Contracting Out (Local Authorities Social Services Functions) (England) (Amendment) Order 2012

Earl Howe Excerpts

Tuesday 20th November 2012 Grand Committee

Moved By

[Earl Howe]

That the Grand Committee do report to the House that it has considered the Contracting Out (Local Authorities Social Services Functions) (England) (Amendment) Order 2012.

Relevant document: 8th Report from the Joint Committee on Statutory Instruments.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, in 2011 an order was passed by noble Lords under the Deregulation and Contracting Out Act 1994 to allow local authorities taking part in two pilot schemes to contract out to outside organisations certain adult social service functions. The order under discussion today amends the original order to allow local authorities to continue this contracting out activity in respect of the pilot programmes beyond the period provided by the original order. The pilots are, first, adult social work practices pilots and, secondly, Right to Control pilots.

The social work practice pilots are testing various models of social worker-led organisations undertaking adult social care functions for which local authorities are currently statutorily responsible. The Right to Control pilots are testing the rights of disabled people to manage some of the state support they receive to live their daily lives. As these are established pilots, I will briefly outline each pilot programme before describing the rationale behind the extensions.

The social work practice pilots were announced in 2010 and the programme has been running for more than a year. The scheme has seen the creation of seven social worker-led organisations that discharge the functions of the local authority in providing adult social care services. On a day-to-day basis, the pilots are independent of the local authority but work closely with it and in partnership with other providers. The local authority pays for the services but maintains its strategic and corporate responsibilities through its contract with the social work practices. We are looking at the pilot sites to test the potential benefits of the social work practices, and whether the innovative approaches improve outcomes and experiences for the people who use them.

The programme aims to bring people who need health and care support closer to those who provide the services they need by reducing bureaucracy, encouraging innovation and increasing the personalisation of services. The Department of Health has provided funding of £1.1 million to help the pilots get up and running and to provide initial support. The pilots are an opportunity to test different models to see what works well. They will be fully evaluated throughout the pilot period, with the final report planned for winter 2013. In considering the need to extend the pilots we listened to the advice of the social work practice working group, which incorporates the sites themselves, and representatives from ADASS, SCIE, the Department of Health and the independent evaluators.

There are two main reasons why we seek an extension to the social work practice pilots from their planned end in summer 2013 to 31 March 2014. First, it has taken longer than we anticipated for many of the sites to become established and begin providing services. This point was highlighted in the recent interim report on the pilots published by SCIE. The proposed extension will ensure that the pilot sites have an increased opportunity to feed into the independent evaluation planned to report in winter 2013.

Secondly, my department must own up to the fact that, in planning the scheme, it did not take into consideration that there would be a gap between the pilots ending and the evaluation reporting. Therefore, extending the pilots to 31 March 2014 will ensure that no pilots will need to end before the evaluation has reported, and that users will continue to be able to access the service. The local authority in each pilot area will have the final say on whether sites are extended. This order creates the opportunity to do so.

The Right to Control, introduced by the previous Government in the Welfare Reform Act 2009 and launched in 2010, gives disabled adults greater choice and control over certain state support they receive to meet their individual needs and ambitions. Disabled adults in the pilot areas are able to combine the support they receive from six different funding sources and then decide how best to spend this to meet their needs. The pilot is due to end in December this year and my honourable friend the Minister for Disabled People intends to extend the pilots by a further 12 months to gain more evidence of the benefits during the pilot programme. A public consultation seeking views on the plans to extend the Right to Control pilot ended on 21 September and among those who commented there was solid support for the extension for a further 12 months.

The Right to Control pilots are being tested in seven trail-blazing areas in England. These trail-blazers, funded by the Department for Work and Pensions, are testing the best ways to implement the right and the results will be used to inform decisions about options on the right in future. Since Right to Control was introduced in 2010, a great deal of progress has been made and over 34,000 people have benefited from it. The interim evaluation of the pilot scheme concluded that there was insufficient evidence on which to make an informed decision about the long-term future of Right to Control. The Government concluded therefore that the best solution was to extend the pilot scheme by a further 12 months to enable us to gather more evidence of what works best, both for disabled people and for the local authorities delivering the Right to Control.

One of the authorities delivering the Right to Control has also been testing delegation of its statutory duty to review social care assessments to third parties, such as user-led organisations. Disabled people have often told us that having their support arrangements reviewed by fellow service users leads to greater satisfaction with the outcome and that the support of their peers gives them greater confidence to request a direct payment and to take control of their own support arrangements. The proposed extension will allow the trail-blazers to continue to test the delegation of this statutory duty. In conclusion, we see the proposed extension in the order as a continued commitment to the developing world of personalisation and one that fully supports the aims set out in the recent care and support White Paper and draft Bill.

This order has the support of councils and their representatives, as well as service users and their carers. It will allow the continuation of new and innovative ways of working to the benefit of individuals and their communities as a whole. More importantly, it will also maximise the evidence and outcomes available to the independent evaluation in both programmes. I commend the order to the House.

[Lord Hunt of Kings Heath]

My Lords, I thank the noble Earl, Lord Howe, for his full explanation of the order before us this afternoon. I find the contents to be unexceptional and it is right to avoid a hiatus in the pilots’ evaluation. The people affected should not have to go back to an old system before knowing whether the Government have decided that they should be extended, so the logic of the order is clear. I will ask the Minister about a couple of points. He mentioned evaluation. In relation to the trail-blazers pilots, he referred to the interim evaluation which, as he said, found the Right to Control had not been extended to a sufficient number of people to provide evidence to inform a decision about the future of the Right to Control approach. Will he say more about the emerging findings as to the impact on disabled people? He made a few comments about that and suggested that the signs so far are encouraging, with some positive outcomes. Could I tempt him into explaining a little more to the Committee?

I also ask the Minister about potential links between the Right to Control trail-blazers and initiatives taking place on public health. Following the debate when the order was first brought before your Lordships’ House in 2011, the noble Earl wrote to Members who had spoken to the order to say that the Right to Control trail-blazer pilot was intended to be run simultaneously with the public health budget pilots. In particular, he mentioned Manchester, where he said that there was one in-depth public health budget site—Manchester—alongside a Right to Control trail-blazer site. I wonder whether he could report anything on that. I also ask the noble Earl what feedback there has been from users of the service on Right to Control pilots.

On the adult social work practice pilots, I understand that the evaluation has been carried out by King’s College London. I have yet to track down any KCL publication on any emerging findings from those pilots. Perhaps the noble Earl could confirm whether anything has been published so far. I understand, however, that the Department for Education has published an evaluation report by King’s College London and the University of Central Lancashire on the original pilots for children and young people in care, in September 2012. That might be of interest in comparing those pilots with the pilots that are now being undertaken. That evaluation, I understand, found mixed views as to whether the pilots performed better than their local authority counterparts, or whether they represented good value for money. Would the noble Earl be prepared to comment on that? Overall, though, we of course support the extension of the pilots.

--- Later in debate ---

[Lord Beecham]

My Lords, I apologise for my late arrival at this debate; I had my calendar wrongly set. I thought that this session began at 3.30 pm. Eighteen months ago I sat where my noble friend now sits. I was then the junior health spokesman for the Opposition and he, of course, is the spokesman for the Opposition. I raised some queries at that time about the pilots while welcoming the principle. Indeed, I entirely endorse what my noble friend has said in continuing to support the concept of the pilots. Some of those questions touched on the point made or implied by the noble Baroness, Lady Barker, in relation to the changing landscape of the health service, with which we are all too familiar. The question now arises of what impact, if any, those changes have for the operation of these pilots. Will they, for example, now come within the remit of the health and well-being boards’ assessment of the joint strategic needs? Will the role of commissioning groups now be embedded in the process? Previously, of course, the PCT would have had responsibility for the health input into these arrangements. The PCTs are virtually defunct and will be over the cliff edge to which the noble Baroness referred very shortly.

I think that I also raised evaluation on the previous occasion. The document that we then considered said that the trail-blazers,

“will evaluate the best ways to implement the Right to Control”,

in relation to that aspect. The question arises as to whether that evaluation, while obviously being sensible for the trail-blazers to undertake, will be the only evaluation? Will there be a collective evaluation of the experience nationally? Will local authority health scrutiny committees be encouraged to report—I suppose that they could in any event, of their own volition—on what is happening locally in order to feed back to the department on progress? It would help to know something about that.

One other aspect of the landscape has of course changed dramatically in the past year. We now have a situation in which local authorities—social services authorities—face dramatic reductions in their budgets. My own authority, Newcastle, will have to find, over the next three years, £90 million a year, which is just over a third of its current budget. Similar positions will be found no doubt in many other social services authorities up and down the country. For all the good intentions of this pilot, it does not seem possible that these new approaches can necessarily be financed to the degree that was originally intended. Does the Minister have any thoughts about the financial position?

The noble Baroness talked about funding the voluntary sector. However, the voluntary sector will also inevitably suffer from cuts across a range of services that the sector has helped to provide, sometimes in very innovative and useful ways. Although I welcome the extension—it is obviously a sensible move—there are clearly question marks about some of the details of the operation, particularly about how this project will stand in the context of the very significant cuts, from which it will be impossible to shield all the social services provision that local authorities would wish to make.

[Earl Howe]

My Lords, I am grateful to all noble Lords who have spoken. In particular, I thank the noble Lord, Lord Hunt, for his welcome of the order and its content. I shall do my best to answer as many questions as I can and follow up those I am not able to answer in writing, copying to all speakers.

I begin with the trail-blazers and the Right to Control, which is where the noble Lord, Lord Hunt, began. He asked in particular about the evaluation of the programme. The interim evaluation was published in February this year and showed that disabled people are benefiting but that there is simply not enough evidence to make a decision on wider rollout. Clearly, an extension of the kind that we seek will give us more evidence. The early signs are positive but that does not provide the basis for a robust decision on permanent arrangements.

The noble Lord asked about the trail-blazer programme in Manchester and its link to public health. Officials in the Department for Work and Pensions and in my own department are working closely to ensure that the lessons from both pilots are gathered and shared. If I can provide him with any further information on that I would be happy to do so in writing. In general, we expect that the extension will provide further management information and case studies that can illustrate the potential efficiencies and the difference that the Right to Control has made to disabled people. We will also be able to capture more lessons learnt during the extension period.

The noble Baroness, Lady Barker, asked about having a control group against which to compare the results from trail-blazers. I will write to her on that point also. However, the main source of evidence will be from the service users themselves, some of whom will have experienced care under normal arrangements. It is on their feedback on the benefits that they see from the Right to Control that we will take decisions.

Turning to the social work practice pilots, the interim report was published on 2 November this year and is available on the Social Care Institute for Excellence website for all to see. It is perhaps worth outlining what we hope success will look like under these pilots: better quality of service; greater work satisfaction for staff; greater satisfaction for service users and their carers through better outcomes; greater community involvement on the part of service users, both individually and through partnership with user-led organisations; greater community cohesion through more joined-up services, because we see the SWP acting as a catalyst to encourage wider partnerships within a locality; more opportunities for volunteering; less bureaucracy and greater efficiency in systems and procedures; and integration of services. If we can capture all those benefits, the pilots will have proved their worth.

On the evaluation of SWP, the social care workforce research unit at King’s College London is independently evaluating the programme for the department. The evaluation is making good progress, with interviews with practitioners almost completed. To date, 47 participants have been interviewed from across the seven sites, including: leads from host local authorities, managers, social workers and other staff in pilots; consultants employed to assist the development of pilots; and local NHS and voluntary sector stakeholder organisation representatives. The next steps include collating evidence on user outcomes and satisfaction and data on finance processes of the SWPs. As I have already said, the final evaluation report is due to be completed towards the end of next year.

The noble Baroness, Lady Barker, asked me whether the evaluation of SWP would extend beyond the range of services that are normally encompassed. Certainly, the evaluation will also cover the effect of SWP on social workers and other practitioners, as well as on users and carers, and how the features of SWP differ from the usual practice control group. Again, if I can elaborate on that in writing, I will.

The noble Baroness also asked about other local authority services. Access to these is agreed between the local authority and the SWP as part of their contract. The SWP’s budget will reflect a proportionate transfer of funding, including corporate costs, so the SWP will be expected to make its own arrangements for support services and placements. It may also make arrangements to access those specialist services that the local authority may provide that have not been included in the funding transfer—for example, sensory impairment or HIV/AIDs—and this type of arrangement would be set out in the contract.

The noble Lord, Lord Beecham, asked about the relationship with the local authority particularly in the “new world” as we are moving to health and well-being boards. In general, both now and into the future, the local authority needs to maintain a close relationship with the SWP as it retains ultimate responsibility for the services delivered and the actions taken by the SWP, but it also needs to allow the SWP scope to innovate and make decisions about the best packages of support and services for the people in the SWP, and how to provide these. We expect the local authority to monitor the outcomes of the SWP, identifying issues early and providing support, while allowing the SWP sufficient autonomy to decide how best to meet the needs of the people with whom it works. It could well be that in many cases it will be appropriate for the SWP to engage with the emerging clinical commissioning groups to ensure that both health and social care provided to service users is joined up. We would certainly expect that to take place in appropriate instances.

NHS Commissioning Board: Mandate

Earl Howe Excerpts

Tuesday 13th November 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I shall now repeat a Statement given in another place earlier today by my right honourable friend the Secretary of State for Health on the subject of the mandate to the NHS Commissioning Board. The Statement is as follows.

“With permission, Mr Speaker, I would like to make a Statement regarding the publication of the Government’s first mandate to the NHS Commissioning Board. The NHS is this country’s most precious creation. We are all immensely proud of the NHS and the people who make it what it is: a service that last year delivered half a million more outpatient appointments, nearly 1 million more A&E attendances and 1.5 million more diagnostic tests than the year that this Government came into office, and is doing so while meeting waiting time targets, reducing hospital-acquired infections and virtually eliminating mixed-sex wards. The essence of the NHS is its values: universal and comprehensive healthcare that is free and based on need and not ability to pay.

Today, I am proud to publish the first ever mandate to the NHS Commissioning Board. From now on, Ministers will set the priorities for the NHS but, for the first time, local doctors and clinical staff will have the operational freedom to implement those priorities using their own judgment as to the best way to improve health outcomes for the people they look after. That independence comes with a responsibility to work with colleagues in local authorities and beyond, and to engage with local communities to create a genuinely integrated system across health and social care that is built around the needs of individual people.

