of that policy. This is not idle speculation. There is proof positive from the decision to decrease the number of acute stroke units in London from 32 to eight; the mortality rate has more or less halved since that decision was taken. So there is clear clinical underpinning.
I note the noble Lord’s understandable regret that Lewisham has been caught up in the problems of its neighbour. However, as the Statement made clear, the people of Lewisham also depend on the services of South London Healthcare Trust, so to say that there is somehow an island of patients who simply go to Lewisham would not be fair.
The noble Lord asked me about publication of the legal advice. I can confirm that the decision of my right honourable friend has been taken in the light of consideration of the legal issues and advice to him that it is lawful. The normal position is that the Government do not publish legal advice; there is a long-standing precedent. However, I can tell him that the legal advice backs up his decision.
Earl Howe
If the noble Lord will allow, I will just cover the final point made by his noble friend.
Given the need to reassure local patients that the changes will indeed lead to better outcomes for them, my right honourable friend took the decision proactively to publish Sir Bruce Keogh’s letter to him, setting out his clinical advice, as it has had a large bearing on his decision. So we have been as open as possible about the clinical basis on which this decision has been taken.
Lord Wills
I am very grateful to the Minister and apologise for intervening inappropriately. On the question of legal advice, notwithstanding the convention, will he agree that it is open to the Government to waive legal privilege in exceptional circumstances and that this might be such a case, since these are clearly exceptional circumstances?
Earl Howe
My advice is that there is no case for waiving that practice. As I said, it is a long-standing principle and indeed the practice of successive Governments that legal advice is given to Ministers in confidence. Therefore I am afraid that I cannot accommodate the noble Lord’s suggestion.
To answer the question asked by the noble Lord, Lord Kennedy, about visiting Lewisham Hospital, I have not done so personally. I try to visit as many hospitals as I can. If I am able to fit Lewisham into my programme, I would be happy to do so.
Baroness Wheatcroft
My Lords, I declare an interest—as so many have—in that my three children were all born in Lewisham Hospital. Thus I share the emotional feeling of many that it seems unfair that Lewisham should be penalised for the spendthrift ways of other NHS trusts. However, my understanding is that Sir Bruce was asked to look not at the financial implications but at the patient implications of restructuring. He has done that and is satisfied with the result. One thing he points out is that, in the future, not every hospital would have the capacity to offer intensive care after maternity care. One of my three children needed intensive care. If Lewisham cannot provide the highest of high-tech intensive care, then some hospitals in London will have to. The issue is that, given the high technology that is now coming in to medicine, not every hospital can be a centre of excellence. We have to spread the resource. That means some hospitals will specialise. As somebody who benefited from what was then the best of intensive care, I am very keen to see that London, and in particular south-east London, should be able to offer that. However, I accept that not every hospital that provides maternity services will be able to. Can the Minister tell me whether he can see—because I cannot—any reason why Sir Bruce would have reached the conclusions that he had, in print, if he did not actually believe them?
Earl Howe
I am grateful to my noble friend and agree with all that she has said. In making this very difficult decision, my right honourable friend’s primary concern has been to protect outcomes for local patients. Indeed, the logic behind these proposals comes from the clinicians themselves, who came together from across London—way before the TSA was appointed—to develop a series of standards for certain conditions. These are based on the simple principle that a critical mass of highly qualified specialist consultants in one place, on a 24/7 basis, available to see patients within one hour and backed up by the latest medical equipment, will give patients better outcomes. At present, no south-east London hospital meets all the emergency or maternity clinical quality standards. Achieving those standards will mean accommodating acute in-patient care across fewer sites. The result will be that people in south-east London will continue to have much better access to A&E and specialist maternity units than the majority of the population in England, and the prediction is that up to 100 lives a year will be saved by this rearrangement of services. My noble friend has raised a very important point because this is about better patient outcomes.
Baroness Gould of Potternewton
My Lords, I want to ask the Minister about the next stages and what happens now. I was interested in the paragraph that says:
“It is important to be clear that my acceptance of these recommendations is conditional on Monitor approving the proposals relating to foundation trusts and on my Department negotiating an appropriate level of transitional funding with organisations such as Kings Partners”.
What is the actual process by which Monitor will now do this? When is it likely to report? When is it likely that the transitional funding will be agreed? What is the process if neither of those things is agreed?
Earl Howe
My Lords, the noble Baroness asks some extremely pertinent questions. Matthew Kershaw, the TSA, expects to start a new job as chief executive of Brighton and Sussex University Hospitals NHS Trust in the spring. That will happen before South London Healthcare NHS Trust is dissolved. As we move into the implementation phase, my right honourable friend will use powers in the 2006 Act to appoint a new TSA to provide the management role normally performed by the board of directors. That takes care of the mechanics of management, and the person appointed will of course have to have the necessary skills and experience to lead the trust. The TSA worked closely with both foundation trusts and Lewisham Healthcare NHS Trust to develop his proposals. The trusts are eager for the mergers to go ahead to realise the benefits that I have described. All three trusts are now working towards having signed heads of terms in place that agree the principles of the transaction and set the basis for the final deal.
Looking forward, the organisational changes will almost certainly not occur until somewhere between June and October. Having said that, the trust managers will immediately start making the necessary operational efficiency improvements, as indeed I know they are keen to do. The actual transfers of emergency maternity and paediatric services to other sites is planned to happen in late 2015. That will not be immediate, because it is necessary to spend the funds that I have mentioned to expand the capacity of these other acute centres.
Baroness Gould of Potternewton
I am sorry to interrupt the noble Earl, but will he actually answer the question about Monitor and the transitional funding arrangements?
Earl Howe
I apologise. Monitor is an independent body; it will have to look at, as it is duty-bound to do, the effect of these proposals on the foundation trusts concerned—namely, Kings and Oxleas—and whether it is satisfied that all legal requirements are met. The TSA was confident in that regard, but we cannot take it for granted. As regards the transitional funding, I mentioned that all three trusts are now working towards having signed heads of terms in place, and the principles of the transactions and the basis for the final deal will include the financial aspects of the mergers. It is important for the department to work to get the best deal for the taxpayer in these transactions. Although an indicative sum of money has been quoted in the TSA’s report for this, it would be wrong, I think, for the department to commit a precise sum of money at this stage. It is important that as much money as possible is saved by the trusts working through these proposals for themselves, before the department steps in. However, we will step in to do what is necessary to ensure that these proposals are properly implemented.
Lord Patten
My Lords, I remember a particularly torrid period of campaigning in Lewisham when in the other place which almost led me to seek the assistance of the A&E department at Lewisham hospital. Does the Minister not agree that on every occasion, however understandable, attachments to institutions and to buildings that have been there for a long time are always trumped by patient outcomes and patient care?
Earl Howe
My Lords, my noble friend has raised a very good point. It is entirely understandable for a local Member of Parliament, and local people, to feel an attachment towards a particular building that, for them, represents the best of what the NHS has to offer. However, as my noble friend points out, what really matters in a healthcare economy is the quality of the service delivered to those people. Services can be delivered in a variety of ways. It is the view of local clinicians—five out of the six local CCGs support these proposals—that the TSA’s recommendations will deliver better quality care and will save lives. It is that wider consideration that my right honourable friend has had in mind throughout.
