NHS: Children’s Congenital Heart Services
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The Lord Bishop of Leicester
To ask Her Majesty’s Government why the removal of extracorporeal membrane oxygenation equipment from Glenfield Hospital does not form part of the review by the Independent Reconfiguration Panel into children’s congenital heart services in Leicestershire, Lincolnshire and Rutland.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Independent Reconfiguration Panel—the IRP—provides advice to the Secretary of State on the plans that the NHS puts forward for significant change to services. The legislation does not allow it to review decisions taken by the Secretary of State. My right honourable friend the Secretary of State has asked the IRP to review the Joint Committee of Primary Care Trusts’ decision on the future pattern of children’s congenital heart surgery and its consideration of the impact of that, which may include possible consequences for this service at Glenfield.
The Lord Bishop of Leicester
My Lords, I am grateful to the Minister for his Answer. In the east Midlands we appreciate the Secretary of State’s decision to review his predecessor’s decision on the future of children’s congenital heart services in Leicestershire, Lincolnshire and Rutland. However, in view of the unique and exceptional network of expertise with a world reputation supporting the so-called ECMO unit—expertise that, once dismantled, would be very difficult to reassemble—does the Minister accept that its future is inextricably linked to the future of children’s congenital heart services? Will he give an undertaking to this House that he will press that point on the Secretary of State?
Earl Howe
My Lords, I accept that there are interdependencies between the provision of children’s cardiac surgery and the children’s ECMO service. If new evidence emerges or there are exceptional circumstances, such as a change in circumstances following either the Independent Reconfiguration Panel review or any judicial review that may occur, then my right honourable friend the Secretary of State may wish at a future time to review the earlier decision.
Lord Bach
Is the Minister aware of how absurd it would be to have an independent report on the future of the heart unit but to exclude any consideration of the fate of the ECMO unit? As the right reverend Prelate said a few minutes ago, they are inextricably linked; indeed, the Minister seems to have conceded that there is a link between them. I remind him that Members of another place from all parties and from different parts of the country made it clear in their excellent debate earlier this week that the two are linked. As the Minister’s right honourable and learned friend Sir Edward Garnier said:
“We all know that the current decision is wrong and needs to be dealt with”.—[Official Report, 22/10/12; col. 188WH.]
Will the Government please look at this again before the whole country—
Earl Howe
My Lords, I hope that my initial Answer will have made it clear that we expect the Independent Reconfiguration Panel to look at the issue in the round, and that includes the consequences of the JCPCT’s decision, were that to be carried through. I hope that that is sufficiently reassuring. However, what the panel cannot do, in law, is review the decision of the Secretary of State. It can, however, take all the circumstances into account, and I believe that it should do so.
Lord Hunt of Kings Heath
My Lords, I remind the House of my health interests in the register. I would like to press the Minister on that point. In the other place on 22 October, the Minister there made it clear that the decision to transfer the ECMO to Birmingham was made as a consequence of the decision of the Joint Committee of Primary Care Trusts. Given that the Independent Reconfiguration Panel is now reviewing the decision of the Joint Committee, are the Government not being unnecessarily legalistic on this point? It would be quite open to the Secretary of State to ask the reconfiguration panel for its advice on the question of the ECMO position. Why on earth does he not do that?
Earl Howe
My Lords, I can only repeat what I said in my initial Answer to the right reverend Prelate: my right honourable friend has asked the IRP to review the decision around children’s cardiac services and its consideration of the impact of that, which may include consequences for the ECMO service at Glenfield. I hope that that Answer puts this question into context. While the IRP cannot review the Secretary of State’s actual decision about the ECMO, which, as the noble Lord rightly said, followed on from the original decision of the JCPCT, nevertheless there are interdependencies between the two services that we expect to be taken into account by the panel.
Lord Walton of Detchant
My Lords, may I express the hope that this review will be concluded speedily? The whole issue of the facilities for paediatric cardiac surgery across the UK has been under consideration for about two years. I have an avuncular interest, of course, in the future of the cardiac unit in the Freeman Hospital in Newcastle, which is one of the most outstanding in the country. I ask for a speedy conclusion because the whole organisation and reorganisation of cardiac paediatric surgery have to await the Secretary of State’s decision.
Earl Howe
The noble Lord, as ever, makes an extremely important point. Children’s heart surgery has been the subject of concern for more than 15 years. Clinical experts and national parent groups have repeatedly called for change, and there is an overwhelming feeling that the time for change is long overdue. I accept the noble Lord’s point that a decision should be reached as speedily as possible. I am advised that the IRP will report to the Secretary of State on 28 February 2013, or following the conclusion of any judicial review if such a review takes place.
The Lord Bishop of Leicester
My Lords, is the Minister aware, in spite of the technically clear Answer that he has given, that the overwhelming medical opinion is that the removal of this unit could lead to significant loss of children’s lives? Are he and the Secretary of State able to contemplate that possibility with equanimity?
Earl Howe
My Lords, of course I do not regard any possibility of children losing their lives with equanimity. I can only say that that aspect was carefully looked at by the JCPCT with strong clinical advice. It reached the conclusion that it would be safe to move the ECMO service to Birmingham.