This mandate makes clear my responsibility as Secretary of State for Health to uphold and defend the enduring values that make the NHS part of what it is to be British. It also sets out my priorities for the NHS Commissioning Board over the next two years and beyond, linked closely to the NHS outcomes framework, the latest version of which I am also publishing today.

The priorities set out in the mandate closely reflect the four key priorities that I have identified to Parliament as my own as Health Secretary. Let me take each in turn. My first priority is to reduce avoidable mortality rates for the major killer diseases where, despite increases in life expectancy, our survival rates are still below the European average in too many areas. If our mortality rates were level with the best in Europe, we could save as many as 20,000 lives every year; 20,000 personal tragedies that could be avoided but are not.

It cannot be right that we are below average for cancer survival rates; that for respiratory diseases we are the worst in the EU 15; and that our performance on liver disease is getting worse, not better. So today I call on the NHS Commissioning Board, working with Public Health England, local government, local commissioning groups and others to begin a concerted effort to bring down avoidable mortality rates in this country.

The mandate asks the NHS Commissioning Board to make measurable progress to improve early diagnosis, giving more people quicker access to the right drugs and treatment when they need it; to reduce the wide and unacceptable variation between different parts of the country, both in terms of inequality of health outcomes and variability of performance by NHS trusts; and to support a renewed focus on prevention—working with local authority partners to help people to quit smoking, drink less, eat better and exercise more.

My second priority is to build a health and care system where the quality of a person’s care is valued as highly as the quality of their treatment. When we place ourselves in the hands of others, we should be confident that we will be treated well, with our dignity respected and that this will be the case regardless of our age or mental state, or whether we are in a hospital, a care home or our own home.

For most people, most of the time, this is already the case. But too often it is not. The appalling revelations from places like Mid Staffordshire and Winterbourne View bring home the desperate need for change. So we must go beyond the enforcement of minimum standards. We must raise our game so that the NHS is recognised globally for its commitment to the highest standards of care for all, just as it is recognised for the highest standards of treatment for all.

The mandate asks the NHS Commissioning Board to ensure that local GP-led commissioning groups work with local authorities and others so that vulnerable people, particularly those with dementia, learning disabilities and autism, receive safe, appropriate, high quality care. The mandate also asks the board to improve standards of care during pregnancy and in the early years of children’s lives. This will include offering women the greatest possible choice over how they give birth, giving every woman a named midwife, responsible for them both before and after their birth, and by reducing the incidence and impact of postnatal depression through early diagnosis and better intervention and support.

The mandate asks the board to measure and understand how people really feel about their care through the new “friends and family” test—asking patients whether they would recommend the care that they receive to their friends or family. This test will cover hospital and maternity services in 2013, with other parts of the NHS following soon after.

It also asks the board to drive up standards of care by championing a transparency revolution within the NHS. This will make us the first country in the world to publish comparative information on performance throughout the healthcare system, including between clinical commissioning groups, local councils, providers of care and consultant-led teams. Mental health, which has long been the poor relation, must have parity with physical health. This mandate asks the board to make clear progress in rectifying this, particularly by looking at waiting times and by rolling out the programme of improved access to psychological therapies.

My third priority is to dramatically improve care for the one-third of people in England who live with a long-term condition, such as asthma, diabetes or epilepsy. As a group, they account for more than half of GP appointments and nearly three-quarters of hospital admissions. This has a huge impact on the individuals concerned, an impact that can be compounded by the way that they are dealt with by the NHS. We need to do much better. So this mandate asks the NHS Commissioning Board to help those who rely heavily on the NHS by harnessing the power of the revolution in technology. Labour’s NHS IT projects failed, wasting billions, but we must not allow that failure to blind us to how technology can transform treatment and care throughout the system.

So today I am asking the board to make sure that by 2015 all patients in England will be able to access their GP records online. In at least parts of the country, those records will be integrated with other medical records across the health and social care system, so that a single record can follow a patient seamlessly from ambulance to hospital to GP clinic and to their own home.

By 2015 everyone will be able to book GP appointments and order repeat prescriptions online, as well as contact their GP by e-mail. Significant progress will also have been made towards ensuring that 3 million people with long-term conditions benefit from telehealth and telecare by 2017. With respect to people with long-term conditions, the mandate also asks the NHS Commissioning Board to ensure that by 2015 more people have the knowledge and skills to control their own care and that carers have the information and advice they need about the support available to them, including respite care.

My final priority is care for older people, specifically for those with dementia. Already one in three people over the age of 65 live with dementia, but, shockingly, even though the right medicines can make a huge difference to people’s quality of life and those of their families, we diagnose fewer than half of those with the condition. I want the diagnosis, treatment and care for people with dementia to be world-leading, so the mandate asks the NHS Commissioning Board to make significant progress in improving dementia diagnosis rates and to ensure that the best treatment and care are available to everyone wherever they live. We also want to see progress in ensuring that hospitals and, indeed, all NHS organisations make significant progress in becoming dementia-aware and dementia-friendly environments.

The mandate also covers other important areas of NHS performance, including research, partnership working, the Armed Forces covenant, and better health services for those in prison, especially at the point when people are integrated back into the community.

The mandate also sets the NHS Commissioning Board’s annual revenue budget. For 2013-14, this is £95.6 billion, with a capital budget of £200 million. An important objective for the board is therefore to ensure good financial management, as well as unprecedented and sustainable improvements in value for money across the NHS.

We are the first country in the world to set out our ambitions for our health service in a short, concise document centred around patients. Its clarity and brevity will help to bring accountability, transparency and stability to the NHS. The previous Government sent endless instructions to SHAs and PCTs, constantly bombarding them with new targets, new directions and new priorities and drowning the NHS in red tape and bureaucracy. In stark contrast, this mandate is just 28 pages long. It signals the end of top-down political micro-management of the NHS, an approach that failed to get the best treatment for patients and the best value for taxpayers.

This mandate demands much closer integration between secondary and primary care and between the NHS and social care. It requires a new style of leadership from the NHS, with local doctors and nurses free to innovate in the way in which they commission care. I look to the board to develop their leadership skills so that they can discharge their duties in the best interests of their patients. The mandate will make it easier for Ministers to hold the health and care system to account, and it will make it easier for Parliament to hold Ministers to account for their stewardship of the system. This is a historic step for the NHS, and I commend this Statement to the House”.

My Lords, that concludes this Statement.

--- Later in debate ---

[Earl Howe]

My Lords, I am grateful to the noble Lord for the welcome he was able to give to aspects of the mandate, not least in the area of mental health where, as he will have noted, the original version of the mandate has been considerably strengthened in a number of places to emphasise the parity of mental health with physical health in a number of ways. I am glad he thinks that that is a positive step and I agree that it is a necessary one if we are to achieve the higher standards in the care of those with mental health problems which we all want to see.

The noble Lord also welcomed the focus on outcomes and the fact that the mandate has been restructured around the five domains of the outcomes framework. We thought it was logical and sensible to hold the board to account for objectives which related directly to indicators within the outcomes framework. That has been warmly welcomed by the board itself.

The noble Lord asked a number of specific questions. First, on personal budgets in mental health, I can tell him that, subject to the results of the current trials in personal health budgets which we expect to announce very soon, we expect that mental health will be one of the areas where patients will be able to exercise direct control over the services they receive. As the noble Lord well knows, patient empowerment in the area of mental health is, in itself, therapeutic. If we can encourage that, we should.

The noble Lord also mentioned mental health in the workplace and I completely agree with what he said about that. I recently mentioned, in your Lordships’ House, the network which Dame Carol Black and I chair in the department looking at health in the workplace and the pledges that have been devised and which businesses can sign up to. One of those pledges indeed relates to mental health. We hope that we can recruit willing enthusiasts from among the business community to sign up to as many of those pledges as they can.

The noble Lord referred to public health, and I agree with him that it is not a matter simply for the department; all government departments need to engage in it. I should say to him that the creation of Public Health England will provide an immediate opportunity for that body to work with other government departments, but also much more widely to ensure that we genuinely have a joined-up approach to public health objectives. He will know that the public health outcomes framework, which has been drawn up to align itself as far as possible with the NHS outcomes framework, will be a powerful driver for improvement across the field of public health.

The noble Lord characterised the mandate as an uncosted wish list. I can tell him that it has been costed, and the NHS Commissioning Board itself was fully consulted before the mandate was drawn up, because it would clearly not be in anyone’s interests to task the board with delivering the unachievable. The board is aware that it will receive real-terms increases in the budget for the NHS—increases the NHS has received during every year of this Parliament. He referred to cuts. I want to emphasise to him that while we are aware that there are significant constraints at a local level, particularly at provider level, the overall budget to the NHS is not being cut; it is increasing, year by year.

The redundancy payments that unfortunately have been necessary of course represent ongoing annual savings from now on. It is always painful to make people redundant, but we deemed that it was absolutely necessary if we were to retain a sustainable health service. Every pound that we save will go straight back into front-line care.

The noble Lord mentioned the performance of the previous Government, and I am the first to pay tribute to the improvement in the health service that took place under that Administration—not least in waiting times. It is why we have explicitly said in the mandate that waiting times continue to matter. They matter to patients, they are clinically a valid measure of patient experience, and we have no intention of abandoning that metric.

The noble Lord also spoke about enforced competition. I should correct him on that because, as he will know from our debates on the Health and Social Care Bill, we believe that competition can sometimes be a tool for commissioners. We do not believe that it should be shoved down anybody’s throat. Competition, as Sir David Nicholson pointed out the other day, should be regarded as a rifle shot, rather than a carpet-bombing exercise. It should be used only where it is in the interests of patients, which is why the first duty of Monitor, the economic regulator of the health service, is to serve the interests of patients.

The noble Lord referred to partnership working, and I was absolutely in agreement with him that there needs to be partnership, not only at a local level between GPs, social care, secondary care providers, but at the level of the arm’s-length bodies. Chapter 7.3 of the mandate covers the latter aspect comprehensively. However, in Chapter 2, we also place great stress on integration of services, which was the subject of a number of debates in your Lordships’ House during the passage of the Bill. Primary care is covered in Chapter 9.2, which is one of the main areas that the board will be commissioning.

The noble Lord asked me about networks, which we debated a few days ago. They can take various forms. The strategic clinical networks, about which he asked me in his Oral Question the other day, embrace, as he knows, four major clinical areas where we believe that considerable change is required if we are to see services improved to the extent that they should be. However, that does not preclude other networks forming at a local level—for example, at provider level—to ensure that services are joined up. I am sure that we shall encourage those networks, wherever they are appropriate, but we are not mandating them.

The noble Lord asked me about measurable progress. Today, we are publishing an updated version of the NHS outcomes framework, which includes an appendix that sets out the detailed definitions for the majority of indicators. We will have robust metrics which we shall be able to use to measure health outcomes. Over the past few months, the Health and Social Care Information Centre has been publishing many of the data as they have become available. Publishing data for the indicators will, in itself, show whether outcomes are improving. In order to interpret progress, we will work with the NHS Commissioning Board and experts to develop a methodology for measuring progress. There is time enough to do that and I will happily keep the noble Lord informed as that work rolls forward.

[Baroness Northover]

My Lords, perhaps I may remind noble Lords that contributions and questions should be brief so that as many noble Lords as possible can participate. I also remind noble Lords that contributions will come from around the House so Members other than those in the Labour Party need to speak now. Maybe we could hear from the Cross Benches.

[Lord Walton of Detchant]

My Lords, I shall speak briefly, not least because before I knew about this Statement, I made an appointment to meet some major professional visitors at four o’clock this afternoon. I make my apologies to the noble Earl.

The general terms of this mandate are to be greatly welcomed. Its structure is attractive and its relationship to the future of the outcomes framework is very welcome indeed. I welcome the concentration on long-term conditions and their management, although it is important to mention that, whereas diabetes, hypertension and mental health are highlighted in the document, there are many other long-term conditions that need special attention, many of them neurological, such as Parkinson’s disease, multiple sclerosis, neuro-muscular diseases, and so on. I also welcome the emphasis on innovation.

My one major question relates to the very paragraph to which the noble Lord referred. Paragraph 9.2 states:

“The NHS Commissioning Board will be directly commissioning NHS services provided by GPs, dentists, community pharmacists and community opticians; specialised care; health services for people in custody; and military health”.

There are the two words, “specialised care”. We have had discussions about this before and my understanding is that the NHS Commissioning Board will commission directly highly specialised services but more general specialised services will be commissioned by the clinical commissioning groups. Indeed, paragraph 9.3 states:

“The Department will hold the Board to account for the quality of its direct commissioning, and how well it is working with clinical commissioners … An objective is to ensure that, whether NHS care is commissioned nationally by the Board or locally by clinical commissioning groups, the results—the quality and value of the services—should be measured”.

Therefore, is there not an incompatibility between these two paragraphs, one saying that all care will be commissioned by the NHS Commissioning Board, and the next paragraph modifying and qualifying that? I think that is a matter for clarification as the mandate goes forward.

[Earl Howe]

My Lords, I am grateful to the noble Lord for his welcome to the overall structure of the mandate and its content. I do not believe that there is an inconsistency between those two paragraphs. We have had a number of debates about specialised healthcare. I can confirm to him what I have said in the past: it will be the responsibility of the NHS Commissioning Board to commission services in relation to highly specialised conditions and, on top of that, those specialised conditions that are currently commissioned by the regional specialised commissioning groups. It is services for not only very rare conditions but slightly less rare conditions that the board will commission. That is a positive step that has been welcomed by the specialised healthcare community. We will spell out in regulations exactly what conditions are specialised conditions.

Paragraph 9.3 states that the way in which the board is held to account should be directly analogous to the way in which other commissioners in the health service are held to account. In other words, the board cannot expect not to be held to account by the department in a similar fashion. I hope that with that clarification, the noble Lord will be reassured.

[Baroness Jolly]

My Lords, I note that the mandate no longer sets quantifiable levels of ambition. The Minister explained how progress might be measured. There will be overarching indicators and improvement areas that will all match or mirror the five parts of the outcomes framework. Will my noble friend the Minister explain to the House how frequently progress is likely to be reported, and how it will be monitored by parliamentarians?