Social Care: Funding
Earl Howe Excerpts(11 years, 3 months ago)
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Lord Warner
To ask Her Majesty’s Government when they will announce their decision on the Dilnot Commission’s recommendations on capping the cost of adult social care for individuals.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Prime Minister and Deputy Prime Minister have committed to announcing further details before the Budget on capping the potentially huge costs of long-term care, giving people the certainty that they need to plan for their long-term care needs. The Government have agreed the principles set out by the Dilnot commission. We expect further details shortly.
Lord Warner
My Lords, I am grateful to the Minister for that reply. Progress is being made, albeit a little slower than many of us would like. Will the Government prepare draft clauses on a capping system for consideration alongside the draft Care and Support Bill? Does he agree that, to work effectively and fairly, national capping of individual liability will require the draft Bill to provide for portable national eligibility criteria?
Earl Howe
My Lords, as the noble Lord is aware, the draft Care and Support Bill is currently going through pre-legislative scrutiny. Our proposals can be amended to support the cap in law and we would include the appropriate provisions when legislation is introduced. I can tell the noble Lord that work is going on drafting such clauses. We have said that we will build national eligibility criteria into the Bill.
Baroness Greengross
My Lords, from what we read in the press, it looks as if the Government’s plans might include a cap of £75,000 and that that will not include accommodation costs. As I understand that 85% of people incur lifetime costs below £75,000, would this not skew the outcomes unfairly?
Earl Howe
My Lords, we have to speak speculatively and hypothetically because I cannot give the noble Baroness any indication of the level at which the Government will finally propose to set the cap. The level of the cap needs to represent an affordable and sustainable relationship between the state and the individual. We will give due regard to the Dilnot recommendations for the cap while taking into account current economic circumstances. We will set out further details in the coming weeks but I am sure that the point that the noble Baroness effectively makes will be closely borne in mind as we approach decision time.
Baroness Jolly
My Lords, with more people needing social care, and with a higher cap than anticipated under Dilnot being probable, what provisions are being made to assist local authorities to cope with managing deferred payments for care?
Earl Howe
My Lords, as my noble friend is aware, the universal deferred payments scheme will be part of the Care and Support Bill. No doubt, we will debate those provisions when the Bill comes before us. I cannot tell her when that will be, but, clearly, they will be the subject of close scrutiny by the Joint Committee.
Lord Campbell-Savours
My Lords, is not one of the unfortunate effects of the Dilnot proposals that they protect inherited wealth at a time when the NHS needs money?
Earl Howe
My Lords, the main benefit of the Dilnot proposals is to protect people from unpredictable and catastrophic costs of long-term care. While the noble Lord could interpret the raising of the means test as a way of protecting the rich, I see the combination of the cap and the threshold as a way of giving greater certainty and predictability for all concerned, because none of us, whether we are rich or less rich, can know whether we will be subject to catastrophic care costs at a later stage in our lives. That is the inherent unfairness which Dilnot and the rest of the commission attempted to address.
Baroness Pitkeathley
My Lords, following on from that answer, does the Minister accept that uncertainty is the most difficult thing for vulnerable people and their families to cope with? They are uncertain about the level of services that they will have because of problems with local authority budgets and they are absolutely uncertain about what their financial liability will be. Therefore, saying that the Government will accept the Dilnot proposals but not saying when or at what level is only adding to that uncertainty in a most unacceptable way.
Earl Howe
My Lords, I might have hoped that the noble Baroness would welcome my initial Answer, which at least gives her the certainty that an announcement will be made before the Budget. As the noble Lord, Lord Warner, said, that is progress and, I hope, welcome progress. However, I take the point that the noble Baroness makes and the sooner we can introduce the certainty that she desires the better.
Lord Mackay of Clashfern
My Lords, first, is it possible that these clauses will be available during the time that the Joint Committee is still working? Secondly, am I right in thinking that Dilnot has nothing to do with healthcare but has to do with what we usually call social care?
Earl Howe
Yes, my Lords, my noble and learned friend is right. The Dilnot proposals focus primarily on social care although there are always knock-on effects for the health service. In theory, it will be possible for us to produce clauses covering the Dilnot proposals for scrutiny by the Joint Committee but I am not in a position to give that undertaking at present.
Lord Sutherland of Houndwood
My Lords, I welcome the announcement that has been made and I hope that it will please more of us than seems to be the case at the moment. We shall see. Does the Minister agree that the effectiveness of the Dilnot proposals for a cap depends on adequate insurance products being available to cover pre-care costs or costs that arise before that cap is reached? If so, have the Government had any discussions with the insurance industry or are any planned?
Earl Howe
My department is engaging actively with the financial services sector for the very reasons that the noble Lord suggests. As I have said, care needs are very difficult to predict and care costs can be open-ended in the current social care system. At the moment, that makes financial products very expensive to buy and difficult to develop. There are many reasons why people do not consider financial products for their care at present, including a lack of awareness that they have to pay. We very much hope that the introduction of a Dilnot-type solution to this problem will encourage the financial services sector to develop these products and we believe that that will happen.
NHS: Clinical Commissioning Groups
Earl Howe Excerpts(11 years, 3 months ago)
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Lord Hunt of Kings Heath
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare my interests on the register.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I can reassure the noble Lord that the board has not discontinued the poverty element of the funding formula. The board was concerned that while the formula provides an accurate model of healthcare need as currently met, if implemented it would target resources away from those areas with the worst health outcomes. It has therefore decided to give all clinical commissioning groups the same growth while launching a fundamental review of allocations.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for that explanation and understand that a flat-rate increase is to be given next year on top of the existing formula. Will he assure me that if the national Commissioning Board, after this review, decides not to go down the route that the previous Secretary of State, Mr Lansley, wanted this review to take—namely, to take money away from the poorer areas and give it to the well off areas—it will see no interference whatever from Ministers in relation to that decision?
Earl Howe
My Lords, that is a very important principle. It is one of the reasons why we felt that the NHS Commissioning Board should be responsible for the allocation of resources to CCGs and not Ministers, to avoid any perception of party-political interference. However, the Government’s mandate to the board makes clear that we would expect the board to place equal access for equal need at the heart of its approach to allocations. That is why ACRA has been charged with developing formulae independently to support the decision that the board takes.
Baroness Jolly
My Lords, the first rule of funding is that recipients are never happy with their allocation. Given that, will the Minister assure the House that, with new configurations that we have with public health and CCGs, the model used will regularly be reviewed to ensure that it remains fit for purpose?
Earl Howe
Yes, my Lords. As I have indicated, as regards the NHS allocations, the board is clear that the model needs to be reviewed. That does not necessarily mean that it will need to change; the board will have to keep an open mind about that. Clearly, the board was not happy that the formula as currently constructed best met future needs. As regards public health, I think that we are in a better place. As my noble friend will know, the allocations were announced recently and they provide for considerable real-terms increases everywhere around the country.
Lord Mawhinney
My Lords, if the Commissioning Board decides to change the present formula, will the new proposal be subject to public consultation before it is implemented?