NHS: Accident and Emergency Services
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Baroness Gardner of Parkes
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare my interest as a local resident.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the reconfiguration of front-line health services is a matter for the local NHS, and any decisions regarding changes to services will be taken locally. I understand that the local NHS has worked closely with Transport for London and also with the London Ambulance Service in developing its proposals for the future shape of health services across north-west London under the Shaping a Healthier Future programme.
Baroness Gardner of Parkes
I thank the Minister for that Answer. My Question could really apply to anywhere in the country. The general principle is how long it takes to get patients to hospital, particularly in emergencies, when it is a matter of life and death in some cases. In London, there is only one air ambulance; I understand that in Paris, there are four and in Sydney there are six. We cannot rely on one air ambulance to deal with the problem. Will the Minister consider the general principle of a national view of traffic in relation to access for ambulances?
Earl Howe
My noble friend makes some important points. As a general point, it is important to say that each ambulance service should plan to provide appropriate resources to meet local demand, because demand varies according to where you are in the country. Planning assumptions in meeting that demand should take into account the likelihood of severe traffic congestion. Plans of that kind may well include resources in addition to traditional ambulance provision, for example, using rapid response vehicles and motorbikes as well as utilising staff such as community paramedics or emergency care practitioners.
Lord Harris of Haringey
My Lords, how many accident and emergency departments in London does the Minister expect to close in the next four years? If he does not know the answer, can he say who is responsible for that and how they are accountable for making a strategic judgment across London about the level of accident and emergency services?
Earl Howe
The premise behind the noble Lord’s question is that it is automatically worse to have fewer A and E departments in an area. I beg to disagree with that premise. In serious or complex cases, the noble Lord will know that patients need to access exactly the right care, so it is often better and safer for them to travel further to see specialists in major centres than to go to a local hospital. Although it may be closer, it may not have the right specialists, the right equipment or sufficient expertise in treating patients with their condition. The prime example of that has been stroke care in London, where 32 centres were reduced to, I think, eight and there has been a dramatic reduction in the number of deaths following admission.
Baroness Jolly
My Lords, does the noble Earl agree that wherever there are improvements to patient care that involve restructuring not only of services but premises, the impact assessment in the consultation document should include general transport and ambulance access?
Earl Howe
I agree with my noble friend. The planning assumptions made in north-west London, which is the subject of the Question, are a good example of that, where Transport for London is co-operating actively by producing some sophisticated analysis not only of ambulance transport times but of bus and car journey times to make sure that nobody loses out in any reconfiguration.
Baroness Whitaker
My Lords, in the noble Earl’s answer to my noble friend Lord Harris, I did not hear an answer to any of his questions about numbers, who makes the decision and who is accountable. Would it be possible to hear that?
Earl Howe
My Lords, I apologise. The Question on the Order Paper relates to north-west London, so I do not have pan-London figures in front of me. The answer to the question is as I gave it in my initial response: those decisions are subject to local determination. That is right, because it is only local commissioners and providers who can assess the situation on the ground properly. As the noble Baroness will be aware, there is a system for escalating decisions—ultimately to the Secretary of State, if necessary, who takes advice from the Independent Reconfiguration Panel in the most extreme cases—but normally, we hope and expect those decisions to be resolved on the ground in the local area.
Baroness Masham of Ilton
My Lords, does the Minister agree that many patients have difficulties accessing their GPs and out-of-hours services? Does he realise that the only resource might be the A and E department? In a case of meningitis, that could be a death sentence if they cannot get that access.
Earl Howe
My Lords, I agree with the noble Baroness. That is exactly why the Government are planning to roll out the 111 service, which will run alongside the 999 service for emergency calls. But where the situation falls short of an emergency, the 111 service will instantly direct the patient to exactly the right service, without a call back being necessary. I am pleased to say that that programme is on track and should be rolled out next year.
Baroness Wall of New Barnet
My Lords, I declare an interest in Barnet and Chase Farm, which is currently being restructured. Does the Minister agree that, with any restructuring of services in the health service, the public are very concerned? A lot of effort is being made by the trust to assure people, but one of the things that keeps coming back—certainly for Barnet and Enfield—is that the bus services do not always work in the way in which the noble Earl has suggested, and that Transport for London is not always co-operative. Very often it is, but sometimes it is not; we are having a great deal of difficulty reorganising bus services in cases where Transport for London will just not hear of it.
Earl Howe
My Lords, in north London and Barnet in particular, Transport for London has diverted the 307 bus route into the grounds of Barnet Hospital, thus improving the link from Enfield. Transport for London has also installed new CCTV cameras in the underpass at North Middlesex University Hospital, in order to enhance its safety. There was a proposal to improve the local underpass at Silver Street station, and that was carried through. I am concerned to hear the noble Baroness’s perception, because all the briefing I have had indicates that Transport for London is very constructive in these situations and will often change bus routes in response to changes in service configuration.
Care Services: Elderly People
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Lord Hunt of Kings Heath
My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and I refer noble Lords to my health interests.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, providers of services are responsible for the safety and quality of the care they provide, and the well-being of the people they care for. Providers should undertake a risk assessment as to whether a criminal record check is needed or not, and what action to take as the result of such a check. Providers should keep a record of this process as an audit trail of their decision-making.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl, and of course we all welcome the rehabilitation of ex-offenders. However, I refer the noble Earl to reports that recent CQC inspections show that more than 220 care agencies working for older people in England have failed to show that they were employing properly qualified and vetted staff. What action will be taken about this? Further, does this not show that the time is now ripe for the statutory regulation of care-home workers?