[Earl Howe]

I am grateful to my noble friend. The board will have to publish its progress against the objectives in the mandate. The Government will publish an annual assessment of its progress. We have set an objective for the board to demonstrate progress against all the indicators in the NHS outcomes framework. We will use a range of evidence to assess the board’s performance, including asking CCGs and other stakeholders for their feedback. This will be important, because it will provide the board and everybody else with a much more rounded view of how the health service is doing. The information will be publicly available, so everyone will be able to judge for themselves whether the NHS has achieved these stretching goals. In year, Ministers will hold the board to account. In particular, the Secretary of State will hold formal accountability meetings with the chair of the board every two months. Minutes of those meetings will be published. The meetings will be an opportunity to review performance and discuss issues as they arise, and as is right and proper.

[Lord Warner]

My Lords, there is much to welcome in this mandate, especially the points that the Minister made about mental health. Perhaps I may gently remind him that he and his Government will be able to send this patient information whizzing round the system and the country only as a result of the much maligned national spine that the previous Government put in place, along with a central contract. It is worth bearing in mind a little history.

The Minister said that this had been a masterly and costed exercise and that the NHS Commissioning Board had said that it could deliver the mandate within the finances available. Will he confirm that this means that the NHS Commissioning Board’s chief executive has accepted that he will have to deliver, through his new role, £20 billion in savings over four years—the so-called Nicholson challenge? We would like to know whether the Nicholson challenge includes that money.

Finally, I will follow up the point about specialist and specialised services made by the noble Lord, Lord Walton. The Minister may recall that in July the new president of the Academy of Medical Royal Colleges make the powerful point that we have far too many 24/7 acute centres. Will it be part of the Commissioning Board’s responsibility, with the money it uses to directly commission specialist and specialised services, to start to make progress on Professor Terence Stephenson’s suggestions that we need fewer specialised centres of a larger size?

[Earl Howe]

My Lords, I pay tribute to the noble Lord’s role in the NHS IT programme. He is right: we have a great deal to be thankful for in much of the IT that was rolled out under the previous Administration. It failed at a local level rather than a national level—it perhaps failed for honourable reasons—but that is history now and we need to move forward and find other ways of delivering the benefits which his Government identified and we are determined should be delivered at provider and commissioning levels. That is why there is emphasis in the mandate, in chapter 2.6, around technology because it is important that we have inter-operative systems at every level.

The noble Lord asked about the costing of the mandate and, in particular, the quality, innovation, productivity and prevention programme—or the Nicholson challenge as it is sometimes known. We refer to that on at least two occasions in the mandate, at chapter 6.4 and chapter 8.1. The NHS Commissioning Board has confirmed that it will continue to implement the Nicholson challenge and we will work with it to ensure that that happens.

As regards service configuration, the noble Lord will note that in chapter 3.4 we draw attention to that issue and, in particular, to the four tests that need to be met before service configuration can be considered acceptable. Those four tests must be determined locally and there must be a clinical buy-in to any reconfiguration of services. That is one of the most important features of the framework surrounding that area. We may well see fewer centres for a number of conditions but, if we do, it will not be through a top-down edict but because doctors and other health professionals think that it is the right thing to do for patients.

[Baroness Cumberlege]

My Lords—

--- Later in debate ---

[Baroness Cumberlege]

My Lords, I, too, congratulate the Government on the mandate. When we were debating the Bill, I requested that the mandate should be short, precise and well-focused, and it is all of those things. I particularly welcome the focus on the importance given to improving standards in maternity services. The mother’s experience and the start of life are very important and have a huge impact on the long-term well-being of children.

I wish to link the outcomes framework with the mandate. On the outcomes framework, at page 11 under “Trauma” we are told that this is an area for further improvement. It states:

“As part of the development of the placeholder ...‘improving recovery from injuries and trauma’ the indicator has now been defined as ‘Proportion of people who recover from major trauma’”.

That links very much with what my noble friend was saying earlier about expertise. The point I want to make on the mandate is that we are told that the objectives in the mandate can be realised only through local empowerment. The board’s role in the new system will require it to consider how best to balance different ways of enabling local and national delivery. These may include the duties and capabilities for engaging and mobilising patients, professionals and communities in the shaping of local services.

My concern is on A&E and the emergency services. With the NHS Commissioning Board having now appointed Tim Kelsey to look at communications, how can we get public leadership to understand that expertise in certain areas is very important for survival? The footballer Fabrice Muamba collapsed on the football field and passed several A&E departments to get to the one that saved his life because the expertise was there. Is there a requirement in the mandate that there should be a mobilising and further education of the community so that it understands what expertise is needed in order to save lives?

[Earl Howe]

My noble friend makes a series of extremely important points and I agree with everything she said about maternity services. Emergency services will be commissioned at a local level by clinical commissioning groups but that cannot be the end of the story. She rightly implied that paramedics and trauma care doctors require skills in sometimes very sophisticated techniques of maintaining life at the scene of an accident, for example, and hospital procedures. These skills must be maintained and improved. The short answer to her question is quite consciously missing from this mandate. This is the need for Health Education England to work very closely with the board because the Centre for Workforce Intelligence and Health Education England will have to ensure that we have not only the right numbers in the NHS workforce but those with the right skills and the right level of skills. As she rightly said, we also need to educate the public that the health service does not consist of a series of buildings; it consists of a network of services. We will have advanced considerably if the public can understand rather better than they generally do that the continuation and improvement of services matter, rather than bricks and mortar.

[Lord Kakkar]

My Lords, I declare my interest as Professor of Surgery at University College London Hospitals NHS Foundation Trust. I very much welcome the noble Earl’s indication that the five objectives of the mandate are now clearly linked to the five parts of the outcomes framework. However, successful and meaningful commissioning decisions will critically place intense focus on the development of metrics in the outcomes framework. Local commissioning will be completely meaningless without objective metrics set as part of the commissioning process at a local level and without the ability to measure those outcomes. With specific emphasis on chronic conditions, what progress has been made on integrated care pathway metrics for integrated care both in the community and in the hospital? If there is little progress, when will we ensure that we have integrated care pathway metrics available to ensure that we drive forward meaningful local commissioning decisions?

[Earl Howe]

The noble Lord has alighted on an extremely important area. We have been very careful in constructing the outcomes framework to make sure that we define deliverable outcome indicators. The NHS Commissioning Board is satisfied that the indicators are realistic but I have to be candid with him. This represents work in progress as the precise way in which the board will demonstrate that it has made progress against each of the indicators has not been defined in every case. I can assure him that it will be. It will be up to the board, however, to construct a system of local accountability to ensure that the clinical commissioning groups are held to account against realistic demonstrable indicators which match those of the NHS outcomes framework, not least in the area of chronic conditions. The patient pathway is work in progress, too, but much of its quality can be measured by reference to the patient experience. That is one of the central domains of the outcomes framework, on which a lot of work has been done. I would be happy to write to him on that.

[Baroness Jay of Paddington]

My Lords, perhaps I may press the noble Earl a little further on the part about IT in the mandate. My noble friend Lord Warner also referred to it. Would he develop a little the expectation in the mandate about developing the electronic patient record, which I feel is an aspiration rather than a practical reality if it is going to take place within two years? Can he help me by describing the way in which progress can be measured, and how is this to be achieved in a period when the pressure is on local resources and there is a dispersal to local responsibility which earlier he described as being a problem?

[Earl Howe]

There are several objectives around our wish to see more patients having access to their records, not only to enable them to order repeat prescriptions and make appointments with their GPs online, which many practices already enable, but also to access their own personal health records where they wish to do so. This, too, is a work in progress. Noble Lords do not need me to tell them that there are clear confidentiality issues involved in this area. What we cannot have is a system that is open to breaches of security. However, work is going on with the Royal College of General Practitioners and the British Medical Association on that point. We have said that it is our ambition that everyone should be able to access their GP records online by 2015. That is the ambition and we think that it is achievable. However, once again I would be happy to keep the noble Baroness updated as work continues.

[Baroness Williams of Crosby]

I thank the noble Earl for the imaginative and humane part he has played in producing this mandate and say that it adds even further to what is already a remarkable record. I want to put two questions to him about the fourth objective in the mandate which in a sense will complement what he has already said about new technology, as well as what the noble Baroness, Lady Jay, has said about it. I want to ask him about two more specifically human aspects that fall under the fourth objective.

The first is the great importance of training health assistants to meet some of the responsibilities of their role in terms of communicating with patients. We are now putting a heavy burden of responsibility on health assistants who, of course, are not fully trained nurses and therefore are not trained in communicating with patients. Secondly, perhaps I may draw his attention to a specific area of what I think is serious failure in the NHS and its relationship with local government, and that is the field of rehabilitation, which is now probably one of the weakest areas in terms of trying to assist patients and give them a good experience of the NHS.

[Earl Howe]

My noble friend is absolutely right to raise both of those issues. On healthcare assistants, I can confirm that the work by Skills for Health and Skills for Care is proceeding in a very encouraging way. We are still on track to deliver a system that will enable healthcare assistants to become accredited on a voluntary basis to a register, and that is obviously a welcome step in the direction of ensuring that we can upskill the workforce both in secondary care settings and in social care. However, much will still depend on nurses in those settings to supervise healthcare assistants, and we look to the management of hospitals and care homes to ensure that proper supervision is conducted and, indeed, that there is proper training at the bedside and in the care homes of elderly people. Again, this is work in progress, but I am glad to say that the progress is real and encouraging.

On rehabilitation, my noble friend is absolutely right to say that we need to ensure that NHS continuing care and social care recognise the importance of ensuring that patients recover quickly. It is our ambition that the patient experience should be published and a measure of the quality of the service that is being delivered. Over the past two years we have made available considerable additional resources to local authorities and we will continue to do that so as to ensure that their budgets are not put under as much strain as they would otherwise be, and thus enable them to deliver these very important services.

Health: Obesity

Earl Howe Excerpts

Monday 12th November 2012 Lords Chamber

[Baroness Cumberlege]

My Lords, I beg to ask the Question standing in my name on the Order Paper. In so doing, I declare my interests as set out in the House of Lords register. Perhaps I ought to add another: I love my food.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the Quality and Outcomes Framework already includes obesity. The process for reviewing clinical and public health indicators in that framework is overseen by the National Institute for Health and Clinical Excellence, which recommends changes annually for consideration as part of the GP contract discussions. NICE will continue to lead on this process but from April 2013 priorities for public health indicators will be set by Public Health England in consultation with the devolved Administrations.

[Baroness Cumberlege]

My Lords, I thank my noble friend for that full Answer. Does he agree that one of the successes in primary care has been the introduction of the Quality and Outcomes Framework, which incentivises GPs? Unfortunately, one of the incentives is to keep a register of obese patients—nothing else, just a register. In fact, that incentivises them to keep people fat. Does my noble friend also agree that obesity, which is forecast to cost the nation, or the NHS, £45 billion, needs prompt action? Will he assure me that under the new reforms that he just mentioned, Public Health England will prioritise the development of these indicators in the Quality and Outcomes Framework?

[Earl Howe]

My Lords, as my noble friend knows, the Secretary of State will set the strategic objectives and policy priorities of Public Health England. It will have operational autonomy and operate transparently. Rates of obesity remain high across England and continue to have clear links to health inequalities. GPs can play a key role in making every contact count by raising the issue of obesity and providing advice or referral to appropriate services, so I do not necessarily accept the criticism that my noble friend levelled at the current QOF indicators. GPs have every reason to act when they see obesity in front of them. I cannot pre-empt exactly what Public Health England will wish to prioritise in the development of the QOF, but I fully expect that it will want to work with NICE to review the evidence base for building on the current QOF obesity indicator.

[Lord Hunt of Kings Heath]

My Lords, I am sure that the noble Earl will agree that action on obesity is best taken when different government departments play their part. If he accepts that, does he regret the abolition of the Cabinet sub-committee on public health?

[Earl Howe]

My Lords, the role of Public Health England will undoubtedly stretch across government departments, because it should and will involve energising the efforts of not just the Department of Health and at not just national level. However, I agree that there is no single magic bullet to solve the problem of obesity. The call to action on obesity published last year set out a range of actions in which government and individuals, as well as local organisations, need to engage if we are to beat this threat to public health.

[Baroness Finlay of Llandaff]

Are the Government considering including in commissioning from health service employers a requirement to address obesity in their staff at all levels, given that the staff are often quite severely obese and act as a very poor role model for those patients whose obesity should be being addressed?

[Earl Howe]

My Lords, this is a very important point. Dame Carol Black and I chair a network within the responsibility deal in the Department of Health which draws together employers from a range of sectors to address health in the workplace. It is a tremendously important opportunity if we can engage employers to realise that it is in their direct interest to ensure that their employees enjoy good health and lead healthy lifestyles.

[Lord McColl of Dulwich]

My Lords—

--- Later in debate ---

[Earl Howe]

I congratulate my noble friend, as ever, on his powerful advocacy in this area. He is absolutely right that NICE recognises in its guideline that dietary management, including calorie intake, is of predominant importance in battling obesity. It does, however, recognise that exercise is important. It emphasises that although an individual’s ability to be physically active may be hampered by their level of fitness, recommendations can be built up gradually. It is a balance. NICE will continue to act as a source of advice for the medical profession. It is an independent organisation, as my noble friend understands, and Ministers consciously do not interfere with its operational integrity or independence. However, we expect it to take advice and evidence from a range of clinical sources.

[Lord Foulkes of Cumnock]

My Lords—

--- Later in debate ---

[Lord Foulkes of Cumnock]

My Lords, I, too, have an interest to declare; I think it is fairly obvious if you look at me. That is why I want to ask a serious question of the Minister. Will he say to medical practitioners and others that it does not help to be critical and condemnatory of those of us who are obese? It is important to give information and encouragement. Otherwise, there can be complications and people can end up with depression and other illnesses, so it is very important to give encouragement. I am glad to say that that is why I have been able to lose more than a stone in the past month.

[Earl Howe]

Not for the first time, the noble Lord is an example to us all. I agree with the point he makes about the way in which doctors engage with their patients on this often sensitive subject. That is why the previous Government very commendably put in place a suite of resources to guide GPs in this area. Those have since been supplemented by electronic training modules on the identification and management of obesity and supporting behaviour change in patients. NICE has produced a clinical guideline to supplement its advice on obesity and exercise to guide clinicians on exactly how they approach this topic.