Earl Howe
My Lords, ACRA, the independent committee, will take advice from all relevant quarters. I am sure that the advice it receives will be taken on board. I do not think that there will be a public consultation as such but, if I am wrong about that, I will write to my noble friend.
Lord Rea
Will the noble Earl reassure us that this new allocation committee will take fully into account the fact that poor people have worse health and, therefore, in an equitable system, it will cost more to include them in the full services that the NHS can provide? Will he reassure us that that will be taken adequately into account and that proper measurements will be made of the health differences between social classes?
Earl Howe
I can give the noble Lord that reassurance. ACRA is not a new committee; it has been long-established, and was a fundamental part of the previous Administration’s approach to funding allocations. I can say to the noble Lord that, by using diagnosis information, the formula that has been adopted for CCGs directly picks up a great deal of the increased prevalence of ill health due to deprivation. It also takes account of the proportion of the population in social housing and in semi-routine occupations, and the number of DLA claimants, which is closely related to deprivation.
Baroness Farrington of Ribbleton
Will the Minister assure the House that, if the board is able to find a formula more reflective of local need in terms of poverty and deprivation, the Government will look at it? They appear not to take such factors properly into account when looking at the revenue support grant which provides services for people in poverty. I declare an interest as someone who lives in Preston, Lancashire, whose needs are being met with a government cut. I am sure that the noble Earl would not approve of that.
Earl Howe
I am pleased to say to the noble Baroness that there has been no cut at all in the allocations to clinical commissioning groups. Indeed, there is a real-terms increase everywhere in the country. I can also reassure her that this will not be a matter for Ministers; it will be decided independently by ACRA advising the board and the board taking the decision.
Lord Cormack
My Lords, I congratulate my noble friend on becoming a privy counsellor.
Lord Cormack
It is a very well-deserved honour. Does he have regular meetings with the chairman of the board, and what plans he has for that?
Earl Howe
I am very grateful to my noble friend. I have meetings from time to time with the chairman of the NHS Commissioning Board, as does my right honourable friend the Secretary of State. I also meet regularly with the chief executive of the Commissioning Board. It is important that there is that interaction between Ministers and the board if there is to be proper accountability.
Lord Laming
Will the Minister say whether poverty was the only element that was removed and, if so, why was this singled out?
Earl Howe
Poverty was not removed. As I hope I have outlined, there are various criteria reflecting deprivation which are most certainly relevant to the fair allocation of resources. Age is clearly another factor, because it would be difficult to envisage an allocation formula that did not take it into account; it is the key factor in determining an individual’s need for healthcare. That is not to say that other factors such as deprivation should not continue to be considered.
Baroness Williams of Crosby
I would add congratulations from these Benches to the noble Earl on his very well-deserved honour which reflects the immense contribution he has made to this House. On the issue of poverty, is the existence of traditional industrial diseases, such as emphysema in mining areas, taken into account in the allocations that continue to be made between CCGs?
Earl Howe
I am very grateful to my noble friend for her kind remarks. The information I have in my brief is as I have stated, in that the indicators reflecting deprivation are quite broad. However, it is for ACRA, the independent committee, to review those indicators to see that the measures are representative and accurate. I am grateful to my noble friend for pointing us towards some other indicators which could be relevant, and I shall make sure that her ideas are passed to the appropriate quarters.
Lord Reid of Cardowan
My Lords, when the Minister says that the decisions on these allocations are, of course, not taken by Ministers, that is correct. However, can he confirm that it is equally correct that the criteria by which those decisions are made are influenced, judged and promoted by Ministers? Is not the most important thing that he said today that the primary determinant of this should be need? Here I declare an interest, because I had to address this when I was Secretary of State for Health. During the period 1979 to 1997, there was almost an indirect, inverse relationship between increases in funding for areas and their social and health deprivation. I am sure that had nothing to do with the coincidence of voting patterns in those areas of social and health deprivation, but it would be reassuring if he could tell us that that is not likely to happen during the term of this Government.
Earl Howe
My Lords, we are determined that it should not happen. I am as aware as the noble Lord of the perception of party-political bias, and it is highly undesirable that there should be such a perception. That is why, in the mandate to the NHS Commissioning Board, we have stated simply that we believe that the right basis for allocating resources is to place equal access for equal need for healthcare services at the heart of whatever formula the board decides to follow.
Lord Hunt of Kings Heath
My Lords, perhaps I may come back to that very important point. The fact is that the advisory committee, presumably following guidance from Ministers and officials, came up with a formula that would have taken money from poorer areas and allocated it to richer ones. That is why the national Commissioning Board decided not to accept it and to go for an across-the-board increase. In the noble Earl’s discussions on the mandate, will he ensure that the Commissioning Board is enabled to come to its own view on these decisions?
Earl Howe
Yes, my Lords. In this case, the board concluded that the formula proposed by ACRA accurately predicted the future spending requirements of CCGs, but it was concerned that the use of the formula on its own to redistribute funding would predominantly have resulted in higher levels of growth for areas that already have the best health outcomes compared with those with the worst outcomes. In other words, the formula on its own would have disadvantaged precisely the areas that the noble Lord is most concerned about. On the face of it, this would appear to be inconsistent with the board’s purpose, which is to improve health outcomes for all patients and citizens, and to reduce inequalities, which is a key aspect of the mandate.
Lord Brooke of Alverthorpe
My Lords, as patients are to be at the heart of the new NHS from April, will it be the Commissioning Board or the Government who are responsible for advising patients throughout the country of their rights and responsibilities?
Earl Howe
My Lords, the NHS constitution is currently under revision. It is a task for the Department of Health to take forward but, as the noble Lord will know, in the mandate and indeed in the Health and Social Care Act the Commissioning Board is charged with upholding and promoting the NHS constitution. The process of updating the constitution is, of course, subject to full public consultation.
Health: Medical Innovation
Earl Howe Excerpts(11 years, 3 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, my noble friend Lord Saatchi introduced this debate most compellingly and very movingly, and I thank him for bringing a subject of such importance to us and one on which your Lordships have considerable expertise, as this debate has amply shown.
Let me start, as many speakers have done, by focusing on the NHS. The unique and integrated nature of the health service has brought many advantages. Since the NHS was established in 1948, innovation has brought incalculable benefits for patients. Treatments have been improved, as has health policy. Inequalities have been reduced. Productivity has been increased. However, while the NHS is recognised as a world leader at invention, the spread of those inventions within the NHS has often been too slow, and sometimes even the best of them fail to achieve widespread use. It still takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice. This is not acceptable. Patients have the right to expect better health, better care and better value from their NHS.
We need to make sure that our staff can get the best, transformative, most innovative ideas, products and clinical practice spread at pace and at scale so that every patient benefits. That cannot happen without innovative minds working with the best resources in a creative and supportive environment. As the noble Lord, Lord Winston, reminded us so powerfully, research is an essential part of the innovation pathway. The Government’s investment in basic health research through the Medical Research Council underpins invention, and our investment in applied health research through the NIHR underpins evaluation. Translation of research is also vital for innovation to progress along the pathway. I hope that the noble Lord, Lord Patel, will be pleased to know that the Government are investing a record £800 million over five years in a series of NIHR biomedical research centres and units. These are translating scientific breakthroughs into better treatments for patients.