Earl Howe
My Lords, it is the responsibility of the employing organisation to carry out appropriate checks on the people they intend to employ. They should take decisions in the context of their responsibility for the well-being of the people who use the service. That position has not changed, and indeed it must be at the core of the safeguarding agenda. Organisations need to risk-assess the suitability of their staff for the role, considering all the information they have on the person, including criminal record checks. If someone has a criminal conviction, the employer should consider how old and relevant that conviction is in the context of the activities that the person would be undertaking and the characteristics of the people they would be looking after. That situation cannot, I think, change substantively.
Lord Patel
My Lords, will the Minister follow up on the question asked by the noble Lord, Lord Hunt? What progress is his department making towards establishing skills requirements in the training and regulation of nurse support workers and care assistants?
Earl Howe
My Lords, we recognise that there is a need to drive up standards in this area. More care workers will be trained, including an ambition to double the number of care apprenticeships by 2017. We have commissioned Skills for Health and Skills for Care to develop, before the end of January next year, a code of conduct and minimum training standards for healthcare support workers and adult social care workers in England. We expect that these will cover minimum training or induction standards for a range of support tasks, including personal care and other activities. Through the Health and Social Care Act 2012 we are creating a system of external quality assurance for voluntary registers.
Baroness Gardner of Parkes
My Lords, is the Minister aware that it is not just an issue about criminals, but an issue about the total shortage of care, which the previous question addressed very clearly? Does he not think that in general care and healthcare we are sadly missing the SENs, and is it not time to develop additional levels of training to fill the gaps both in care homes and the National Health Service?
Earl Howe
My Lords, we need to focus on a mixture of things. As my noble friend rightly says, we need to look at workforce numbers and capacity. We need to look at minimum training standards, which I have referred to, and we need to look at quality. We are doing that by targeting for the first time personal assistants and their employers with greater support and learning through the Workforce Development Fund, which will help with recruitment and retention. We need better leadership because high-quality leadership is essential for the delivery of all the proposals in the care and support White Paper, and we are setting up a new leadership forum to bring together expertise. I should add that we need better intelligence on the ground as well, and that we shall see from the local Healthwatch organisations when they are established.
Baroness Pitkeathley
My Lords, the Minister has pointed out that the employer, the provider, is responsible for the recruitment and training of care workers, and I am sure he will confirm that that applies whether they work in the private, the public or, indeed, the voluntary sector. In view of some of the scandals that there have been involving care workers, does he agree that we need to encourage value-based recruitment so that people are recruited not only for their technical skills, which can be provided through training, but for their compassion and empathy?
Earl Howe
Yes, I firmly agree with that. It bears upon the point that I alluded to very briefly, which is that the risk assessment process should not just be a tick-box exercise. It should assess the suitability of the individual and their own characteristics, the environment in which they will be working, the kind of people for whom they will be working and whether they have the right skills and characteristics as the people required to do that job.
Baroness Masham of Ilton
My Lords, does the Minister agree that it is not only the elderly who are vulnerable but also some very disabled people, including some with learning disabilities?
Baroness Jolly
My Lords, safeguarding the vulnerable needs real commitment from us all. Will the Minister tell the House whether the Government intend to support this by ring-fencing funds, as have Wales and Scotland?
Earl Howe
My Lords, we are not taking that approach. However, we have declared our intention to strengthen safeguarding arrangements to prevent and reduce the risk of significant harm to adults in vulnerable situations. That is a key priority for the Government. We intend to put safeguarding adult boards on a statutory footing. This will assist in furthering the agenda which my noble friend rightly raises, by ensuring that organisations involved in safeguarding have to make a co-ordinated contribution to local adult safeguarding work. Of course, it continues to be an offence for a provider to employ a person barred by the Independent Safeguarding Authority.
National Health Service (Clinical Commissioning Groups) Regulations 2012
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Lord Turnberg
I am afraid that my message tonight will be rather familiar. Although I listened carefully to the noble Baroness, Lady Cumberlege, whom I respect enormously for her experience, I am afraid that I cannot agree with her. Commissioning services in the NHS is an extremely complex activity. For CCGs to make rational decisions, they need the best data and information available about their populations and how to meet their needs.
I understand that economists talk about perfect and imperfect markets. Perfect markets exist where both the purchaser and provider know exactly what they are getting and giving. This is particularly important when we talk, for example, about packages of integrated care, especially care across the hospital community divide. Who better to provide the data and information that CCGs need than those working locally in our hospitals? CCGs should not only understand the needs of their populations; they also need to know something about what can realistically be provided locally to meet those needs. Relevant questions might include whether the local hospital provider has the relevant orthopaedic surgeons who can do specialised and complicated knee or hand surgery, whether it has the oncologists and haematologists to deal with all cancers or only some, and whether it has the relevant up-to-date scanning facilities. There will be a dozen other questions that only local knowledge can answer.
It seems obvious to many in the field that local specialists and nurses from the local trust are in much the best position to provide the answers, and to engage constructively with GPs in the provision of services. The idea that there is a conflict of interest appears to me to be nonsense. Of course there is local interest. Local consultants and nurses are there to provide local knowledge and information. The idea that consultants and nurses from elsewhere can be parachuted in to provide local information is asking too much, quite apart from the problem of whether another trust will be willing to allow its staff time off to travel around the country.