NHS: Death at Home

Earl Howe Excerpts

Thursday 8th November 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I congratulate the noble Lord, Lord Warner, on securing this debate and on his excellent speech. Indeed, we have listened to a series of moving and powerful speeches throughout the debate, which I, for one, greatly appreciate. We have heard of a number of excellent experiences of care for people approaching the end of their lives. Unfortunately, there have also been reported some much less happy experiences, not least those referred to by the noble Lord, Lord Blair, and the noble Baroness, Lady Masham.

I know that the noble Lord, Lord Warner, is a keen supporter of better end-of-life care services, and I confirm to him immediately that the Government are committed to developing and supporting end-of-life and palliative care services, to ensure that the care people receive, whatever their diagnosis and wherever they are being cared for, is compassionate, appropriate, good quality and supports the exercise of choice by care users. That position is common to all speakers this afternoon.

As noble Lords have so eloquently said, we know that most people would prefer to be cared for and die at home, in familiar surroundings, with their family and friends, and this can also mean a care home where that has become someone’s home. However, we also know that most people die in hospital, the place where many would least prefer to be. Realistically, as the noble Lord, Lord Dubs, pointed out, many people will continue to die in hospital. They may be too ill to be anywhere else, they may need specialist care, they may have an illness that quickly takes hold, or it may be their choice to do so, following discussions with their families and care professionals about their health and care needs. Because of this, we continue to work to ensure that hospital care improves and much encouraging work is being done on this, including through the National End of Life Care Programme’s Transform programme for acute trusts. This will really improve services, integration and, ultimately, people’s experiences.

However, as the noble Baroness, Lady Masham, movingly reminded us, many people die in hospital unnecessarily and more could be cared for and die at home if resources were in the right place and if systems enabled services to be provided where and when they were needed. We made the commitment in the White Paper, Equity and Excellence: Liberating the NHS to,

“move towards a national choice offer to support people’s preferences about how to have a good death”.

Liberating the NHS: No Decision About Me, Without Me reiterated our commitment to introducing a right to choose to die at home, including a care home, when services are well enough developed to allow that to be a realistic offer so that people have access to appropriate, high quality care. Responses to the Liberating the NHS: Greater Choice and Control consultation demonstrated strong support for this.

This choice has, of course, to be within the current legal framework. For choice to become a reality, commissioners and providers need to ensure that quality services, especially in the community, are available. A lot of work is needed in order to enable this to happen, but we are making steady and encouraging progress. The latest data show that 42.4% of people now die in their usual place of residence—that is, at home or in a care home—where people say they want to be. I take the point of the noble Lord, Lord Warner, about local variation, which we must certainly tackle and will, through the strategy, but we can compare that figure to 2008, the year the Department of Health’s end-of-life care strategy was published, when 38% of people died in their usual place of residence. In contrast to that, just over half die in hospital. Again, that’s a big improvement from 2008, when about 58% of people died in hospital. This means that almost 30,000 extra people have been able to die in the community, where they wanted to be. For each of those people, for each of their friends and family members, that is a huge comfort.

The steady progress has been the result of much hard work by many health and social care professionals, all underpinned by our ongoing work to implement the end-of-life care strategy. Your Lordships will know that the strategy received cross-party support when published in 2008. It aims to improve care for people approaching the end of life, whatever their diagnosis and wherever they are, including enabling more people to be cared for and die at home if they wish. On 16 October, we published the strategy’s fourth annual report, which describes in detail the work being undertaken. This can be found on the department’s website and I commend it to your Lordships as a good and encouraging read, but I want to highlight two key areas.

Electronic palliative care co-ordination systems allow people to express their preferences for care, to ensure proper care planning and for that care to be co-ordinated. The noble Lord, Lord Low, and the noble Baroness, Lady Masham, in particular, will welcome this. The EPaCCS contain key patient information and are intended to be accessible to all appropriate service providers, including ambulance services, out-of-hours services, A&E and community services. I believe that they have the potential to improve communication, co-ordination and the planning and delivery of care. More than 30 EPaCCS are now implemented or in development around the country and the rollout is continuing.

I also want to mention VOICES, the first ever national survey of bereaved relatives, helping us to understand how people actually experience care at the end of life and giving commissioners an invaluable critique of services. A critical common theme of these and other activities is communication between services, between organisations and, most important, between patients, their families and health and social care professionals. The noble Baroness, Lady Finlay, was wholly right in drawing attention to this, as she was on so much else in her excellent speech. I cannot overemphasise the part it plays in improving care at the end of life to the benefit not only of the patient, but of the bereaved.

On Monday, the Government launched a consultation on a range of proposals for strengthening the constitution, drawing on the recommendations of the NHS Future Forum. I was particularly appreciative of the comments of the noble Viscount, Lord Craigavon, on those proposals. One of the forum’s recommendations was that the constitution should be much stronger on patient involvement and shared decision-making. We agree. Our proposals make several important changes here—strengthening principles, rights and pledges. In particular, I say to the noble Baroness, Lady Masham, that we also set out a new responsibility on NHS staff to involve patients, their families and carers and to treat patients not only well but compassionately. But we go further by proposing to include end-of-life care in the constitution for the first time.

First, as mentioned by the noble Lord, Lord Hunt of Kings Heath, we propose to strengthen the right of patients, their families and carers to be involved fully in discussions and decisions about their health and care, including their end-of-life care. This draws on the new statutory duties on commissioners to promote the involvement of patients set out in the Health and Social Care Act 2012.

Secondly, we propose to introduce a new pledge on care planning. This sets out a commitment by the NHS to involve patients in discussions about planning their care and to offer them a written record of what is agreed if the patient wants one. This would apply to patients with long-term conditions or at end of life.

The Government believe in and fully support the constitution. We have identified a range of proposals to strengthen it. As part of this, we feel it is helpful to make clear to patients what they are entitled to expect from the NHS at the end of life.

The noble Lord, Lord Blair, the noble Baroness, Lady Greengross, and the noble Viscount, Lord Craigavon, among others, drew attention to the need for there to be awareness of people's wishes at the end of life and to give informed choice to patients. To be able to have real choice, people need to understand what their options are and have proper discussions about the issues around end of life care. But that is constrained by our general lack of willingness to discuss death and dying. That is why we are supporting the Dying Matters Coalition, which is encouraging discussions among the public and raising awareness of end-of-life care issues. That is a particularly welcome development.

A number of noble Lords referred to the draft mandate, including the noble Baroness, Lady Greengross, the noble Lord, Lord Warner, and my noble friend Lord Howard of Lympne. We are aware of the concerns that have been raised during the consultation process that the draft mandate did not include end-of-life care. It is being given careful consideration as we come to finalise the mandate over the coming days.

My noble friend also referred to uncertainty over the future of state funding for hospice care. I would like to acknowledge today the important role of the hospice sector, particularly its valuable contribution to care in the community such as hospice at home services. My noble friend will be familiar with the work that we are taking forward on the development of a per-patient funding system. The aim of the department’s work on palliative care funding is to develop a per-patient system. The work will build on that of the independent palliative care funding review. The new funding system that we are aiming to develop and introduce will cover care regardless of which organisation provides it, encourage more community-based care so that people can remain in their own homes and be fair and transparent to all organisations involved in end-of-life care. The aim is to have a new system in place by 2015, which I hope is of some reassurance to the right reverend Prelate the Bishop of Norwich.

The noble Lord, Lord Hunt, asked about free social care at the end of life, as recommended by the palliative care funding review. In the care and support White Paper we stated:

“We think there is much merit in providing free health and social care in a fully integrated service at the end of life”.

The White Paper went on to say:

“We will use the eight palliative care funding pilot sites to collect the vital data and information we need to assess this proposal, and its costs, along with the Review’s other recommendations. A decision on including free social care at the end of life in the new funding system will be informed by the evaluation of the pilots, and an assessment of resource implications and overall affordability”.

The noble Lord, Lord Low, mentioned his wish that the constitution should cover test and treatment options and care planning. On this, as on a number of other issues, including the Liverpool care pathway, I am afraid that time prevents me from replying as I have just been reminded of the clock. However, I assure noble Lords that I shall write on points that I have not covered.

For the future, we have committed to undertake an evaluation of the progress we have made. This will take place in 2013. It will inform us when the introduction of a right to choose to die at home, including a care home, might realistically be feasible. We are currently considering how this evaluation might best be undertaken. I will ensure that your Lordships are kept fully up to date with this work once it has commenced. Your Lordships can be reassured that we remain committed to continuing our work to improve quality and choice in end-of-life care.

House adjourned at 6.27 pm.

Health: Cancer

Earl Howe Excerpts

Wednesday 7th November 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, £42 million has been allocated by the NHS Commissioning Board to support strategic clinical networks in 2013-14. Networks will cover a number of priority conditions and patient groups, including cancer. It is for local health communities and the board to determine the number and size of networks, based on patient flows and clinical relationships, and to deploy their resources appropriately.

[Lord Hunt of Kings Heath]

My Lords, does the noble Earl accept that cancer networks have done an outstanding job in improving the quality of service and outcomes? Does he agree that there is widespread expectation that the number of cancer networks will be reduced, the staff in many places will be made redundant and the new set-up will not be as effective as the current one? Will he respond to that?

[Earl Howe]

My Lords, I agree that clinical networks are a success story in the NHS. They have raised standards, supported easier and faster access to services and encouraged the spread of best practice. We very much want to see that continue. The final number of strategic clinical networks and the number of clinical staff who support them have not been finalised yet. Those numbers will be determined locally so it is too early to speak with any certainty about final staff numbers. We do not anticipate many compulsory redundancies at all. A number of staff have been deployed to other posts already. The aim of all this is to achieve not only a more effective series of networks but a more efficient system as well. We believe that that will be delivered.

[Baroness Morgan of Drefelin]

My Lords, I, too, declare an interest, as chief executive of the Breast Cancer Campaign. Does the Minister agree with the charities Cancer Research UK, Macmillan, and Cancer 52—which represents the rare cancer charities—that this is a real issue of concern? The uncertainty is causing a real haemorrhaging of expertise out of the networks that have been such a success in driving up standards in cancer services.

[Earl Howe]

My Lords, I accept that the uncertainty has been unfortunate and, in some cases, damaging. The noble Baroness is right in her broad observations. However, the intent to maintain networks was signalled very early on this summer by the Commissioning Board. The standard operating framework, which will apply to all clinical networks, will be published very shortly. I think that that will provide helpful additional clarity. However, I repeat to the noble Baroness that the aim here is to maintain networks and to ensure that the good work continues and that the expertise which we still have in networks is translated across into the new system.

[Lord Clement-Jones]

My Lords, the NHS strategy document The Way Forward stresses that, as regards cancer, the new networks will focus very tightly on what is called domain 1 of NHS outcomes, which is reducing mortality. But surely for all those who have experience of cancer, is not enhancing the quality of life absolutely crucial too, and should not the networks be concentrating on that as well?

[Earl Howe]

Yes, my Lords. While the document to which my noble friend refers does make explicit that the cancer strategic clinical network will be focused around domain 1, which is reducing mortality, nevertheless improvements to patient experience and patient safety underpin all NHS care and those matters will be similarly embedded in the work of all strategic clinical networks.

[Lord Turnberg]

Does the noble Earl agree that the cancer networks have been invaluable in supporting research into new treatments and that any reduction here would be regrettable?

[Earl Howe]

I absolutely accept that one of the benefits we have seen from the clinical networks is the spread of innovative best practice through the health service, particularly in local areas. That is very much what we wish to preserve. The networks will help local commissioners of NHS care to reduce unwarranted variation in services and encourage innovation. We are determined to see that continue.

[Lord Patel]

As the Minister responsible for quality outcomes in healthcare, will the noble Earl report to the House on whether he is monitoring the effects on cancer outcomes of the reduction in the staffing of cancer networks?

[Earl Howe]

We will certainly be monitoring the outcomes in the field of cancer, but I would just like to impress upon the noble Lord that the creation of the clinical support teams—the network support teams—will ensure that the whole service is more efficiently delivered. By having 12 support teams there to underpin all the networks, we will ensure that we have a more cost-effective system.

[Baroness Masham of Ilton]

My Lords, does the Minister agree that our cancer outcomes are not as good as those in some other countries in Europe? What is the reason for that? Does he agree that it would be a very retrograde step if the cancer networks lost expertise which we badly need?

[Earl Howe]

I agree with the noble Baroness, and it is part of the reason why we felt that the recent health service reforms to align clinical decision-making with financial decision-making were so important. The reason why this country lags behind has been clearly set out in a number of documents and, broadly speaking, it is because patients do not present early enough with their symptoms and doctors do not refer early enough to specialist consultants for treatment. There is a lot of work to do there, and I am sure that the noble Baroness will be reassured to know that there will be no let-up in that area.

[Lord Colwyn]

My Lords, we are five, six or seven minutes into this Question, but I am not sure I understand what a cancer network is.

--- Later in debate ---

[Earl Howe]

My Lords, the essence of a cancer network is the web of relationships between individual clinicians. Networks are a source of advice and support and they are there to drive quality improvements locally. The networks will be established to cover patient groups or conditions where improvements to services can be made through an integrated approach. I hope that I have emphasised sufficiently that networks are there to support commissioners in their work.

NHS: Women Doctors

Earl Howe Excerpts

Tuesday 6th November 2012 Lords Chamber

[Baroness Hollins]

My Lords, on behalf of my noble friend Lady Deech, and at her request, I beg leave to ask the Question standing in her name on the Order Paper.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, over the past 10 years, from 2001 to 2011, the number of female doctors in the National Health Service has increased by 75%. Female consultants have increased by 105%, female registrars by 288% and female GPs by 58%. The Government, in partnership with other organisations, including NHS employers, the NHS Leadership Academy and royal colleges, support good working practices, such as flexible working, job sharing and part-time working, which support the retention of female doctors.

[Baroness Hollins]

Is the Minister aware that part-time training in the NHS is becoming much less available because of workforce pressures and difficulties in filling hospital rotas? Now that the majority of medical students are women, does he agree that the challenge is how to support those doctors who wish to work part time, perhaps while their families are young or while they have other caring responsibilities, and then to support them to move between full-time and part-time work that makes proper use of their talents and training? I declare an interest as president of the BMA and also as someone who worked part time for seven years as a trainee doctor.