Demands on healthcare continue to rise for now and the foreseeable future. We must meet those demands from within our current real-terms funding, while at the same time improve quality. Accelerated change is not so much a goal as an absolute necessity. This means that doing more of what we have always done is no longer an option. We need to radically transform the way in which we deliver services. Innovation is the only way in which we can meet these demands. Spreading innovations in large disaggregated organisations is notoriously difficult. It is one of the biggest challenges facing the NHS. Systematic bottlenecks come with the territory. To make things harder still, technology adoption can be very complex, often requiring significant and disruptive reorganisation. New methods can require different expertise and mean new training, while care pathways have to be overhauled and existing procedures decommissioned. There can be financial barriers or issues of silo-budgeting. Of course, if we are to change this there have to be effective and efficient ways for innovations to reach the patients who need them. This must be across the NHS. That is why implementing the recommendations in Sir David Nicholson’s report, Innovation, Health and Wealth, is crucial. It set out a delivery agenda for spreading innovation at pace and scale throughout the NHS. Its programme is designed as an integrated set of measures that will together support the NHS in achieving a systematic and profound change in the way in which services are delivered.
The innovation landscape before the publication of IHW lacked transparency and accountability; there was variable compliance with NICE technology appraisals, and the picture was confused and cluttered with layers of organisations seeking to serve as gateways for interaction between the NHS, academia and industry partners. Value for money for patients, the NHS, UK plc and healthcare partners was, I have to say, doubtful and innovation was not a central priority throughout the system. IHW seeks to overcome barriers to innovation that have built up over decades, and aims to deliver long-term, sustainable change embedded right at the heart of the NHS. To do that, we need not only to change structures and process but, as the noble Lord, Lord Kakkar, reminded us, to change culture and behaviour—and this takes time.
Innovation is a top priority for the new NHS. This was most recently illustrated by the publication of its planning guidance on 18 December which clearly stated:
“All NHS organisations should demonstrate how they are driving innovation and developing delivery mechanisms for long-term success and sustainability of innovation in their health economy”.
To spread ideas right across the NHS means working collaboratively with all those who have an interest. I am completely in agreement with my noble friend Lord Ribeiro on this. This is why we want to see a more systematic delivery mechanism so that innovation spreads quickly and successfully through the NHS. This can happen in a number of ways, in particular through Academic Health Science Networks, or AHSNs. The NHS needs a stronger relationship with the scientific and academic communities and industry to develop solutions to healthcare problems and get existing solutions spread at pace and scale. AHSNs present a unique opportunity to align clinical research, informatics, innovation, training and education and healthcare delivery—exactly the issues highlighted by the noble Lord, Lord Winston. They will improve patient and population outcomes by translating research into practice, developing and implementing integrated healthcare services. My noble friend Lord Saatchi will be glad to know that our ambition is for every NHS hospital to be part of an AHSN.
The noble Baroness, Lady Masham, expressed her view that clinical research was somewhat of a poor relation in comparison to delivery of services. We have done a great deal to turn that situation around. Through its integrated academic training programme, the NIHR has taken a lead in reversing the decline in clinical academic careers. Around 250 NIHR academic clinical fellowships and 100 NIHR clinical lectureships are now available annually for medics. Last month we announced the award of five new NIHR research professorships in the second competition for these awards, and a third round is under way.
The noble Lord, Lord Winston, my noble friend Lord Willis and the noble Baroness, Lady Warwick, focused on regulation and the varying degree to which it can be a force for good. I listened with concern to what my noble friend Lord Willis had to say about the Health Research Authority. He is so up to date that I probably do not need to tell him this, but the House may be interested to hear that the HRA is collaborating with other regulatory and advisory bodies, for example the MHRA, to create a unified approval process for the approval of health research and to promote consistent and proportionate standards for compliance and inspection. This should reduce the impact of regulation on research-active businesses, universities and NHS trusts; it will improve the timeliness of decisions about research projects and hence improve the cost-effectiveness of their delivery; and it has the clear support of the Academy of Medical Sciences’ review of health regulation and governance.
My noble friend Lord Ryder rightly focused on earlier access to drugs. That is one of the reasons why we have introduced the cancer drugs fund, as the noble Lord, Lord Turnberg, was kind enough to mention, of £600 million over three years. Clinicians can now proscribe the cancer drugs that they feel their patients will benefit from, and 23,000 patients have already benefited from it. I will write to him on the future of the fund.
My noble friend Lord Willis referred to adaptive licensing. This is a subject in which I have taken a personal interest. It is an important area but, I would say, one in which there are many complexities. He is quite right that the MHRA has convened an expert advisory group to consider matters such as this, and I attended its meeting last October. However, we need pharmaceutical companies to come forward and nominate candidates for adaptive licensing. So far, despite asking, no such candidates have been proposed, but we are pressing forward in that area as fast as we can.
My noble friend Lord Ryder also referred to genomic and personalised medicine, an area of major importance in the delivery of personalised medicine, as he said. My right honourable friend the Prime Minister announced on 10 December that the ambition of the UK is to achieve a paradigm shift in the development of high throughput genome sequencing. Our ambition is to sequence 100,000 patients and have a small number of contracts in place to deliver this from 2014. From a standing start, I think that is going to be an impressive achievement, and we are on track to deliver it.
My noble friend Lord Saatchi took us very movingly to the subject of cancer, and a number of other noble Lords have also spoken about it. I fully recognise that, with cancer, screening and the identification of symptoms are vital, and perhaps the single most important thing that will improve outcomes. I will write to my noble friend about this, because all is not lost in this area. We have cause for hope, contrary to what he said, not least in ovarian cancer, where there has been a slow but steady improvement in one and five-year survival rates over the past few years.
My noble friend Lord Ribeiro rightly focused on the slowness of adoption of techniques developed in the UK. I agree that that is the problem. It is one that we are trying to address, but it is a matter of culture, which, as I have said, takes time to change. In addressing long-term culture change, we are seeking to make innovation at pace and scale everybody’s business in the NHS. People throughout the service have to feel ownership of the agenda. The IHW programme is bringing together a community of leaders at different levels in the system who will work together over the next few months to build commitment and ownership in the NHS, to ensure that innovation really is at the heart of the way the NHS does business.
As so often, time is my enemy. I have a number of other things that I would like to have said if I had had more time, not least to my noble friend Lord Rennard, the noble Baronesses, Lady Masham, Lady Finlay and Lady Morgan, and, indeed, others. If they will allow, I will write to them all and to other noble Lords whose questions I have not answered.
I believe we can point to a great deal of progress being made at a time of great change in the NHS, but much more needs to be done to deliver the improvements we need. We must not be complacent, and I am not. We owe it to patients, the public and our stakeholders to achieve that systematic adoption and diffusion of innovation that I have referred to. We are committed to a future in which innovation is a core function of the NHS. That will help us achieve our overall aim, which is to have health outcomes as good as any in the world.