We do not want or need disinterested clinicians in the CCGs; we need interested clinicians. I hope that the noble Earl will listen if not to my noble friend Lord Hunt then to the royal colleges, which are very strongly in favour of local input from the secondary sector.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Hunt, for tabling this Motion, which provides a welcome opportunity to clarify the Government’s intentions in making these regulations on clinical commissioning groups—an opportunity that I feel is rather necessary in the light of some of the speeches that we heard this evening.
The regulations set out the legal requirements on the size and membership of a CCG’s governing body. Together with amendments made to the National Health Service Act 2006 by the Health and Social Care Act 2012, they provide a clear legal framework within which CCGs can appoint their governing body and develop appropriate governance arrangements. CCGs will be different from previous commissioning organisations. They will be built on the GP practices that together make up the membership of the CCG. These member practices must decide, through developing their constitution, how the CCGs will operate. They must ensure that they are led and governed in an open and transparent way that allows them to serve their patients and population. It is vital that CCGs are clinically led, with the ownership and engagement of their member practices, so that they can bring together advice, as noble Lords emphasised, from the broadest range of healthcare professionals to influence patterns of care and to focus on patients’ needs.
That is a necessary preface to the subject that has been the focus of much of tonight’s debate: the role of the governing body of the CCG. Following the NHS Future Forum, we introduced measures in the then Health and Social Care Bill to strengthen governance arrangements for CCGs, primarily through the requirement for each CCG to have a governing body that would have responsibility for ensuring that the CCG operates effectively, efficiently and economically, and does so with good governance. As we discussed during the passage of the Bill, our intention was to provide the public with greater confidence that CCGs would have suitable governance arrangements in place, including independent views and strong leadership, and would have proper checks and balances for the stewardship of public money. CCGs will be the guardians of significant amounts of taxpayers’ money. It is therefore only right that there are strict requirements in relation to governance, probity and transparency of decision-making. We must balance the benefits of the clinical autonomy of doctors with a robust management of potential or actual conflicts of interest. It is essential to get this right, and that means a proportionate and reasonable approach.
The Health and Social Care Act already provides real safeguards against conflicts of interest. The CCG must make arrangements in its constitution for managing conflicts and ensuring the transparency of its decision-making process, and it must have appropriate governance arrangements, including a governing body with lay members and other health professionals. These arrangements will be scrutinised by the NHS Commissioning Board as part of the process of ensuring that a CCG is fit to be established as a commissioner.
The requirements in relation to the secondary care doctor and registered nurse are therefore part of an overall package of requirements to ensure that they operate with good governance. We made clear in the Government’s response to the NHS Future Forum in June last year that neither the secondary care doctor nor the registered nurse should be from a local provider in order to prevent any potential conflicts of interest. We did that because a conflict of that nature would be a constant issue for a secondary care provider, given that CCGs will be responsible for commissioning the vast majority of hospital services. In contrast, CCGs will not commission primary care—that will be the responsibility of the NHS Commissioning Board. Therefore, for the most part, GPs on the governing body do not have a conflict of interests, and in any case GPs will not necessarily be in the majority on a CCG governing body.
On any occasion where CCGs consider commissioning local community services, arrangements must be made to manage both actual and potential conflicts of interest in such a way as to ensure that they neither affect the integrity of the CCG’s decision-making process nor appear to do so. The NHS Commissioning Board has issued guidance and a code of conduct for CCGs to deal with that set of circumstances.
What then is the role of the secondary care doctor and registered nurse on a CCG governing body? Their primary role, along with other members of the CCG governing body, will be to ensure that the governing body exercises its functions effectively and with propriety and absolute fairness. However, each member of a governing body will be expected to bring additional perspectives to underpin the work of a CCG. For the specialist doctor and the registered nurse, this perspective will be to provide a view beyond primary care and a broader understanding of health and social care issues—specifically patient care in a secondary care setting for the specialist doctor and, for the nurse, the contribution of nursing to patient care.
That is different from the role of clinicians in commissioning. Involving clinicians in commissioning has been one of the primary goals of our healthcare reform. I need to underline that as it is very much separate from the specific role of the CCG governing body. The detailed work on service design will not be done by the governing body of a CCG: rather, it will be done by the CCG itself, working with clinical networks and other multiprofessional groups. The governing body will have oversight of the governance of this decision-making process.
CCGs have a legal duty to obtain advice from people with a broad range of professional expertise when carrying out their commissioning responsibilities. My noble friend Lady Williams was absolutely right in saying what she did on that score. This could involve, for example, a CCG employing or retaining healthcare professionals to advise the CCG on commissioning decisions. Local knowledge and an in-depth understanding of local health issues will come not only from local GPs and their member practices but from other local clinicians, including local secondary care clinicians, who will work with CCGs to review local health needs and design local services. So the arguments presented by the noble Lord, Lord Hunt, and others around excluding local secondary care clinicians from the governing body as affecting the quality of the CCGs commissioning are wholly misplaced.