[Earl Howe]

My Lords, I agree with the noble Baroness. I think this is less of a problem with retention of female doctors than a problem with the career progression of female doctors, which is a serious and significant issue. The noble Baroness, Lady Deech, published a very well argued report about three years ago, and a number of worthwhile initiatives have been started as a result of that. I do think that these need greater focus with more support at a higher level. Women are in a significant minority in more senior leadership roles in the NHS, and that is a loss all round.

[Baroness Cumberlege]

My Lords, I declare an interest, and my interests are in the register. Does my noble friend agree that some of the brightest women in the land choose a medical career and are well equipped to take on positions of leadership? Does he also agree that they are under-represented on the boards of the new clinical commissioning groups? Can he suggest to the national Commissioning Board that it examines this issue before authorising the individual boards?

[Earl Howe]

My noble friend makes a very important point. There is good evidence that women doctors make safer decisions, are often better at communication than men and understand better the needs of women, and we need them to inspire the next generation of women doctors. Therefore, to fish for clinical leaders from half the talent pool is not a sensible thing to do. As for CCGs, my noble friend makes a very important point. The NHS Leadership Academy has established development opportunities, including action learning sets for female CCG leaders. But we recognise that more work is needed at a system level to aid progress in this area.

[Baroness Afshar]

My Lords, do we have any details about minority women in high positions in the medical profession? Many minority women, particularly Muslim women, would prefer to be seen by a woman expert if they can possibly do so, and it is a matter of regret that very often they cannot.

[Earl Howe]

The noble Baroness raises another very important issue. Unfortunately, I do not have any information in my brief on that point, but if I can obtain it I shall be happy to write to her.

[Lord Sharkey]

Does the Minister agree that monitoring the number of women in leadership roles in the NHS from consultant upwards will be a marker of appropriate career progression?

[Earl Howe]

Yes, indeed, my Lords. The noble Baroness, Lady Deech, raised that in her report as an action point. It can be done at a trust level or at a higher level in the health service. But it is certainly important to monitor—I understand that the term is “credentialing” —the skill sets of those doctors, who may move out of the health service and want to move back in again, so that jobs can be found for them more easily.

[Baroness Wheeler]

My Lords, I am sure the Minister will agree that recruiting women into the medical profession is just as vital as retaining them once they are trained and working. Given the high costs of university fees and the burden that these place on young people, particularly those from poorer backgrounds and those with family and caring responsibilities, how will the Government ensure that women are not put off applying to medical school?

[Earl Howe]

My Lords, there is no evidence that there is a problem with female recruitment into the health service. Indeed, the male-to-female gender balance over the past few years has decreased from 1.83:1 in 2001 to 1.25:1 in 2011. However, I recognise that we should not be complacent. Even with the increased participation of women in medicine, we appreciate that more can be done to improve the selection of senior doctors into senior positions.

[Lord Ribeiro]

My Lords, I declare an interest as a member of the committee chaired by the noble Baroness, Lady Deech. In 1998, I introduced the first job-sharing scheme for female trainees in London and Essex. This involved two girls who both had children and managed to complete their training before the 48-hour week was introduced. What efforts are the Government making to encourage job-sharing and less than full-time training?

[Earl Howe]

My Lords, the Government fully support flexible working. We encourage organisations to take account of the recommendation made by the noble Baroness, Lady Deech, on that subject and adopt working arrangements that are amenable both to doctors who are parents and doctors who are carers.

[Lord Patel]

My Lords, first, I declare an interest. In my family there are four women doctors—I do not call them “girls”. They are all higher achievers than I could ever be. Does the Minister agree that there are in some of the most demanding specialties more women doctors in higher positions than in some of the other specialties and that in the specialties where there are not, it is the attitude of the senior doctors—possibly even male doctors—that is the problem?

[Earl Howe]

I discussed this subject in my briefing with departmental officials. There are multiple and quite complex barriers to career progression, including a conflict of roles between someone’s clinical responsibilities and their domestic responsibilities. There are structural barriers, as I have mentioned, in relation to part-time work, and in terms of general practice there is the sessional GP contract, which is another barrier to progression. The lack of role models is a factor and we should not overlook individual and organisational mind-sets, to which the noble Lord alluded, which result in lower personal aspiration in this area.

NHS: Liverpool Care Pathway Inquiry

Earl Howe Excerpts

Monday 5th November 2012 Lords Chamber

[Baroness Knight of Collingtree]

To ask Her Majesty’s Government what procedure will be adopted in carrying out the proposed NHS inquiry into the Liverpool Care Pathway.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, there is no procedure, as there is no such inquiry. A number of organisations, led by the National End of Life Care Programme, Dying Matters and the Association for Palliative Medicine, are looking into complaints, patient experience and clinical opinion on the Liverpool Care Pathway. We do not make policy decisions based on anecdote. If the work in hand suggests cause for concern, we will respond on the basis of that evidence.

[Baroness Knight of Collingtree]

My Lords, is my noble friend aware that large numbers of people with personal experience of how the LCP is now operating complain that their relatives were denied hydration in hospital and died in acute pain and discomfort, with no knowledge whatever or agreement of having been put on this pathway? Is he aware that patients often survive if relatives step in in time and give their dear ones help and water? One rang me a few days ago and she is now going on a cruise. Will my noble friend assure us that there will be an inquiry, which has been promised and announced in the press, and that it will be truly independent and not carried out by those who have vested interests? Nothing else will do.

[Earl Howe]

My Lords, there is never any cause for complacency in a matter of this kind, and I can reassure my noble friend that the Government will keep this issue under review. At the same time, I hope she will allow me to respond in slightly more forthright terms than I normally do, because there has been an enormous amount of misreporting and misinformation around the Liverpool Care Pathway, which has been endorsed publicly in a consensus document by 22 of the leading professional organisations and patient organisations in this area, including Marie Curie. We cannot ignore that. As I mentioned in my Answer, some of those organisations are looking carefully at the reports to which my noble friend alluded. It is notable that not a single complaint has reached the regulators in this area, which I suggest indicates that there may be less substance to some of these stories than may first reach the eye. However, I emphasise that there is no complacency.

[Lord Alton of Liverpool]

My Lords, as the noble Earl comes to look at the consultation on the National Health Service constitution over the coming months, will he take the opportunity to look at the care pathway in Liverpool itself, where last week I was able to meet Professor John Ellershaw and those who devised the pathway? Given that 80,000 patients a year are treated on the pathway, does the Minister accept that it works very well for many of them; that while the philosophy is not the problem, the procedures used in some places have been; and that one of the principal concerns is dehydration? Does he agree that that is something to be looked at, as well as the level of training of those doctors who are responsible for the palliative care of people at the end of their lives?

[Earl Howe]

My Lords, I fully agree with the noble Lord. Training is integral to the care pathway, as is the need to consult the families of patients and, if possible, the patients themselves before a decision is taken to put them on the Liverpool Care Pathway. On the NHS constitution, I completely take the noble Lord’s point. The proposed change to the NHS constitution makes it absolutely clear that patients and their families and carers have the right to be fully involved in discussions and decisions about their care, including that at the end of life. We are clear that that should already be happening, but we understand from reports that that is not always the case. As regards end-of-life care, I think there is sometimes a taboo on discussing death and dying and press reports show how damaging that can be. I shall indeed take all the noble Lord’s points on board, particularly as regards nutrition and hydration.

[Baroness Wall of New Barnet]

My Lords, I am relieved by the Minister’s response to the noble Baroness, Lady Knight. He is absolutely right that the care people receive at the end of their lives is hugely important. National statistics show that 29% of eligible people are on the care pathway. In my own trust, Barnet and Chase Farm, 28% of people are currently on it. The involvement of carers in those discussions is huge and a whole protocol is attached. I, too, am extremely worried about the publicity, some of which I am sure is well meant, but it can be very damaging to a system that provides a great deal of care. My mother-in-law was on the Liverpool Care Pathway in Liverpool hospital and had a very good experience. Please can we ensure that in any discussions we look at the overall benefit to elderly people at the end of their lives?

[Earl Howe]

The noble Baroness is quite right. So often, good experiences are not reported. Predominantly we hear from patient organisations and the Marie Curie organisation that in the vast majority of instances where the Liverpool Care Pathway has been used, it has resulted in better care for the dying person. She is absolutely right. Nevertheless, where the pathway is not being properly followed, we have to take the matter seriously and ensure that there is proper training and communication with care staff.

Mental Health (Approval Functions) Bill

Earl Howe Excerpts

Wednesday 31st October 2012 Lords Chamber

Moved By

[Earl Howe]

That the Bill be read a second time.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the purpose of this Bill is simple but urgent and vital. On Monday, I described to noble Lords how the need for it arose and came to light. I am glad to have this opportunity to continue that discussion today.

[Lord Skelmersdale]

My Lords, I hesitate to interrupt my noble friend on the Front Bench but it would be helpful to those noble Lords who want to listen to what he has to say about this important Bill if other noble Lords were to leave the Chamber silently.

[Earl Howe]

My Lords, I am grateful for that. I am glad to have this opportunity today to continue the discussion and explain further why we believe we must take this action. I begin by repeating my deep gratitude to noble Lords on all sides of the House for the highly constructive, sensitive and helpful approach that they are taking to this issue. Were it not for that, we would not be able to respond with the speed needed to resolve matters in the best way available to us and the best interests of patients.

As noble Lords appreciate, detaining a mentally ill person in hospital and treating them against their will is clearly a matter of the utmost seriousness, and must be treated as such both by the law and by health and social care practitioners. The statutory framework is contained in the Mental Health Act 1983, which sets out that for assessments and decisions under certain sections of the Act—including detention decisions under Sections 2 and 3—three professionals are required to be involved: two doctors and an approved mental health professional, usually a social worker. One of the two doctors must be approved under Section 12 of the Act.

To recap, when strategic health authorities were established in 2002, the Secretary of State at the time quite properly and lawfully delegated to them his function under the 1983 Act of approving the doctors able to be involved in making these decisions. Early last week, the Department of Health learned that in four of the 10 SHAs—North East, Yorkshire and Humber, West Midlands and East Midlands—the function of approving clinicians had been further delegated by the SHAs to NHS mental health trusts over a period extending, in some cases, from 2002 to the present day. The issue was identified as a result of a single doctor querying an approval panel’s processes. Ministers were informed later in the week as soon as the extent of the issue became clear and since then have been kept informed of and involved in the action being taken. Our current assessment is that about 2,000 clinicians were not approved properly in line with the provisions of the 1983 Act and that those clinicians have participated in the detention of between 4,000 and 5,000 of the patients currently detained in NHS or independent sector hospitals.

There are two important points to make clear now: first, the decision to detain a patient under the Mental Health Act is primarily a clinical one. There is no suggestion and no reason to believe that the irregularity of the approval process for these clinicians has resulted in any clinically inappropriate decision being made, whether the decision was to detain or not. Nor is there any suggestion that the clinicians approved by mental health trusts are anything other than entirely properly qualified to make these recommendations. All the proper clinical processes were gone through when these patients were detained. There is no reason why the irregular approval process should have led to anyone being in hospital who should not be—or vice versa—and no patients have suffered because of this. The clinicians had no reason to think that they had not been properly approved. They acted in total good faith and in the interest of their patients throughout this period.

As of Friday last week, the SHAs concerned had corrected their procedures and all the clinicians involved had been properly approved. In the light of our legal advice, we do not believe that any decisions that have been made about patients’ care and detention require review because of this irregularity. Doctors should continue treating patients who are currently detained under the Mental Health Act in the usual way.

The second point I want to make is that we have been advised by First Treasury Counsel that there are good arguments that the detentions involving these particular approval processes were, and are, lawful. Given the seriousness of the issues, counsel also argues the need for absolute legal clarity and advises that this is most safely resolved through emergency retrospective legislation. We are heeding that advice. As soon as the irregularity was identified, the department moved swiftly to identify the best course of action and to put the necessary preparatory work in place. Officials immediately sought initial legal and clinical advice and swiftly analysed the options, including the reassessment of all the potentially affected patients, working with the health leads in the regions involved and clinical experts from the Royal College of Psychiatrists.

When the Secretary of State was briefed on the situation, he asked for detailed information on the time it would take and the clinical risks involved in reassessing all potentially affected patients. Last Friday, he asked for an emergency Bill to be drafted over the weekend, as a matter of contingency. He briefed the Prime Minister personally the following day. Following further discussions and analysis over the weekend, the decision to introduce emergency legislation was taken on Sunday.

At all times, our priority has been to resolve this in a way that follows clinical advice about the most sensitive way to deal with a highly vulnerable group of individuals. It would not have been feasible quickly to reassess all the patients and could well have caused great distress to them and their families.

We have also worked to remedy the problem as it relates to current and future detentions. The accountable officers for the four SHAs in question have written to Sir David Nicholson, chief executive of the NHS, to confirm they have made the necessary changes to their governance arrangements. Furthermore, the accountable officers in the other six SHAs have written to Sir David to confirm that they have, in the light of this issue, reviewed their own arrangements and that they are in full compliance with the Mental Health Act.

Our best medical advice is that all the detained patients who have been affected and, where appropriate, family members, should be informed, but first we need to consider carefully how best to give people all the information and advice that they are entitled to in ways that do not cause unnecessary confusion or distress, so we need to take a little more time to make sure we get that right. Sir Bruce Keogh, the NHS medical director, will write shortly to SHA medical directors with further advice, which will be informed by the view of clinical experts and organisations representing detained patients and their families. It is vital that doctors, other mental health professionals and, most importantly, patients and their families have absolute confidence in the decisions made.

I am also aware that Mind and Rethink Mental Illness are providing very helpful advice to patients and their families and carers through their information lines and on the websites. This is just one aspect of the valuable assistance they have provided in dealing with this matter, and I am very grateful to them for it.

I will turn now to the scope of the Bill. Although we are aware of the problem only in the four areas going back to 2002, the Bill applies in principle to the approval of all clinicians under the Mental Health Act since its introduction in 1983. It retrospectively validates the approval of clinicians by those organisations to which responsibility was delegated up to the point when all the relevant clinicians were fully reapproved and their status put beyond doubt.