NHS: Liverpool Care Pathway
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Baroness Knight of Collingtree
To ask Her Majesty’s Government what procedures will be adopted in carrying out the NHS inquiry into the Liverpool Care Pathway announced on Monday 26 November 2012.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, as we announced today, the noble Baroness, Lady Neuberger, has been appointed to oversee the review of the Liverpool care pathway and is currently determining its procedures. The review will examine how the Liverpool care pathway is used in practice, and will look in particular at the experience of the Liverpool care pathway by patients, families and health professionals, as well as considering the role of financial incentives in its use. It will report by the summer.
Baroness Knight of Collingtree
My Lords, there will be very much satisfaction at the appointment of the noble Baroness concerned as chairman. Does my noble friend agree that this inquiry was set up following the receipt of more than 1,000 complaints from relatives of patients who had been put on the Liverpool care pathway, and that the Government are not ignoring their complaints, as those about Stafford were avoided some time ago? Is it acceptable that, out of 130,000 people who die yearly on the pathway—everyone who is put on it—only half are told that they are being put on it and neither they nor their relatives are allowed to know or complain that that is the case?
My noble friend the Minister is very widely respected for his fairness. Will he now consider attending a meeting sponsored by five Peers and a Bishop and addressed by two professors, two consultants and patients’ representative, to hear the case against what is going on?
Earl Howe
My Lords, I am grateful to my noble friend for her endorsement of the appointment of the noble Baroness, Lady Neuberger, whom the whole House greatly respects. She is right that after seeing recent criticisms in the media and having received a great many letters in the department, the Minister of State for Care and Support, my honourable friend Norman Lamb, held a meeting at the end of November with patients, families and professionals, both supporters and opponents of the Liverpool care pathway. At that meeting, he announced his decision that there would be an independent chair to oversee a review of the experience of the pathway. However, it is important to emphasise that the pathway itself has not been called into question but, rather, how it is being used. My noble friend is right to draw attention to the concerns around the lack of engagement with patients and their families, which is often a feature of the complaints received.
Lord Walton of Detchant
My Lords, does the Minister accept that the principles of the Liverpool care pathway, when precisely defined and carefully applied at the right time and in the right circumstances, make an invaluable contribution to the care and passing of individuals with terminal illness? In light of the circumstances referred to by the noble Baroness, does he further accept that the unfortunate recent publicity has been the result of circumstances in which those principles have been misinterpreted and misapplied?
Earl Howe
Yes, my Lords. The LCP, if I may use the abbreviation, is internationally recognised good practice as a framework for managing care for people in their last few days or hours of life. It was created as a way of bringing hospice-style care into hospitals and helping staff who may not be palliative care specialists to provide appropriate care to allow people to die in comfort and with dignity. However, we have consistently made clear in guidance for implementation that the pathway cannot replace clinical judgment and it should not be treated as a simple tick-box exercise. I am afraid that, from the complaints that have been received, that sometimes appears to be what has happened.
Baroness Browning
My Lords, I, too, welcome the appointment of the noble Baroness, Lady Neuberger; I am sure that we all have confidence in her as chair of this review. Can my noble friend confirm that the terms of reference will specifically make sure that a direct comparison is made between what is appropriate in terms of the expertise and continuity to be found in the hospice movement and the rapid changes of staffing, including bank staff used in general wards of general hospitals?
Earl Howe
I am grateful to my noble friend for drawing attention to a very important point. It has always been emphasised in connection with the LCP that to ensure that it is used properly it is important that staff receive appropriate training and support, and that relevant education and training programmes are always in place. In view of the degree of staff turnover to which my noble friend refers, I am confident that the noble Baroness, Lady Neuberger, will have that fact in her sights.
The Lord Bishop of Exeter
My Lords, does the noble Earl agree that if there is to be full confidence in what is undoubtedly a useful clinical tool that has helped many thousands of people to experience better care in the last hours and days of their life, non-clinical priorities in the use of the pathway, especially financial priorities, must be eradicated, and every patient should be treated solely according to their needs? Does he further agree that it would be far better to link CQUIN payments to staff training in the use of the pathway, rather than the numbers of patients being placed upon it?
Earl Howe
My Lords, once again, I am sure that the noble Baroness, Lady Neuberger, will wish to look at that very issue. The CQUIN payment framework that the right reverend Prelate mentioned was designed to incentivise good practice, and the LCP is considered internationally to be best practice. In one sense, it is therefore logical that the two should be combined. It is equally important for me to emphasise that the Department of Health has not attached any set financial targets to the LCP; on the other hand, some commissioners in the NHS have introduced local incentives. The way in which those incentives have been applied should be the subject of close attention.
Baroness Jolly
My Lords, the Liverpool care pathway is widely used, but some care providers choose to use a slightly different pathway. Will my noble friend confirm that all similar pathways will be included in the inquiry led by the noble Baroness, Lady Neuberger?
Earl Howe
I will be happy to speak to the noble Baroness about that. I was not aware that she had that in mind. I do not think that there would be an objection on anyone’s part if she did, but it will really depend on the extent to which there is widespread concern about the use of those other pathways.
Health: HIV Strategy for England
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Lord Collins of Highbury
To ask Her Majesty’s Government what plans they have to publish a cross-departmental HIV Strategy for England, in line with the Political Declaration made at the United Nations General Assembly in 2011.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, tackling HIV remains a priority for the Government. We believe the way forward is to develop a framework that covers both HIV and broader sexual health issues. We therefore plan to publish a policy document on sexual health and HIV shortly.
Lord Collins of Highbury
I thank the Minister for that response. One issue that is obviously of big concern is testing. Half of the people diagnosed with HIV are diagnosed late. With the commissioning of HIV testing being highly fragmented under the new NHS arrangements in England, how will the Government ensure that HIV testing recommendations from NICE and the British HIV Association are implemented consistently across the country?
Earl Howe
My Lords, the new commissioning arrangements will allow each commissioning organisation to play to its strengths and will mean better services for patients. Local authorities will be able to link sexual health provision into other public health provision and other services such as family support and social care. HIV treatment is complex, specialist and expensive. That is why the NHS Commissioning Board will commission the NHS to provide treatment. During the White Paper consultation there was wide support for that. The key will be for local health and well-being boards and Public Health England to have a role in supporting integration at a local level to make sure that the commissioning of services is joined up in all parts of the country.
Lord May of Oxford
My Lords, the Minister will undoubtedly be familiar with the relatively recent and very thoughtful Select Committee report from this House urging specific measures aimed at reversing the regrettable rise in the incidence of new infections of HIV. Already one of those measures has been mentioned; not all of them are highly technical. Some of them address the fact that, in several studies, young people today show themselves to be much less well informed about sexually transmitted infection than in the past. Could the Minister assure me that these underlying problems outlined in that report will be taken account of in the proposed cross-departmental strategy and if not, why not?