As to the restrictions placed on councillors preventing them from serving on CCG governing bodies, I start with a point of principle. We have been very keen from the outset of our reform programme to limit political interference in the day-to-day activities of the NHS. We have always been clear about that. Consequently, in addition to local authority members, we are also excluding MPs, MEPs and London Assembly Members from serving on a CCG governing body. However, our proposals do not mean that councillors are excluded from CCGs. A local councillor may still serve as a member of a committee or sub-committee of a CCG governing body, with the exception of the remuneration committee, as long as a CCG has set out the arrangements for such a committee in its constitution. A councillor falls within the description of an individual “specified in the constitution” as being eligible for membership of a committee. A CCG may provide in its constitution for any function of the governing to be exercised on its behalf by a committee or a sub-committee of the governing body, or by any individual of a description specified in the constitution. These arrangements could therefore allow for a local councillor to play a pivotal role in the CCG’s decision-making without formally being on the governing body.
Earl Howe
My Lords, the question I was asked was about the officers of local authorities, and I hope I have clarified that. A member of a local authority is an elected councillor, of course, and is debarred from a governing body, as we have discussed. If the noble Lord, Lord Harris, will allow me, I will write to him on the point.
Lord Harris of Haringey
Paragraph 5 of Schedule 4 refers to:
“An employee of a Primary Care Trust”.
Lord Harris of Haringey
They may be excluded from being a lay member, but one of the lay members is defined as someone who has,
“knowledge of the local area”.
However, if by chance they happen to be a part-time employee of any local authority in the country, they are excluded, and I want to know why that is. Why not leave it to the good judgment of the local people?
Baroness Thornton
Before the noble Earl leaves the issue of lay members, I have a question about having only two lay members—I am sorry that I did not jump up in time to ask it before he started summing up. The noble Earl and I sat opposite each other for several years discussing regulatory reform of the NHS, and one thing that I think we agreed on was that for all the new regulatory bodies that are now appointing lay members, 50:50 was the right balance to ensure proper regulation and accountability. Why is that not the case with the CCGs? What is different here? We felt that it was safer to have 50% in the regulatory reform of the NHS. Why do we not have 50% on the CCGs?
Earl Howe
My Lords, it will be up to local CCGs to determine their own constitutions, as I have said. What we are attempting to do in these regulations is simply to set down the bare minima. As we discussed during the passage of the Act—these provisions were well rehearsed—providing there are two lay members, a secondary care clinician, a nurse and an accountable officer, that is the extent of the prescriptiveness that we feel is appropriate from the centre. Otherwise, it looks very much like the Government dictating the governance arrangements. The Future Forum’s recommendations were very clear that we should not go down that path.
It was suggested that CCGs were experiencing difficulties in appointing secondary clinicians or a registered nurse. I understand the concerns that noble Lords have raised on that score but I have recently spoken to the NHS Commissioning Board, which has started the process of considering applications from emerging CCGs. The news I have is that CCGs have so far successfully recruited to these roles. In addition, the medical and nursing royal colleges have offered to help CCGs in sourcing appropriate candidates, which is very welcome.
The noble Lord, Lord Warner, referred to the HSJ article of 11 October. I will clarify my answer when I write to him, which I will be happy to do. We are very pleased not only that so many clinicians have chosen to apply for leadership roles, which they have, but that so many first-rate clinicians have done so, whether as clinical chairs or clinical officers in CCGs. What is important is that there is a good mix of expertise in the broader leadership team of clinicians and managers, to help the CCG discharge its responsibilities effectively, and that is what we are now seeing.
I have a number of examples of where the drive towards integration is really taking shape on the ground. My noble friend Lady Jolly mentioned South Devon and Torbay; this is a service designed by secondary care doctors and GPs working together in a clinical pathway group for urology, and the whole impetus of the CCG is to improve collaboration and get over the gulf between primary and secondary care. There is another excellent example of integrated services in Wokingham, which again I would be happy to write about.
The noble Lord, Lord Hunt, asked whether police commissioners and Peers could be members of a CCG governing body. Yes, they can. He also asked who was consulted over these regulations. As I have indicated, the proposals were developed in response to the NHS Future Forum, the listening exercise that set out requirements around the secondary care doctor and registered nurse. The proposals were further discussed with emerging CCGs, primary care organisations, the medical royal colleges and, yes, colleagues in the NHS Commissioning Board Authority.
The regulations discussed today provide a fair and transparent rules-based framework to complement the provisions in the Health and Social Care Act around the establishment of CCGs. Creating a responsible and accountable CCG with good governance is essential for good management, good performance, good stewardship of public money, good public engagement and—our ultimate goal—good outcomes for patients. I commend the regulations to the House.
Lord Hunt of Kings Heath
My Lords, I shall be brief. I thank the noble Earl, Lord Howe. He started by referring to the importance of clinical leadership and I would not disagree with him, but he has not really answered the point that the biggest potential conflict of interest is if GPs are in a majority on the boards—and I would hazard a guess that, in most places, they will be. They do not commission primary care, but their decisions can shift resources into primary and community care services. That is the essential conflict of interest.
The Government’s legitimisation of what must be some of the worst drafted regulations that I have ever come across would stand up in relation to conflicts of interest in other professions if one had any inkling at all that they recognised that CCGs carry a huge risk in relation to the GPs’ own position. The Minister said that the CCGs are about clinical leadership. As my noble friend Lord Warner pointed out, you are not even getting that, because only 20% or so of the accountable officers of those CCGs are to be GPs. The remainder are to be managers. Let us be clear: the accountable officer will in effect be the chief executive. The noble Baroness, Lady Finlay, said that the exclusion of local consultants and nurses from CCGs would mean that, in large parts of the country, the people appointed would have no local knowledge whatever. I agree that, in London, it may be more practical; in most of the rest of the country, it will not be.