I would like to clarify who this Bill is targeted at. The “persons” referred to in Clause 1(1) are those who have exercised the approvals function only—no one else, and no other function—under the Mental Health Act 1983. Although it addresses a very particular issue, the Bill deliberately avoids going into further detail about which persons it applies to. Attempting to include a totally comprehensive list of which bodies or people believed in good faith that they were exercising the approvals function in the past would have created what we believe would have been an unacceptably high risk of omitting agencies or individuals that should have been included.

Although the Bill may appear to bestow a wide-ranging retrospective validation on “any person”, in fact, it is very narrowly targeted. It validates only any approvals given in the past and relates only to the function of giving approvals to clinicians as having particular skills—for example, as having special experience in the diagnosis or treatment of mental disorder. Once approved, the clinicians are then allowed to carry out certain functions under the Mental Health Act, such as giving medical recommendations in relation to a patient whose possible detention is being considered. The Bill helps to ensure that we regularise the situation completely and finally.

Crucially, the Bill will not deprive anyone of any of their normal rights to seek redress if they have been detained for any other reason apart from the narrow issue of the delegation of authority to approve by the SHAs. Nor will it affect any future detentions or legitimise any similar failures in future.

Necessary as we believe that it is to address the issue in this way, it is also important that we get to the bottom of how this happened. Therefore, the Secretary of State has asked Dr Geoffrey Harris, chair of NHS South of England and former chair of Buckinghamshire Mental Health Trust, to undertake an independent review looking at how this responsibility was delegated by these four SHAs and, more broadly, the governance and assurance processes that all SHAs use for delegating any responsibilities. We will also ask Dr Harris to look at this in the context of the new NHS structures that come into force from next April to see whether any lessons need to be learnt.

It is imperative that this review is swift, and we have asked Dr Harris to report by the end of the year with recommendations to ensure that every part of the system employs the highest standards of assurance and oversight in the delegation of any functions.

In conclusion, I stress to the House that we have reviewed thoroughly with lawyers, clinicians and NHS managers all possible alternatives to introducing this retrospective legislation. We have been advised that all alternatives would be highly disruptive to the welfare of many of the most vulnerable patients within the mental health system, and would also deprive many other patients of the care they need while any action is undertaken. That is why, in such exceptional circumstances, we are proposing this retrospective legislation.

--- Later in debate ---

[Earl Howe]

My Lords, I again express my sincere gratitude to noble Lords who have spoken in this debate for recognising both the seriousness of the issue and the need for rapid action to resolve it. The expertise and wisdom that noble Lords bring to bear on these difficult questions has been extremely valuable. Regardless of the urgency, this is a matter that demands proper scrutiny, and that is exactly what the House is providing today, albeit within abnormal time constraints.

It is also important to record, once again, our appreciation of the invaluable help and advice that we have received from partners such as Mind, Rethink and the Royal College of Psychiatrists. Their primary concern is naturally those whom they represent so ably, but we are genuinely grateful for the mature and calm way that they have responded. We shared the same ultimate objective—to do what is best for the patients affected by a technical error.

I shall now do my best to address the questions put to me. Perhaps I may begin with the questions posed by the noble Lord, Lord Pannick, who relayed the concerns of the Constitution Committee. One of those concerns was why the Bill is drafted as it is, bearing in mind that the source of the mischief was the inappropriate delegation by strategic health authorities, resulting in the technical irregularity to which I have alluded. The answer to that question is that because we do not know the exact administrative arrangements that were in place before 2002 when SHAs came into being, it was impossible to limit in the way that the noble Lord suggested the framing of Clause 1. He suggested an addition at the end of Clause 1(1) specifying whether or not the SHAs had legal power to delegate. I can understand why the noble Lord made that suggestion, but we wanted to make sure that we captured any events of which we are currently unaware that may have occurred prior to 2002, before strategic health authorities were set up.

[Lord Pannick]

My Lords, because we are not going to have a full Committee stage, I hope that the Minister will indulge me in relation to this matter. Is there reason to think that there is any problem whatever other than delegation? I appreciate that it may relate to events prior to 2002, but surely it is only improper or possibly improper delegation of functions that is the mischief here.

[Earl Howe]

The main mischief, I respectfully suggest to the noble Lord, is that the panels which approved the clinicians involved did not, strictly speaking, have the direct power to do that. That is the issue that the Bill tries to capture. The Bill deliberately does not include a comprehensive list of which bodies or persons believed in good faith that they were exercising the approvals function in the past. If we limited the Bill in the way that the noble Lord suggests, we would run the risk of failing to cover some of the approvals given by bodies that we may otherwise have failed to list. I ask the noble Lord to accept that the way in which the Bill is drafted is in the form of a blanket, which gives us certainty that we may not inadvertently have left out any bodies prior to 2002 that may have been guilty of a similar lack of authority.

[Lord Hunt of Kings Heath]

I hope that the noble Earl will forgive my intervention because this is an important point. As the noble Lord, Lord Pannick, said, we are not having a Committee stage, and this is the only time when we can raise this matter.

The problem relates to the approval function. The way that I read it, as the noble Baroness, Lady Murphy, put it so eloquently, is that there might be a quack who somehow got through the system because there has not been the sign-off by the strategic health authority, which could check that the panel had done the right thing by actually exercising an approval function in agreeing—as part of a panel—to someone losing their liberty and being sectioned under the Mental Health Act. The issue is whether this rather open-ended, retrospective clause would give the okay to that as well. The noble Earl has essentially suggested that the problem is the vagueness about the organisational arrangements that were in place prior to 2002. I understand that but it seems to read in such an open-ended way that it could give almost a green light to poor practice or practice that should not have taken place within the panel so constituted under the Mental Health Act.

[Earl Howe]

I understand the question but I believe that that concern is misplaced. The panels operating in this area apply agreed national criteria for approval. Those criteria are clear and extremely rigorous, and that is why we are confident that doctors must meet the same high standards across the country irrespective of whether this technical irregularity applies. The technical irregularity was simply that the panel did not refer back to the strategic health authority for ratification the recommendations that it had made. It is my understanding that strategic health authorities, as a matter of course, accept the advice of the specialist panels. Therefore, I do not share the worry that, somehow or other, quacks or inappropriate clinicians have been appointed to these very onerous and responsible roles.

I now turn to the other main concern raised by the noble Lord, Lord Pannick, and the reason why the Bill has been drafted to refer to, “any person”. I see why he believes that the Bill appears to bestow a wide-ranging retrospective validation on any person, but in fact, the Bill is very narrowly targeted. It only validates any approvals given in the past and it relates only to the function of giving approvals to clinicians as having particular skills, for example, as having experience in the diagnosis or treatment of mental disorder. Once approved, the clinicians are then allowed to carry out certain functions under the Mental Health Act, as I said earlier. It is not the case that the Bill validates anyone other than persons who purported to approve clinicians. It is that role, and that role alone, that is referred to in the Bill.

The persons referred to in Clause 1(1) are as I have described. The Bill deliberately avoids going into further detail about which persons it applies to because, as I have said, attempting to include a totally comprehensive list of which bodies or people who believed in good faith that they were carrying out the approvals function would have created an unacceptably high risk of omitting agencies or individuals that should have been included. I hope that that is helpful.

I am advised in a further answer to the noble Lord, Lord Pannick, that if the power had been wrongly exercised by a panel and an inappropriate clinician had been authorised, that could still be challenged. That is to say: the challenge would be on the basis that the power was wrongly exercised but it would not be a challenge to the power to exercise the approval. I hope that that is helpful further clarification.

On the concerns raised by the noble Baroness, Lady Murphy, she asked how on earth strategic health authorities could have believed that they had this power to delegate. I share noble Lords’ dismay that we could have arrived at this situation but, having been advised by my officials, I am now more understanding of how this could have arisen. Strategic health authorities are able to delegate this function to certain bodies and in certain circumstances. However, they are not able to delegate it in the way that has come to light here. That is why we are legislating.

The options open to strategic health authorities for delegating their functions in relation to all issues are set out in regulations issued in 2002. In relation to the approval of clinicians under the Mental Health Act—which may include clinicians such as psychologists—there were also directions issued in 2008. Such approvals may be delegated to PCTs and therefore there is scope for legitimate confusion as to the exact way in which strategic health authorities had the power to delegate in this area.

I do not think there is any evidence for the fear expressed by the noble Lords, Lord Hunt and Lord Pannick, and the noble Baroness, Lady Murphy, that mental health was somehow not being given the priority it should be in those four strategic health authorities. What happened was that rather than carry out the approval process in-house, the four strategic health authorities decided to deliver the function through a contract with a mental health trust, believing that the focus brought about through a specific contract and the expertise and connections of a mental health trust would deliver a more rigorous and effective approvals process. However, the effect of these arrangements was that the approval functions were to be carried out by the trust, and the regulations and directions specifically set out, as I have said, with which bodies the SHAs may make arrangements to exercise the functions. They cannot completely delegate their responsibility in the way that they did, but it can be exercised on their behalf by a committee, a sub-committee or an officer of the authority. In essence, the panels in the trusts should have been regarded as advisory to the SHA, not having the approval functions themselves.

The noble Baroness, Lady Murphy, asked why this was not picked up sooner. The incorrect delegation was within the process between the strategic health authority and the mental health trust. To all appearances, the process of approving doctors and the quality of the doctors in these four SHAs was the same as in the rest of the country. However, this is a matter with which Dr Harris will no doubt wish to concern himself.

The noble Lord, Lord Hunt, asked me whether we could more precisely define the extent of the problem in terms of the number of patients affected. As of today, my advice is that the north and midlands SHA clusters have reported that they have currently identified 4,117 affected patients—1,265 in the north SHA cluster and 2,852 in the midlands.

I turn now to the questions posed by my noble friend Lady Jolly. She asked me whether the intention of Clause 1 is to give power not only retrospectively but also with effect from today. I hope I have made it clear that that is not the case. It takes effect from today retrospectively as soon as it receives Royal Assent, but it has no effect in relation to future approvals because all people involved in this process have now been properly approved. She asked me to confirm that the people who think they are approved actually are and do not need to undergo any validation or further approvals. The answer to that is yes, if she is referring to approved clinicians or Section 12-approved doctors, which I believe she is.

She asked about the lessons to be learnt from 1 April next year once strategic health authorities cease to exist and how the preparations for the transfer of responsibilities are being progressed. From next April, the Department of Health will be responsible for this specific approval process for approved clinicians. The Secretary of State said yesterday that while this will be a departmental process, we do not want the process to be remote from local areas. He also pointed out that we intend to have a structure that draws on local and regional expertise to help us make the right decisions on the suitability of doctors for the role, and we hope that Dr Harris will advise the department on this when he conducts his review.

The noble Baroness asked where the definitive list of SHA roles and responsibilities is and who is its guardian. The guardian is the Department of Health, while the actual list of strategic health authority roles is set out in the 2002 regulations, the National Health Service (Functions of Strategic Health Authorities and Primary Care Trusts and Administration Arrangements) (England) Regulations 2002, and the precise details on approved clinicians are set out in the Mental Health Act 1983 Approved Clinician (General) Directions 2008. That usefully lists the 28 competencies required of an approved clinician. She asked whether we can be confident that there are no other areas where action has not been taken by some or all of the SHAs. We know of no other areas or functions affected, but again Dr Harris’s review will look at the issues of governance and assurance of delegating responsibilities.

I thank the noble Baroness for making a valid point as regards the transition, but as I have alluded, the Harris review will look at issues of the governance and assurance of delegating responsibilities. Moreover, the review will report by the end of the year, so that will be before the completion of the transition process that my noble friend has so rightly brought to the attention of the House. The one remaining question my noble friend asked me concerned communicating with patients and the timescale of that. I shall repeat what I said before: we think that we need to take time to get things absolutely right, which I know she will understand. However, we hope to be able to issue advice within the next few days. I would reiterate that both the advice and the approach to delivering it will be agreed by both clinical experts and representatives of patients and families. I thought that I had covered every point, although I now see that the noble Lord, Lord Hunt, asked me a question about approvals post April 2013. The one thing I should have added was that we do not intend to delegate the function to the NHS Commissioning Board.

I hope that I have now answered satisfactorily the questions that were raised and that I have provided additional reassurances where necessary. Again, I thank noble Lords and others outside the House for their understanding and for the very significant contribution they have made to the debate.

Bill read a second time. Committee negatived. Standing Order 46 having been dispensed with, the Bill was read a third time and passed.

Winterbourne View

Earl Howe Excerpts

Tuesday 30th October 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I shall now repeat as a Statement an Answer given earlier today by my honourable friend the Minister for Care Services in another place on the safeguarding of former Winterbourne View residents. The Statement is as follows:

“The review into the abuse at Winterbourne View Hospital established by my right honourable friend the Member for Sutton and Cheam set out 14 actions to transform care and support. Central to the review is ensuring the safety and well-being of these very vulnerable people. I shall publish the final report before the end of November.

When Winterbourne View closed, NHS commissioners put in place independent clinical and managerial supervision and commissioned an independent assessment of every patient. The Care Quality Commission worked with commissioners to relocate Winterbourne View patients to suitable alternative placements.

The Department of Health review team commissioned NHS South of England to follow up the 48 patients who had been in Winterbourne View in March and September of this year. That revealed that 19 former patients were the subject of safeguarding alerts. In response to this, officials asked commissioners to take the appropriate action and confirmed that a follow-up would take place in six months’ time.

I was concerned to be informed that this follow-up had revealed that there are current safeguarding alerts for six former patients. I am assured that these are all being followed up to ensure the safety and well-being of the individuals concerned. Furthermore, the September follow-up exercise revealed that 32 Winterbourne patients were now living in the community in their own family homes, supported living or a residential care home; 16 were still living in hospital settings.

The priority is to improve commissioning to develop the good local services which will prevent people being inappropriately sent to hospital. We are working closely with the NHS Commissioning Board, the Local Government Association and directors of social services on what support local services need.

While a small number of people will need hospital treatment, we expect to see and indeed must see a substantial reduction in the number of in-patients. We intend to strengthen safeguarding arrangements to prevent and reduce the risk of abuse and neglect of adults in vulnerable situations. Where there are safeguarding concerns, the local safeguarding of adults boards need to be closely involved. These boards will be placed on a statutory footing, ensuring a co-ordinated approach to local adult safeguarding work.