Earl Howe
My Lords, the noble Lord is right to draw attention to the need for targeted prevention messages in this area. Following a competitive tender last year my department awarded the Terrence Higgins Trust a contract worth £6.7 million for three years. Known as HIV Prevention England, the programme targets gay men and African communities, the groups that remain the most at risk of HIV in the UK. That work includes promoting HIV testing through the Think HIV campaign; primary prevention messages, which we must get to the right audiences; and developing the evidence base on what works in HIV prevention. That DoH programme, I emphasise, is in addition to work funded by the NHS and local authorities.
Baroness Hussein-Ece
My Lords, the Minister will be aware of the links between HIV and tuberculosis, and of how important it is that when we talk about HIV we also talk about TB. Are there any plans in the strategy that is mentioned to include TB, given that cases of both HIV and TB are on the rise?
Earl Howe
My noble friend is absolutely right to mention the connection between HIV and TB. The complexities that arise from comorbidity of that order are fully taken account of in the approach taken by both the health service and local authorities to the testing and treatment of HIV patients. The individuals attending a TB clinic are offered and recommended an HIV test as part of their routine care. This is applicable to all patients irrespective of age. NICE has issued guidelines which recommend the use of a specialist test for people with HIV, and if the test is positive a clinical assessment will be performed to exclude TB and consider treating latent TB infection.
Baroness Gould of Potternewton
My Lords, is the Minister aware of a recent study undertaken on behalf of the British HIV Association on the relationship between women with HIV and domestic violence, which shows that half the women interviewed have shared a lifetime of what is called intimate partner violence—IPV? In the light of that evidence, can the Minister indicate what action is being taken by government to raise awareness of this very serious level of violence against women with HIV and, secondly, whether there will be any routine screening to find out the level of IPV among these women? Furthermore, does he agree that if we had a national strategy for HIV, surely issues such as this and things such as unemployment, as well as other areas, could be taken into account?
Earl Howe
My Lords, the noble Baroness raises an extremely important issue about violence against women. There is a great deal of activity in my department designed to bear down on that and I should be happy to write to her about it. On the issue that she specifically alluded to at the end of her question, we think that, as most HIV is transmissible sexually, it makes much more sense to build that dimension into a sexual health strategy which embraces not only HIV but all transmissible sexual conditions.
Baroness Masham of Ilton
My Lords, is the Minister aware that there are many commissioning bodies for various aspects of HIV, such as CCGs, a commissioning board, local authorities, community nurses and voluntary organisations? Does he therefore agree that it is most important to have some strict guidelines and a strategy so that there is not a muddle?
Earl Howe
The noble Baroness makes a very good point. I can tell her that the sexual health policy document, which we will be publishing shortly, will set out our plans for improving sexual health generally, as well as our plans for offering support to women facing unwanted pregnancy. It is an important document. It is crucial that we take the time to get it right and make it clear that, as she points out, all the commissioners in the system need to work together with the benefit of advice not only from the commissioning board but from local health and well-being boards at a local level.
NHS: Reconfiguration of Services
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Lord Hunt of Kings Heath
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer noble Lords to my health interests in the register.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, patients’ interests must remain the paramount consideration in any NHS reconfiguration, including merger. We expect the competition authorities to consider the costs and benefits of proposals and to make a final decision based on the balance of impact on patients.
Lord Hunt of Kings Heath
My Lords, the noble Earl will recall that the Health and Social Care Bill was amended to emphasise the importance of the integration of services. This merger was designed to integrate services and to provide a higher quality of care in the hospitals concerned. Does he recognise that this intervention by the OFT, which knows virtually nothing about the health service, will send a signal throughout the National Health Service that the ideology of competition is graded as being more important than either the integration of service or the quality of service? Can we expect the Government to send a signal to the OFT that it should desist? Otherwise, this will cause great concern in the National Health Service.
Earl Howe
My Lords, the referral of this merger proposal by the OFT to the Competition Commission is not at all a result of the measures brought in by the current Government; it is a result of the provisions of the Enterprise Act 2002. Even if there had been no Health and Social Care Act last year, we would have found ourselves in this situation. This is the very first time that a proposed merger of two foundation trusts has raised competition issues and there is no doubt that the OFT would have had an interest whatever the situation. In the Act we avoided double jeopardy, whereby the Co-operation and Competition Panel, set up by the previous Administration, might have determined its view on this merger and then there would have been a second-guessing process by the competition authorities. We have avoided that and that is very positive. Aspects of this merger obviously impact on patients and patient choice, and it is right, in the judgment of the OFT, that scrutiny should be given to the matter.
Lord Marks of Henley-on-Thames
My Lords, will my noble friend confirm that before the decision was taken to refer the proposed Dorset merger to the Competition Commission Monitor’s advice was obtained by the OFT, as it should have been pursuant to Section 79 of the 2012 Act? Is it right that in giving that advice Monitor’s duty was to have regard to the quality of healthcare services? If that is right, is this not an example of this part of the 2012 legislation working in precisely the way it was designed—putting patient care at the heart of decision-making in this difficult area of hospital mergers?
Earl Howe
I am grateful to my noble friend and I can give the confirmation that he seeks. Monitor’s advice was sought and obtained by the OFT. He is quite right that that it is one of the benefits from the Health and Social Care Act. In situations of this kind we expect Monitor and the NHS Commissioning Board to engage with the Competition Commission on FT mergers but before that with the OFT because Monitor, as a health-specific regulator, has the insight into the considerations that bear most closely on the interests of patients.
Lord Winston
My Lords, does the noble Earl agree that, whatever the explanation, the involvement of the OFT suggests an increasing privatisation of the health service? Given that the health service so often does not cost out individual treatments per patient very successfully, that raises the issue of competition between private providers in such areas as this. Would the noble Earl be kind enough to comment on that?
Earl Howe
I do not agree with the noble Lord. Competition issues arise within the health service and the matter in the noble Lord’s Question is specifically a health service issue. There are, of course, competition issues involving the independent sector and the charitable sector as well but that is not the focus here. It was the previous Government who recognised the benefits of competition for patients. Our attitude to it is very pragmatic. The key objective for commissioners is to ensure that patients receive the best possible services irrespective of whether they are from the public, voluntary or private sectors. It is for commissioners working with patients to decide where competition is appropriate. It is a means rather than an end in itself.
Earl Howe
I am aware of that issue. It is very much in the sights of Monitor as it conducts the fair playing field review which, as the noble Lord will remember, was the product of an amendment proposed by the noble Lord, Lord Patel of Bradford, and passed in your Lordships’ House. The report that will ensue from that commitment by the Government will be published later this year and I am quite sure it will embrace the point mentioned by the noble Lord.
Carers
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Lord Touhig
To ask Her Majesty’s Government what is their estimate of the saving to public funds as a result of the work of unpaid carers in the United Kingdom.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government themselves have not estimated savings to public funds as a result of unpaid carers’ contribution to care and support, although we are aware of estimates by other organisations. There is scope for debate about how best to put a financial value on this care but there can be no doubt about its huge value to those who receive care and to the wider community.
Lord Touhig
My Lords, I am sure that the Minister would agree that we owe a great debt to the carers of this country and, indeed, the Government recognise that because they have promised that families with a disabled child and in receipt of disability living allowance will be exempt from the housing benefit cap. However, according to the regulations, when that disabled child becomes a disabled adult, the child is considered to be a separate household from the parents who they live with. No matter that the disabled adult will perhaps need the same level of care that they received as a disabled child; the parents will then be subject to the housing benefit cap. Why?