I agree with all the points raised by the noble Baronesses, Lady Jolly and Lady Williams, but it is not sufficient to say that there will be a review in 2014. At this late stage, I invite them to join us in the Lobbies tonight. I could not disagree with anything that either noble Baroness has said. They tore apart the regulations. Will they not join us tonight?
I was amazed by the remarks of the noble Baroness, Lady Cumberlege. She came to the health service, as did I, through local government. Local government is having to take some immensely tough decisions. Having a local authority councillor around the board table of a CCG would help legitimise its decisions and help tie in the local authority with difficult decisions that have to be made. Excluding them is a huge mistake. I do not understand—clearly, the department forgot them—why elected police commissioners are deemed worthy of service on a CCG board when elected MPs and councillors are not. When my noble friend Lord Prescott is duly elected a police commissioner in a few weeks’ time, as one hopes, he will be eligible to serve on the whole clinical commissioning group, but no MP and no councillor. These are some of the most nonsensical regulations that I have ever seen.
The Minister said that we should not worry because local authority councillors, local doctors and local nurses can serve on the committees of a CCG—no conflict of interest there—but they cannot serve on the board. However, the board is the sovereign decision-making body of the CCG. I would have thought that most clinical commissioning groups would have wanted to have local expertise, whether it is local authority representation, a doctor or a nurse.
The Minister then said that these are only minimum requirements. Well, Schedule 4 states:
“Individuals excluded from being lay members of CCG governing bodies … An employee of a local authority in England and Wales or of any equivalent body in Scotland or Northern Ireland … A chairman, director, governor, member or employee of an NHS foundation trust”.
Excluding a chairman, director or governor of a foundation trust is fair enough, but a member? My trust has 100,000 members. Patients are automatically enrolled in membership of my trust unless they decide to opt out. We are talking about 100,000 people living in the catchment area of my hospital who are not allowed to be lay members of a CCG. Surely they are the very people you would want to be lay members of a CCG.
Lord Hunt of Kings Heath
My Lords, I am most grateful to the noble Earl for that enormously helpful clarification. The point is this: why should they not be statutory lay members of the CCG? There is no guarantee that CCGs will appoint any more lay members. I have yet to hear any rational explanation as to why this statutory instrument has been drafted in this way.
As we know, the noble Earl, Lord Howe, is a very fair man and always engages in debate. He will know that this statutory instrument has been ripped apart tonight. Even at this late hour, I ask him to withdraw the instrument. If he is not prepared to do so, I will test the opinion of the House.
NHS: Professional Qualifications Directive
Earl Howe Excerpts(11 years, 6 months ago)
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Lord Kakkar
To ask Her Majesty’s Government what progress they have made in negotiations at European level on the working time and recognition of professional qualifications directives in the light of their impact on the delivery of care in the NHS.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, negotiations on both directives are ongoing. The Government remain of the view that both measures should support labour-market flexibility without imposing significant extra costs on member states to ensure that any negative impacts that we have seen are ameliorated and, most importantly, to ensure that patient safety is maintained.
Lord Kakkar
My Lords, I declare an interest as professor of surgery and consultant surgeon at University College London Hospitals. In today’s Daily Telegraph the presidents of the Royal College of Surgeons and the Royal College of Physicians make an urgent plea for action on these two elements of legislation to halt a devastating deterioration in clinical training and patient safety. Do Her Majesty’s Government collect data on the number of patients harmed as a result of the implementation of these two directives, for instance from coroners’ inquests where they have been implicated in patient deaths, and on the financial consequences in terms of the employment of locum doctors in the NHS to ensure that hospitals are 48-hour-week compliant? If these data are not collected will the Minister commit to organising for their collection in the future to better inform this Parliament and to add impetus to the Government’s negotiations with their European partners?
Earl Howe
My Lords, it is the responsibility of individual NHS trusts to ensure that service rotas are compliant with the working time directive. In line with the Government’s coalition agreement to reduce duplication and resources spent on administration, the department reduced bureaucracy for the service by removing the burden of central monitoring of compliance and we are leaving this role to organisations at local level. The last assessment of the working time directive was undertaken in January 2010 and reported that nearly 99% of doctors’ rotas were compliant with the directive but we are in no doubt about the concerns that exist within the medical professions about the inflexibilities within the rules of the directive. As regards the mutual recognition directive, the department does not plan to collect directly any data relating to it. The professional regulators. who are the competent authorities, collect data in respect of the number of people applying for recognition under the directive.
Lord Ryder of Wensum
My Lords, is my noble friend aware of the fact that the clinicians at the Institute of Cancer Research where I am the chairman regard the working time directive as being of no benefit at all to their patients? In view of this fact, can he please tell me now—or if not now, in a letter with a copy placed in your Lordships’ Library—the details of the meetings that have taken place between Ministers and senior officials and their opposite numbers in Brussels? The Government have long believed that they are able to revoke or to revise this directive but so far, after two and a half years, I see no progress at all.