This Government will put the necessary legislation for safeguarding adults boards, and local councils should bring clarity to their roles and responsibilities. But it is the responsibility of the care provider to ensure a culture of safety, dignity and respect for those in their care, including stopping abuse before it happens. Those providers must be held to account for the care they provide”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, I am grateful to the noble Lord, Lord Hunt, for his comments and questions. Turning, first, to the very distressing programme that was shown on television last night, we know that some of the people who were at Winterbourne View hospital are now receiving good-quality personalised care in community settings that is appropriate for them. However, it is deeply concerning that some people have been so affected by what they experienced at Winterbourne View that they have had to go into more secure settings. Equally, we are very concerned that others continue to experience poor-quality care.

The Government take this very seriously, and that is why Department of Health Ministers set up a wide-ranging review not just into what happened at Winterbourne View but into the state of care and support services for people with learning disabilities or autism who may have mental health problems or behaviours described as challenging. We have heard a lot from people who have experienced the services, as well as from their families. We have been working across the health and care sector to identify what needs to be done to make sure that vulnerable people get the care and support that they deserve.

I make no apology that that has taken some time. We are determined to treat this issue very seriously and bring forward a firm programme of action to really make a difference. We will publish the final report of the DH review shortly, together with a concordat setting out the commitment for change and inviting external partners to sign up to specific actions to deliver that change.

The noble Lord asked me about commissioning. In general terms, in our perception commissioning has been too remote from the patients whom it is intended to serve, and I think that the noble Lord’s remarks reflected that point. Clinical commissioning is intended to push decision-making much closer to patients and local communities with the aim of ensuring that local people are able to hold commissioners to account more effectively for what they achieve. Commissioning decisions will also be better informed by local clinical knowledge and insight.

The noble Lord asked whether all families have been given full information about the alerts. In essence, that is a matter for the local commissioners but I can tell him that the Department of Health has reminded health and care bodies of their responsibilities in that area.

The noble Lord called into question the capacity of the CQC to take on as much work as we are requiring of it. He will know that the department has undertaken a performance and capability review of the CQC. The resulting report was published back in February. It found that the CQC had made significant progress in the previous nine months, and I believe that it is continuing to make that progress. It has shown, in particular, a new focus on its core purpose—to protect patients by concentrating on essential standards—and in strengthening its operational base. The review has already made recommendations to strengthen the board of the CQC and board structures, including changing the board, so that instead of comprising only non-executives, it becomes a unitary board of majority non-executives, with senior executives on the board where they can be better held to account. It also recommended that the CQC needs to review and reinstate the board support and development programme and strengthen capability at executive team level. The department will oversee the implementation of these recommendations.

I share the noble Lord’s confidence in David Behan as chief executive of the CQC, having got to know him quite well during my time in the department. The noble Lord raised the issue of skills and training. We have had a number of debates on this subject over the past few months and, as he will know, the department has commissioned Skills for Health and Skills for Care in partnership with unions and employers, regulators and educators, to produce by January next year national minimum training standards and a code of conduct for healthcare support workers and adult social care workers.

I would just say, however, that to my mind the skills required in looking after those with learning disabilities and challenging behaviour are of a different order from the skills needed in other settings and we need to nuance the standards to ensure that the right skills are being imparted to the right people. Commissioners need to encourage hospitals and assessment and treatment units for adults with these disabilities to make sure that their employees are signed up to the proposed code of conduct that we plan to put in place and the minimum induction and training standards for unregistered health and social care assistants. We are working with the National Skills Academy for Social Care to explore how registered managers can get better support, which includes regular monitoring and supervision. Indeed, Skills for Care is developing a framework of guidance and support on commissioning work for solutions to meet the needs of people with challenging behaviour.

Finally, the noble Lord asked me whether I was satisfied that Postern House represented a safe and secure environment. Following the programme last night, my officials are pursuing that matter with urgency, as we speak, and once I have an assurance to give him about the current state of affairs at that care setting, I shall be happy to pass it on to him.

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[Lord Laming]

My Lords, the Minister has made it plain that it has been the Government’s position for some time that people with learning disabilities should be enabled to live with local personalised services, supported in the community. The fact that some former residents of Winterbourne are now living with their families is an indication that this policy has been implemented all too slowly. There are too many units like that around the country. Will the Minister tell the House what levers are being employed to speed up this policy so that people have a range of local services designed to meet their personal needs?

[Earl Howe]

My Lords, I am absolutely in agreement with the noble Lord, Lord Laming, that it is really important that people are held to account for making change happen. We have indicated what we think that change should be, and that is why we have developed a concordat with key partners to get them to commit to the actions they will take. We also plan to strengthen the learning disability programme board, in particular to make sure that key delivery partners—such as the NHS Commissioning Board, the CQC, ADAS and the Local Government Association—are core members. The board will review progress on implementing the action set out in the final departmental report and the concordat. We have tried to address the issue that the noble Lord homed-in on—which is speed of action—but the core of his point was that there are too many people currently in specialist in-patient learning disability services, including assessment and treatment units, and that they are staying there for too long. This is often due to crises which are preventable or which can be managed if people are given the right support in their own homes and in community settings. That is the agenda that faces us.

[Baroness Jolly]

My Lords, what action can be taken against partners that fail to comply with the concordat?

[Earl Howe]

My Lords, I think that part of this involves defining roles and responsibilities. There is no single answer to my noble friend’s question. However, the transparency of the delivery of care, measuring outcomes and measuring the quality of commissioning in local areas are all important. It is also important to ensure that systems are in place to expose poor practice when it occurs. The problem with Winterbourne View is that, for too long, people did not know that those dreadful things were happening. Therefore, levers such as the introduction of local Healthwatch, the promotion of the new elements of the NHS constitution and ensuring that the CQC focuses its attention on where risk may most strongly lie, all have to be considered in the mix. I can tell my noble friend that this very subject will be covered in the report that my department will be publishing by the end of next month.

[Lord Elton]

My Lords, my noble friend is right: the care of people with learning difficulties requires a different order of commitment, compassion and patience. The Government are putting some weight on referring and sending people with learning difficulties out of institutions and into private homes. Can he give us reassuring news about the ease or difficulty of supervising the quality, consistency and continuity of the care which can be given in circumstances where these people are dispersed and each individual needs some kind of monitoring allocation of their own?

[Earl Howe]

My noble friend is absolutely right: this is not a simple matter. That is why we believe that commissioning should not be remote from those for whom care is commissioned. There needs to be regular monitoring by commissioners of the quality of the service that has been commissioned. Equally important, commissioners need to satisfy themselves on the suitability of the placement in the first instance. Best practice and guidance are clear: people with learning disabilities, autism or behaviour that challenges should benefit from local, personalised services and should be supported to live in the community wherever possible. The creation of clinical commissioning groups and health and well-being boards will encourage that local dialogue and insight to make sure that the services available in an area are appropriate and of a capacity for those who require them.

[Baroness Donaghy]

My Lords—

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[Baroness Donaghy]

Is the Minister satisfied that not a single senior manager or owner went to jail as a result of the Winterbourne View scandal? Given that, how on earth is a culture change going to be promoted in these organisations? Can he assure the House that the responsibility and any judicial changes will be considered as part of any review?

[Earl Howe]

My Lords, the noble Baroness makes an important point. We have been clear that those who lead organisations where people suffer abuse or neglect should be held accountable. We have made it clear that there is a gap which needs to be addressed. A range of options is available through regulation; for example, by barring people from running care homes or hospitals ever again or, indeed, through criminal sanctions. As I have mentioned, very soon we will publish our final recommendations on what more can be done to prevent abuse and protect those who are in vulnerable situations.

[Baroness Emerton]

My Lords, I thank the noble Earl for his response in terms of support workers, and particularly on challenging behaviour. My past experience nearly 20 years ago of decanting hundreds of patients from large institutions satisfactorily into the community was due to the fact that the psychologists made an independent assessment of each individual of their clinical and environmental needs, and thus the training needs of the support workers. Can the Minister assure us that a holistic approach in terms of multi-professional involvement will be taken, and that it will particularly be led by evidence-based psychologists who understand challenging behaviour?

[Earl Howe]

I agree fully with the noble Baroness. The aim and aspiration for this group of individuals is that they should benefit from personalised services. What that means is that their needs should be individually assessed professionally by multi-disciplinary teams. The noble Baroness did not do this, but there are some who suggest that we need to get rid of in-patient services altogether. There are individuals who will continue to require in-patient services, but these should be used only in very limited cases. We need to aim towards a situation where no one is sent unnecessarily into in-patient services for assessment and treatment. We know that that has not been happening. For the small number of people for whom in-patient services may be needed for a short period, the focus has to be on providing good quality care that is safe, caring and open to the community, which is another important aspect, and that people can move on from these services quickly. Planning starts from day one to enable people to move out of the in-patient setting into more appropriate care as quickly as possible. That comes back to intelligent commissioning.

[Baroness McIntosh of Hudnall]

My Lords, is it not the case that a great many workers in this sector are extremely low paid? Does the Minister think that there might be any correlation between the fact that they are low paid and the quality of care they deliver? I do not mean to imply that there is any excuse for the sort of behaviour that was revealed in the “Panorama” programme, but could any form of pressure be applied by regulators and commissioners to the commercially driven organisations that provide this care so as to prevent them continuing to employ people on very low wages to do such sensitive work?

[Earl Howe]

My Lords, there is more than a nugget of truth in what the noble Baroness says. Many of us have been troubled for a long time that work of this kind is insufficiently valued by society, and that is reflected in the rates of pay. That is why I am a firm believer in raising skills in this sector as a reflection of the value we place on care workers. The programme that we have in train over the coming months should steadily deliver that. To come back to the commissioning question, I am also a believer in ensuring that commissioners should be satisfied that the settings to which they send individuals have an appropriate mix of skills to look after the people concerned. That has not always happened. There is no single answer to this, but I identify myself with the particular point she has raised about remuneration.

[Lord Cotter]

My Lords—

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[Lord Cotter]

My Lords, I very much welcome the mention of training once again today. It is so important that support workers are trained. One issue that has come to my notice quite frequently is that through a lack of training, support workers question the trained professionals an awful lot. The management also need to be trained to back up the professionals who are trained in their job as a vocation, so that the less well trained support workers respect their decisions.

[Earl Howe]

I agree with my noble friend. Where supervision is required, it is the job of the manager to ensure that it takes place, and that the supervision, staff ratios and so on are appropriate. We come back to the question of the responsibility placed on the shoulders of managers and proprietors of care homes. As the Statement made clear, this is very much a responsibility of providers, who need to be held to account for the quality of care that they provide.

[Viscount Tenby]

My Lords, I declare an interest both as a trustee of an organisation dealing with women with learning disabilities and also as a father of someone in that category. Although everyone can applaud the move to independent living within the community—nothing could be better—this has considerable financial implications, at a time of great financial stringency and rationing within the NHS. Can the noble Lord assure me that sufficient funds will be found and made available for this most important development?

[Earl Howe]

My Lords, the commissioning of this type of care will, in the future, be the joint responsibility of clinical commissioning groups and local authorities. We are encouraging as much close co-operation as possible at a local level. The noble Viscount will know that across-government funding is tight. However, we as a Government took the decision to protect the health budget, which is in fact rising in real terms every year of this Parliament. That does not reduce the pressure placed on the budget, because historically the pressures on the health budget have been higher than the rate of inflation; nevertheless, in protecting the health budget, we are also supporting local authorities to the tune of more than £7 billion over the spending review period to ensure that their social care services are not seriously depleted or damaged. It would be idle of me to say that there is no problem, but the funding available should be enough to support these services over the medium term.

[Lord Clinton-Davis]

This is not a simple matter. Does the Minister agree that an interim report will not provide all the answers and that this matter ought to be kept under constant review by Parliament in due course?

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[Earl Howe]

Yes, my Lords, I agree with that. We must not take our eye off the ball. Once this report comes out, we have to ensure that its recommendations are carried through and constantly monitored. It will be, in part, the job of the NHS Commissioning Board to hold the ring and ensure that local commissioners are supported with the proper guidance, and held to account for the outcomes that they achieve, across the whole NHS but particularly in this area. That focus on outcomes is important when we consider how the service is held to account. We will be publishing very shortly the final version of the mandate that the Secretary of State gives to the NHS Commissioning Board as the means by which the board will be held to account by Parliament and the public.

[The Earl of Courtown]

My Lords, I declare an interest as a patron of a home providing residential care for adults with autism spectrum disorder. What we have all heard, read and seen about the Winterbourne View care home has been quite terrible. Does my noble friend the Minister agree that there are many homes out there providing a very good service to people suffering from these problems?

[Earl Howe]

My Lords, I am very grateful to my noble friend because it is all too easy to sink into a state of despair over these services. He is absolutely right: many, many good examples of excellent care are being delivered to those with learning disabilities. The challenge is to ensure that best practice is spread, but I am grateful to him for reminding the House of that important fact.

[Lord Elton]

My Lords, learning-difficulty patients are extremely aggravating at times and their carers have enormous power over them and can be tempted to abuse it—hence the results we have seen. The same can be said of prisoners and prison officers. When I was Minister for the Prison Service many years ago I was aware of the problem of the abuse of prisoners by prison officers who had a tendency to bully. I commissioned work on identifying the psychological profile of potential bullies, which was useful in reducing that invasion of human rights in prisons. Will my noble friend look into a similar approach when it comes to the way in which carers are recruited?

[Earl Howe]

My Lords, my noble friend makes an important point. The thing that shocked us all in the context of the BBC programmes was the extent to which restraint and physical abuse occurred in care settings, which was clearly inappropriate and also extremely distressing and damaging to the individuals involved. We are working with the DfE, the CQC and other stakeholders to drive up standards and promote best practice in the kinds of areas my noble friend is no doubt thinking of, particularly in the use of restraint. We believe that there should be a set of core principles to govern restrictive physical interventions. We think the guidance needs to be updated and that there needs to be improved training in this area. We will particularly consider in our review what additional guidance is needed for specific groups, including people with learning disabilities and behaviour that challenges.