Earl Howe
My Lords, the noble Lord will have to forgive me because I will need to write to him about benefits, which do not directly fall under my remit in the Department of Health. However, I can say to him that more young carers services are extending their age group to cover young adult carers, and there needs to be a proper join-up between the two. In some situations, it is true that the young adults’ needs are unmet; they can fall down the gap and not receive adequate support. A transition between children’s services and adult services should be smoother—we acknowledge that, and we are addressing this in the draft Care and Support Bill.
Lord Wigley
My Lords, does the noble Earl accept that many unpaid carers manage to carry their enormous responsibilities only because of respite care and other assistance, sometimes from paid sources, and that if those paid sources were not available, many people now living at home might find themselves in institutional care? Will he therefore, in any government cut backs, make sure that no action is taken that undermines the position of carers?
Earl Howe
I agree with the noble Lord. Carer’s breaks are extremely important, which is why we have pledged to invest £400 million between 2011 and 2015 to improve the NHS’s support carers to enable them to take a break from their caring responsibilities. The current operating framework for the NHS requires the service to work closer than ever before with local carers organisations and councils to agree plans to pool resources and ensure that carers get the support and the break that they deserve.
Baroness Barker
My Lords, is the Minister aware that in November 2011, in a report from the Cass Business School for Carers UK called The UK Care Economy: Improving Outcomes for Carers, the authors noted that the only reliable data about carers comes from the census, which is national? Given that CCGs and health and well-being boards are about to start commissioning services locally and that their information is at best incoherent and inconsistent, what help will the Government give them in order properly to assess the numbers of carers and the level of need they are supposed to be meeting?
Earl Howe
My Lords, my noble friend makes an extremely important point. Our report, Recognised, Valued and Supported: Next Steps for the Carers Strategy, had four key priorities, one of which was to identify carers earlier. Healthcare professionals undoubtedly have a role to play in supporting those with caring responsibilities to identify themselves as carers in the first instance. We therefore made around £850,000 available in the previous financial year to the Royal College of General Practitioners, Carers UK and the Carers Trust to develop a range of initiatives to increase awareness and understanding of carers’ needs in primary care. We are building on that further.
Baroness Pitkeathley
My Lords, I remind the House that the figure usually given is £119 billion that is being saved from public funds. Since the census now shows that the number of carers has increased by 11%, no doubt that figure will go up. Since many carers give up paid work to become carers and only 600,000 of them receive the carer’s allowance, does the Minister agree that many of them will be building up poverty for themselves in the future? What guidance must be given, therefore when carers’ assessments are being made to enable them to stay in paid work for as long as possible?
Earl Howe
My Lords, the latest figure I have for carers from the census is that there are 5.4 million unpaid carers in England. The noble Baroness was right to mention the figure of £119 billion, although it is a figure we can argue about. It is probably an overestimate as regards the cost to public funds. However, she makes a very important point about employment. The Government fully recognise the importance of supporting carers to remain in work. The Department of Health has established a task and finish group with employers for carers to explore how to improve support for carers to remain in employment. Jobcentre Plus provides practical assistance for carers seeking work; in particular, it can offer practical support for all carers who are employed for less than 16 hours a week.
The Earl of Listowel
My Lords, is the Minister aware of the concern of many adult carers of children with disability at the number of changes in social workers that their child has, and how that undermines their ability to be effective advocates for these children, especially as they make the transition to adult services? Does the Minister monitor the number of changes in social workers supporting such families? How can we ensure that this important factor is improved upon?
Earl Howe
My Lords, the noble Earl makes an extremely important point about continuity of care. I am not aware that my department monitors the point that he raises, although it is one that we expect local authorities to bear closely in mind as they fulfil the criteria to be rolled out in the social care outcomes framework, which contains a strong strand relating to service user satisfaction.
Health: Cancer
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Lord Aberdare
To ask Her Majesty’s Government what steps they are taking to ensure that the Department of Health 2013 generic cancer symptoms awareness campaign will help improve early diagnosis of pancreatic cancer.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, from today, we are piloting a general cancer symptoms campaign to raise awareness and encourage people with relevant symptoms to visit their GP. The campaign will run in five cancer network areas until mid-March and will be relevant to a range of cancers, including pancreatic cancer. Data, including GP attendance, urgent referrals for suspected cancer and diagnostic test activity, will be collected and analysed to assess the impact of the campaign.
Lord Aberdare
My Lords, pancreatic cancer is the fifth most deadly cancer in the UK, accounting for some 7,900 deaths a year. UK survival rates are significantly worse than in some other countries, as are the numbers of patients being referred for operations, the only effective cure. Since earlier diagnosis is essential to improve these outcomes, what plans does the Minister have to ensure that the proposed campaign includes new tools to help GPs detect pancreatic cancer and better pathways for them to refer suspected cases for further testing and support?
Earl Howe
The noble Lord is absolutely right about the importance of earlier diagnosis. I can give two examples of work running this year to assist GPs in the assessment and earlier diagnosis of cancer patients, including those with pancreatic cancer. Rolling out from March, Macmillan Cancer Support, with funding from the department, will be piloting an electronic cancer decision support tool for GPs to use as part of their routine practice in order to help identify and assess more effectively patients with possible cancer. The initial pilot will cover a number of cancers, including pancreatic cancer. Further, the National Action Cancer Team is supporting the distribution of further desk-based versions of risk assessment tools for use in general practice, and these include a pancreatic cancer risk assessment tool.
Baroness Gardner of Parkes
My Lords, is the Minister aware that people think that there is no effective treatment for pancreatic cancer—we are always told that lung and pancreatic cancer are the two worst—but other treatments are being given in other countries? A very dear relation of mine in Australia has benefited from having radium pellets injected directly into the secondary lesions and is progressing very well indeed in the second year since her treatment. Her symptoms are much improved. Can he give an assurance that we will give people in this country hope that we will look at treatments being used in other countries that are improving pancreatic cancer outcomes and ensure that we are not left behind in this area?
Earl Howe
My Lords, I am very interested to hear about the treatment mentioned by my noble friend and I can remind her, although I am sure she needs no reminding, that one of the key roles of NICE is to keep evidence of new treatments under review. I do not doubt that as a result of my noble friend’s intervention, it will wish to look at that particular treatment. Pancreatic cancer can grow initially without any symptoms and it is possible that people might not recognise the symptoms. That is why the “Know 4 sure” campaign, which I have mentioned, highlights four key symptoms including loss of weight and pain, which can be symptoms of pancreatic cancer.
Lord Turnberg
My Lords, is it not the case that the diagnosis of pancreatic cancer is extremely difficult? The organ lies deep within the abdomen and cannot be seen or felt, so by the time the patient shows symptoms, it is often too late. What we really need is research that will provide us with a biomarker which can be used for screening and early diagnosis. Can the noble Earl tell us whether research along these lines is going on within the NHS?