Earl Howe
My Lords, it is important to understand that the EU social partner process, which is driving the discussions at the moment and has been extended to 31 December, is autonomous. It operates independently of both the Commission and the Council and the Government have no formal role in any social partner negotiations. Having said that, we have made it clear to the Commission and to partners in Europe that securing long-term sustainable growth has to be the EU’s key priority. We will continue to work with our partners to ensure that EU measures support labour-market flexibility and do not impose significant costs on member states or burdens on business. The Government would welcome proposals coming forward that would preserve the right for all workers, including those in the NHS, to choose the hours that they work, including in particular flexibility in the areas of on-call time and compensatory rest as well as the preservation of the individual opt-out.
Lord Turnberg
Does the noble Earl agree that the working time directive as it now operates is detrimental both to patient care and doctor training? Is it not time that we stopped at least the nonsense of counting time in the 48 hours as time when one is on call, even though one may never be called? Will the noble Earl make sure that the case is made to the EU that at least this part of the directive is rescinded?
Earl Howe
The SiMAP and Jaeger judgments are very much the focus of our representations to the EU Commission. The disquiet about those judgements and the inflexibility that they have brought is shared by other member states. It is also important to recognise that none of us wants to go back to the past, with tired doctors working excessive hours. Tired doctors make mistakes; there is substantial evidence to support that. No one wants or deserves to be treated by tired doctors. There is a balance to be struck. The inflexibilities in the directive need to be addressed, but we should not go back to the bad old days when doctors became too tired to do their work.
Baroness Jolly
My Lords, if a clinician fails to understand a patient or to make themselves understood, their clinical competence is undermined. Will the noble Earl tell the House the current situation regarding the required level of English language competence of a doctor or other clinician from an EU state who wishes to practise in England?
Earl Howe
My Lords, we are now talking about the mutual recognition of professional qualifications directive. We have made it clear that we want to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests. As a result, we have explored the idea of strengthening language testing for doctors through the use of responsible officers; and explored also the GMC’s ability to take action where concerns arise. The directive review is a key priority for the Government, and the Commission’s proposals include greater flexibility on language. It is helpful that the proposal from the Commission makes it clear that controls on language checks are permissible and may be undertaken before a professional is able to practise.
NHS: Walk-in Centres
Earl Howe Excerpts(11 years, 7 months ago)
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Lord Collins of Highbury
To ask Her Majesty’s Government how many NHS walk-in centres have been closed or had their opening hours restricted since May 2010, and how many are scheduled to close or have their opening hours restricted.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, since 2007, the local NHS has been responsible for NHS walk-in centres. It is for primary care trusts to decide locally on the availability of these services. No information on walk-in centre closures or opening hours is held centrally.
Lord Collins of Highbury
My Lords, I was expecting that response. Will the Minister acknowledge that these closures will channel, unnecessarily, patients towards accident and emergency departments at times when GP surgeries are also closed? This will almost invariably increase NHS costs in the medium term. Or is the Government’s strategy to blame local clinicians for cuts in NHS services?
Earl Howe
My Lords, the Government’s clear policy is that people should be able to rely on high-quality, 24/7 urgent and emergency care that is right for them, when they need it. That is our starting point.
I say to the noble Lord that since walk-in centres were invented the array of services available to patients has been considerably enhanced. It is not just a case of going to an A and E department as an alternative. There are now many GP health centres, minor injuries units, urgent care centres and, in the extreme case, ambulance services, so I do not necessarily accept the premise of the noble Lord’s question.
Baroness Masham of Ilton
My Lords, is the Minister aware that I have a colleague who went to the Victoria walk-in centre and found it closed? She went, in the end, to St Thomas’s. The whole procedure took her four hours. She had a urinary infection. Many of the people who go to these centres are working people who come up to cities and are away from their home environment.
Earl Howe
My Lords, I am sorry to hear of the experience of the noble Baroness’s friend. I asked my officials to let me know which walk-in centres were available within striking distance of this building. There are, in fact, five NHS walk-in centres in or very near central London. I am aware of another privately run centre as well. A quick search on NHS choices will bring you to a menu of options.
Baroness Gardner of Parkes
My Lords, will the Minister tell me whether all general medical practitioners have surgeries where you can walk in at some time of the day? That would take quite a load off people. Is that an obligation? My practice has this and it is marvellous. You can go in at 8.30 on any morning and will be seen if you are an emergency. Is that common? Is there a need for more of that?
Lord Harrison
Does the Minister share my surprise that data are not available for the number of closures of such walk-in centres in the past two years?
Baroness Jolly
My Lords, no one doubts the worth of walk-in centres or minor injury units. It is well established, but we need to know where they are. Will the noble Earl tell the House how often the information on the Department of Health website is updated? Who is responsible? Will he please pass on the message that it is woefully out of date and inaccurate, thus defeating its object?
Lord Brooke of Alverthorpe
My Lords, reverting to the earlier question about access to GPs, I hope that the NHS and the Minister will have information on the length of waiting times for patients to see their doctors. Indeed, we had questions on this issue earlier in the year. What steps have been taken to reduce the ever-increasing length of waiting lists to see doctors, particularly in the London area?
Earl Howe
My Lords, the noble Lord raises an important point. I am aware that in certain parts of the country there is considerable concern about the length of time that patients sometimes need to wait for a GP appointment. However, that is not the case all over the country. We expect GP practices to configure themselves so as to ensure that the waiting time is kept to a minimum. It is an area on which we are working closely with the profession to resolve.