Mental Health Act

Earl Howe Excerpts

Monday 29th October 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I shall now repeat a Statement made earlier this afternoon by my right honourable friend the Secretary of State for Health on the subject of the Mental Health Act. The Statement is as follows.

“With permission, Mr Speaker, I wish to make a Statement about an issue relating to the Mental Health Act 1983. It has become apparent that there are some irregularities around the way that doctors have been approved for the purpose of assessing patients for detention under the Act. For assessments and decisions under certain sections of the Act, including detention decisions under Sections 2 and 3, three professionals are required to be involved—two doctors and an approved mental health professional, usually a social worker.

In 2002, when strategic health authorities came into being, the then Secretary of State properly and lawfully delegated his function of approving doctors under the Act to them. However, it came to light last week that in four out of the 10 strategic health authorities—North East, Yorkshire and Humber, West Midlands and East Midlands—in a period of time dating from 2002 to the present day, authorisation of doctors’ approval appears to have been further delegated to NHS mental health trusts. I was made aware of the issue and kept up to date with the actions being taken. Our latest best estimate is that approximately 2,000 doctors were not properly approved, and that they have participated in the detention of between 4,000 and 5,000 current patients within institutions in both the NHS and independent sectors. Rampton high-secure hospital is in one of the affected areas. Some patients at Ashworth high-secure hospital are also included.

There is no suggestion that the hospitalisation or detention of any patient has been clinically inappropriate, nor that the doctors so approved are anything other than properly qualified to make such recommendations, nor that these doctors might have made incorrect diagnoses or decisions about the treatment that patients need. All the proper clinical processes were gone through when these patients were detained. We believe that no one is in hospital who should not be, and no patients have suffered because of this. The doctors would have no reason to think that they had not been properly approved. They acted in good faith and in the interest of their patients throughout this period.

In the light of our legal advice, we do not believe that any decisions that have been made about patients’ care and detention require review because of this irregularity. Doctors should continue treating patients who are currently detained under the Mental Health Act in the usual way. We have received advice from First Treasury Counsel that there are good arguments that the detentions involving these particular approval processes were and are lawful, but Counsel also argues the need for absolute legal clarity. The legal advice is that this should be resolved through emergency retrospective legislation.

As soon as the irregularity was identified, my department worked swiftly to identify the best course of action and put the necessary preparatory work in place. It first became aware of this problem last week. Officials immediately sought initial legal and clinical advice. We then swiftly analysed possible options, including the option of reassessing all potentially affected patients, working with the health leads in the regions affected and clinical experts from the Royal College of Psychiatrists. When I was briefed on the situation, I asked for detailed information on the time that it would take and the clinical risks involved in reassessing all potentially affected patients. On Friday, I asked for an emergency Bill to be drafted over the weekend, as a matter of contingency. I briefed the Prime Minister personally the following day. Following further discussions and analysis over the weekend, the decision to introduce emergency legislation was taken yesterday, and we have since worked to prepare the necessary materials. At all times, my priority has been to resolve this is a way that follows clinical advice about the most sensitive way to deal with a highly vulnerable group of individuals.

We have also worked to remedy the problem as it relates to current and future detentions. As of today, all the doctors involved have now been properly approved. The accountable officers for the four strategic health authorities in question have written to Sir David Nicholson, chief executive of the NHS, to confirm that they have made the necessary changes to their governance arrangements. Furthermore, the accountable officers in the remaining six strategic health authorities have written to Sir David to confirm that they have, in the light of this issue, reviewed their own arrangements and that they are in full compliance with the Mental Health Act.

Although we believe that there are good arguments that past detentions under the Mental Health Act were and are lawful, it is important that doctors, other mental health professionals and, most importantly, patients and their families have absolute confidence in the decisions made. That is why, in relation to past detentions, we have decided that this irregularity should be corrected by retrospective legislation. Although we are aware of the problem only in the four areas going back to 2002, the proposed legislation will apply in principle to the approval of all doctors under the Mental Health Act since its introduction in 1983. It will retrospectively validate the approval of clinicians by those organisations to which responsibility was delegated, up to the point when all the relevant doctors were fully reapproved and their status put beyond doubt. The legislation will not deprive people of their normal rights to seek redress if they have been detained for any other reason apart from the narrow issue of the delegation of authority by the SHAs, nor will it affect any future detentions or legitimise any similar failures in future.

We are proposing to introduce the draft legislation to the Commons and, through best endeavours, looking for it to complete its passage through all the appropriate stages in this House and the other place as soon as is practicable. While addressing this technical issue, it is also important that we get to the bottom of how this happened and that we learn any lessons to help inform the operation of the new system architecture from April 2013. As such, I have asked Dr Geoffrey Harris, chair of NHS South and former chair of Buckinghamshire Mental Health Trust, to undertake an independent review to look at how this statutory responsibility was delegated by these four SHAs; and, more broadly, the governance and assurance processes that all SHAs use for delegating any statutory responsibilities. I will also ask him to look at this in the context of the new NHS structures that come into force from next April, to see whether any lessons need to be learnt. It is imperative that this review is swift and I have asked Dr Harris to report to me by the end of the year with recommendations to ensure that every part of the system employs the highest standards of assurance and oversight in the delegation of any functions.

I stress to the House that I have reviewed with lawyers, clinicians and NHS managers possible alternatives to introducing this retrospective legislation. I have been advised that all alternatives would be highly disruptive to many of the most vulnerable patients, and would also deprive many other patients of the care that they need while any action is undertaken. However, all the advice that I have received has been unequivocal in stressing the need for absolute clarity of the legal status of any hospitalisation or detention of patients, in the interests of those patients, their families, those caring for them and the wider public. That is why, in such exceptional circumstances, this retrospective legislation is being proposed. Both a draft Bill and the accompanying Explanatory Notes will be published this afternoon. I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, I am extremely grateful to the noble Lord for his supportive comments, and I shall do my best to answer as many of his questions as I can. He first asked me what train of events led up to this situation. Earlier in the year, a doctor challenged a refusal by the Yorkshire and Humber approvals panel to approve him under Section 12. This challenge highlighted the possibility that the Secretary of State’s approval function, which had been properly delegated to SHAs, may, in some areas, have been unlawfully further delegated to NHS trusts. Yorkshire and Humber and then the northern SHA cluster took their own legal advice, which confirmed that the trust had been acting ultra vires in issuing the approvals. The northern SHA cluster identified that this applied to the arrangement in North East SHA and alerted the Midlands cluster, where it was possible that the same issue might apply in East Midlands and West Midlands. On 22 October, the northern SHA cluster alerted the Department of Health to the issue surrounding the approval of doctors and the possible knock-on effects that that would have. Events then took the course that I outlined when repeating the Statement. I can confirm to the noble Lord that we are satisfied that all 10 strategic health authorities have now gone through the proper process for approving doctors under the Act. The four that may not have been compliant have regularised the situation.

The noble Lord asked whether more than the 4,000 to 5,000 patients that I indicated when reading the Statement might be affected. It is possible that more are affected, but the key point is that the legislation that we are introducing this week will cover all affected patients, whatever the process was that led to their detention.

The noble Lord asked whether there were any plans to communicate with patients. We have worked, and continue to work, with the Royal College of Psychiatrists to ensure that patients and staff will understand clearly what has happened, how it affects them and what the situation now is. Sir David Nicholson, the NHS chief executive, today has written to all SHA leaders setting out the situation and the immediate need for them to communicate across their mental health organisations. The Department of Health is also assisting in that process.

The noble Lord also asked how many patients were detained in high-secure hospitals. I do not have the exact numbers. However, a small number of patients in secure hospitals are detained under sections of the Act covered by approval under Section 12 but these patients are not in secure hospitals by virtue of a criminal section. On whether I could share with the House the legal advice that the department has received, I am sure that he will know that it has been the practice of successive governments not to do that for very good reasons. However, if the noble Lord is in any doubt about the advice that we have received, I am very happy to give him access to my officials in the department who can talk him through this.

Quite rightly, the noble Lord said that your Lordships’ House has in the past been extremely cautious about approving retrospective legislation and I am the first to acknowledge the validity of that comment. In no way do the Government enter into retrospective legislation lightly. As he said, it is very much a last resort. We looked at the only possible alternative, which was to reassess each and every one of the 4,000 to 5,000 patients currently detained in every setting. We would need to have done that within 72 hours, which is what the law allows. In our judgment, it was logistically impossible to do that.

Furthermore, if we had attempted to do that, it would have undoubtedly caused a great deal of anxiety and distress to the patients involved, and their families, while taking away from other patients the attention of the clinical staff who look after them. The very clear advice that we received from not only our legal experts but also the clinicians was that the retrospective legislation route was undoubtedly the best route to go down. It is not now necessary to reassess patients. I believe that that perhaps is the central consideration we should have in our minds.

The noble Lord, Lord Hunt, also asked whether this affair reflected a failure of policy implementation or the underlying legislation. Certainly, from our scrutiny, there is no defect in the legislation. What has happened is that powers have been inappropriately delegated by those four strategic health authorities. The panels whose job it is to approve the clinicians failed to refer back to the strategic health authority for ratification the recommendations that they were making, which is the only thing that we believe was not done under this process.

The noble Lord also asked what would be the arrangement after April 2013. The power under the Mental Health Act to approve clinicians in this context will revert back to the Department of Health. There will be a refreshed set of arrangements which will be co-ordinated and managed by the department. Those arrangements are being put in place over the next few months.

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[Baroness Jolly]

My Lords, will the review look at whether the SHAs have made any approvals under any other legislation, such as the Mental Capacity Act?

[Earl Howe]

My Lords, the review by Dr Harris will take into consideration any lessons that need to be learnt. We have asked him to take into account any other possible lessons that we should take on board, particularly in the run-up to April 2013. However, I am happy to reassure my noble friend that her request will be passed on. If there is a relevance to the Mental Capacity Act, I will ensure that Dr Harris takes it into account.

[Baroness Pitkeathley]

My Lords—

[Lord Lloyd of Berwick]

My Lords, like the noble Lord, Lord Hunt of Kings Heath, I would hope that the Minister could tell us a little more about how these irregularities came to light only last week. The problem, of course, is that there is a well known maxim of the law that the delegate of a power—that is to say the person to whom a power is delegated—cannot delegate it to another. I think that it is expressed in Latin as delegatus non potest delegare.

It is no doubt that maxim which has caused the lawyers to have had some doubt about the lawfulness of the detention in these cases. Indeed, it is perhaps surprising—again, the noble Lord might be able to give us some understanding about this—that these irregularities have not come to light before. Now that they have, I agree with the advice given by First Treasury Counsel that there is here a need for absolute clarity and that the best way to achieve that is by legislation. The whole point of it is that it should have retrospective effect. I end by congratulating the Government on reacting so quickly.

[Earl Howe]

I am extremely grateful to the noble and learned Lord, Lord Lloyd. In front of me, I have a very detailed timeline of the events which have led to the current situation, starting from the early summer of this year when the doctor who was turned down for approval in Yorkshire and Humberside SHA challenged the decision. Subsequently, he dropped his appeal but the legal advice taken on his grounds for appeal highlighted the possibility that the arrangements for the panel convened by the Rotherham, Doncaster and South Humber NHS Foundation Trust to exercise this function were unlawful. From that point, questions were asked not only in that strategic health authority but in neighbouring strategic health authorities and the department was alerted a few days ago.

The noble and learned Lord rightly asked how this could ever have happened and not been picked up. We will rely on the review by Dr Harris to tell us the answer to that question, but I am grateful for his support.

[Baroness Pitkeathley]

In further clarification to the response that the noble Earl gave to my noble friend about communication with patients, will he tell the House more about how that communication is to take place, whether there is a timescale for it and whether the communication also will extend to patients’ families who will be particularly worried by some of these developments?

[Earl Howe]

My Lords, I would willingly give the noble Baroness further details. Unfortunately, I do not have any beyond those that I gave to her noble friend Lord Hunt. I will gladly pick up the very valid points that she has made and let her know as soon as I can. Perhaps when we reach Second Reading of the Bill, which I believe has been timetabled for Wednesday, I shall have a more detailed answer to give her. If she is not in the Chamber, I shall make sure that she receives it by other means.

[Lord Williamson of Horton]

I have a particular interest in the Mental Health Act 1983, because I played some role in getting some provisions on to the statute book. I am normally very against any retrospective legislation, but in this particular case I strongly support the view taken by the Government, because it is absolutely essential to avoid a situation in which we impose disruption and distress on a large number of people who are vulnerable and in difficult circumstances in any event. For what I may call “human reasons”, the alternative was rightly ruled out, and I support the Government’s view.

[Earl Howe]

I am most grateful to the noble Lord, Lord Williamson. Indeed, it was the well-being of patients that was central in our mind when we sat down to consider how to resolve this very unfortunate situation at the end of last week. I hope and believe that patients should not suffer any inconvenience or distress at all as a result of the remedial route that we chose.

[Baroness Ford]

I welcome a review by Dr Harris, but can the Minister say whether, outwith the sphere of mental health, the department has any concerns that there are other areas of health where the Secretary of State would normally delegate authority to strategic health authorities and where that delegation might be further delegated? Is there any belief in the department that any other areas could be similarly ultra vires?

[Earl Howe]

We know of no such instances, but again we have asked Dr Harris to investigate that issue. I am sincerely hopeful that he will not find any other irregularities, but we cannot of course rule out that possibility.

[Lord Laming]

We are all grateful for the way in which this matter has been handled, and particularly pleased that it will not result in any fundamental change in mental health legislation. I come to this from a point of ignorance, so I hope that the Minister will excuse what seems an innocent question. Does this mean that the future emergency legislation that will come to the House is aimed at deeming that the practitioners who dealt with these cases are now licensed to deal with them, or does it mean that the patients have been deemed to be appropriately assessed?

[Earl Howe]

The question that the noble Lord, Lord Laming, asks is not a naive one at all—it is a very important one. The draft legislation that has been prepared is very narrowly drawn and its effect will be to ratify retrospectively those decisions taken by the panels that assess doctors for approval and treat those decisions by the panel as if they had been lawfully made. So it does not apply directly to patients but to the approval of the clinicians involved.

[Baroness Barker]

Could the Minister say something about the role of regulators and professional bodies, and why none of them picked up this issue over time? Will that matter form part of Dr Harris’s review?

[Earl Howe]

Yes, it will, my Lords.