Earl Howe
My Lords, via the Medical Research Council we are supporting a study to assess the effectiveness of a new test called the Mcm5 protein test to see if it can help to diagnose cancer of the pancreas, bile duct and gall bladder. I am also aware of a number of other research projects that my department is funding in the field of pancreatic cancer and I would be happy to write to the noble Lord with the details.
Lord Sharkey
My Lords, where you live will dramatically affect your chances of surviving pancreatic cancer. In south-west London the one-year survival rate is 22% while in north Trent it is 11%. Do we know why this is? What are we getting right in south-west London but not in north Trent?
Earl Howe
My noble friend is absolutely right to raise the point. To support the NHS in tackling regional variations in cancer survival rates, we are providing data to providers and commissioners that allow them to benchmark their services and outcomes against one another and to identify where improvements need to be made. Surgical resection is currently the best curative intervention for pancreatic cancer, and through the National Cancer Intelligence Network we have already made available data collections on the survival rates and surgical resection rates across a range of cancers, including pancreatic cancer.
Lord Kakkar
My Lords, what proportion of patients diagnosed with pancreatic cancer is managed in specialist centres by a specialist, multidisciplinary team? What proportion of patients in those centres is entered into clinical trials? We all recognise that participation in clinical research improves clinical outcomes in these centres.
Earl Howe
My Lords, the UK now has the highest national per capita rate of cancer trial participation in the world, which is something that not everybody realises. We have improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I will write to the noble Lord with information about specialist centres, but he will know that surgery for pancreatic cancer is a complex business and needs to be undertaken by those who are very well versed in that particular line of clinical activity. I am sure that a high proportion will be treated in those centres but I will find out more if I can.
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interest. On the question of variation, the noble Earl mentioned earlier the role of GPs. Will he accept that there is a wide variation in the performance of GPs? Can he confirm that we can expect the NHS Commissioning Board from 1 April this year to start taking action where GPs are not doing what is required?
Earl Howe
Yes, my Lords, because a major role of the Commissioning Board is to support general practice and, indeed, vice versa. In the current year, cancer networks are continuing to support GPs to diagnose cancer earlier through a range of work including continual professional development, primary care-led audits of cancers, and ensuring that GPs are prepared when patients present in response to public cancer awareness campaigns. Therefore, there is a range of work going on to ensure that GPs are better versed in this area.
Diabetes
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Lord Kennedy of Southwark
To ask Her Majesty’s Government what action they are taking to reduce the number of amputations due to diabetes.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, foot complications of diabetes are usually preventable. Early identification and prompt treatment prevent amputations. NICE guidelines recommend annual foot checks, which are included in the quality and outcomes framework for general practitioners. NHS Diabetes has established regional diabetes footcare networks. People with vulnerable feet require expert protection, while those with problems need urgent specialist care. Local national health services are responsible for commissioning podiatry services and multidisciplinary specialist footcare teams for people with diabetes according to local needs.
Lord Kennedy of Southwark
I draw the attention of the House to my declaration of interests in respect of Diabetes UK. One hundred and twenty-five amputations take place each and every week in England alone, and 80% of those are preventable. The record of the Department of Health is not good; the figures are going up, not down. If I asked this question in a year’s time, what progress does the Minister expect that his department would have made to reverse that trend?
Earl Howe
The noble Lord is absolutely right that this is a major public health issue and one that impacts very seriously on the health and well-being of individuals, so it is a priority for us. We are committed to reducing the number of avoidable amputations among people with diabetes. In fact, progress is being made: although the number of amputations is going up, the rate is falling. However, we are under no illusion that this will be a growing problem because of the growing number of people with diabetes. All our work on improving completion of the NICE nine care processes for people with diabetes and improving timely access to specialist diabetic footcare multidisciplinary teams will support that aim, and the Diabetes UK Putting Feet First campaign has real potential to improve awareness of foot complications in diabetes.
Lord McColl of Dulwich
My Lords, does the Minister agree that the real way to reduce the number of amputations is to reduce the incidence of diabetes and that the way to do that is to do something about the obesity epidemic, which is the main cause of diabetes and one of the main causes of amputation? What is he doing to try to prevent that quango, NICE, misleading the nation and politicians, as it did, into believing that the answer to the obesity epidemic was to take more exercise when, although exercise is important, the real answer is to eat fewer calories?
Earl Howe
I agree with my noble friend about the importance of targeting obesity as a serious public health risk and one which leads to diabetes in many cases. I believe that, if my noble friend were to talk to NICE about its recommendations to prevent obesity, he would find that its line is slightly modified from the one that he has criticised. We should pay tribute to NICE for the good work it has done in the specific area of diabetes. The recommendations and guidelines it has issued have been very positive. There is, of course, a quality standard for diabetes, which is also excellent.
Baroness Hollins
My Lords, people with learning disabilities and those with serious mental illness have a higher incidence of diabetes. They have a later diagnosis and are therefore more at risk of complications. Does the Minister agree that one way to reduce the number of amputations associated with diabetes would be to improve access to diabetic care for people with learning disabilities or mental illness?
Earl Howe
My Lords, yes, I certainly do. There are a number of positive ways in which we can do that. One is the NHS health check, which should, if it is performed correctly, pick up those with undiagnosed diabetes. Early identification of diabetics is key in this area, particularly for those who are at risk of ulceration. Other ways are targeting preventive services at those most at risk, including those with learning disabilities; early management of foot infection and rapid access to multidisciplinary teams; and having good diabetic foot prevention and ulcer management services in local areas.
Lord Harrison
My Lords, the point at issue is surely this: that to prevent the four out of five needless amputations that currently take place, Her Majesty’s Government need to respond to the Question of my noble friend Lord Kennedy by saying how they will ensure that there are those multidisciplinary groups with specialist knowledge of feet and the ability to make sure that there is not a postcode lottery as there is now. They should be properly monitored by the Government to ensure that a proper service is offered to diabetics at a time of decline in the amount of money going into the National Health Service.
Earl Howe
My Lords, there is no single magic bullet that will solve this problem, but undoubtedly better monitoring in general practice is one answer; the QOF incentivises that. The NHS outcomes framework will also incentivise clinical commissioning groups to ensure that those with long-term conditions—particularly diabetes—are properly looked after. The benefits of multidisciplinary teams are now proven. The evidence is there and, if we can shine a spotlight on the statistics—and there is, as the noble Lord knows, a wide variation in success rates across the country—that will be the key to driving better performance throughout the health service.
Lord Patel
My Lords, does the Minister agree that part of the problem is that while the NICE guidelines, if implemented throughout the country, would reduce the variation rate in amputations, particularly of lower limb extremities, it is not mandatory to implement those guidelines? He may be aware that several nations, including Scotland, have recently reported a reduction of 30% in the amputation rate, following strict protocols in diabetic management.
Earl Howe
My Lords, there are centres of excellence throughout the United Kingdom, from which I am sure the health service as a whole can learn. The noble Lord is absolutely right. He mentions the NICE guidelines; he is right that they are not mandatory, but they do point to best practice. By highlighting the data, we can ensure that commissioners and practitioners ask themselves the right questions about whether best practice is being followed.