The Earl of Sandwich
The Minister knows that there are patients who are suffering acute symptoms from prescribed-drug addiction and withdrawal, as well as from taking illegal drugs. Some of those people are in great distress. Where should they go now in the NHS if they suffer these acute symptoms?
Abortion
Earl Howe Excerpts(11 years, 7 months ago)
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Baroness Thornton
To ask Her Majesty’s Government whether they intend to legislate to reduce the time limit for abortions.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government have no plans to review the Abortion Act 1967. It is parliamentary practice that any proposals to change the abortion laws come from Back-Bench Members and that decisions are made on the basis of free votes. The current time limit for an abortion is 24 weeks’ gestation.
Baroness Thornton
I thank the noble Earl for that Answer. He must forgive me and others for being worried about this matter after recent statements from his right honourable friend the Secretary of State and other senior members of the Government, who of course have a perfect right to their personal views, but we also need to know how that might influence public policy. For clarification, does the Minister mean that the Government will not support any change to the abortion time limits for the duration of this Parliament? Indeed, when will the Department of Health publish its sexual health policy document, which has been delayed for the past 18 months? Will it include any reference to abortion time limits, availability and funding?
Earl Howe
My Lords, I am grateful to the noble Baroness for acknowledging that my right honourable friend is entitled to express his long-held personal view, which he did the other day. With regard to her first main question, however, successive Governments have taken the view that they should rest on the evidence. There is currently no call from the main medical bodies for a review of the Act in relation to time limits, and the British Medical Association and the Royal College of Obstetricians and Gynaecologists support that view. I hope that the noble Baroness regards that as a clear enough answer in support of my initial Answer. As regards the work that is being done in my department, it is expected that the sexual health strategy will be published within a few months.
Lord Laming
My Lords, can the noble Earl assure the House that he will use his very well respected skills to persuade colleagues across government and indeed more widely that this matter needs to be handled with great care and sensitivity for the well-being of children and women and indeed for the well-being of all the adults involved in the process? This matter can have a life-long effect on everyone involved and it needs to be handled with care.
Lord Hamilton of Epsom
We have an Abortion Act today because a Private Member’s Bill was introduced by David Steel—now the noble Lord, Lord Steel—in another place. I voted for that Bill, although I am not sure that I voted for abortion on demand, which we now have, but surely that is the right way to deal with these matters—a free vote in the House of Commons and in your Lordships’ House—and that should continue.
Baroness Gould of Potternewton
My Lords, further to the Minister’s reply, some time ago the Government set up a parliamentary committee, of which I was a member, to look at counselling for abortion. For some time we have had no idea whether that will go ahead. Can the Minister tell us whether the consultation planned at that time will go ahead? Further, can he indicate the outcome of the review of abortion services conducted by the Care Quality Commission?
Earl Howe
My Lords, the department is currently considering the best way to make progress with pregnancy options counselling in the context of improvements to sexual health as a whole. As regards the noble Baroness’s second point, the Care Quality Commission looked into the allegations that were made about the pre-signing of HSA 1 forms and found that a number of trusts were non-compliant. The CQC is working closely with these trusts to ensure future compliance, but we are awaiting the conclusions of the investigations by other agencies, including the police, the GMC and the Nursing and Midwifery Council.
The Lord Bishop of Derby
My Lords, does the Minister agree with the comment on this issue made by my colleague the most reverend Primate the Archbishop of Canterbury that every abortion is a tragedy? I think that that is the context in which this matter features in people’s lives and why counselling is important. Further, will the Minister consider whether there should be a proper debate in this House about the social and moral issues surrounding the enormous increase in the number of abortions?
Earl Howe
My Lords, I am sure that the whole House will greatly respect the moral authority that the most reverend Primate carries in all quarters of our community. As regards the law itself, however, we must remember that it was a measure passed by Parliament as a whole. Abortions in this country are carried out legally under the terms of the Act and that must remain the position until Parliament decides otherwise.
Lord Wigley
My Lords, will the Minister accept that the introduction of the Act by the noble Lord, Lord Steel, was to head off the horrifying numbers of back-street abortions? Whatever the view of this Chamber and another place may be on the matter in general, we must avoid by all means reverting to that possibility.
Lord Elton
My Lords, my noble friend Lord Hamilton referred to abortion on demand and the right reverend Prelate referred to the great increase in the number of abortions. Can my noble friend tell us how many abortions there have been in the past 12 months for which he has figures and, if possible, how many of those were for mothers who have previously had abortions?
Earl Howe
My Lords, in 2011 in England and Wales there were 189,931 abortions. On the question of repeat abortions, I can tell my noble friend that there is a mildly encouraging statistic in that the number in the very young is going down. I am happy to write to my noble friend with further particulars.
Baroness Symons of Vernham Dean
My Lords, is not the issue here the concern about late abortions at 24 weeks when children are possibly coming to a point of independent viability? Can the Minister tell us the most recent statistics for abortions that take place between 23 and 24 weeks, as it is the issue of late abortions that is causing so much concern?
Earl Howe
My Lords, 91% of abortions in England and Wales were carried out at under 13 weeks’ gestation and 78% were at under 10 weeks’ gestation. The under-10 weeks’ percentage has risen since 2002, when the figure was 57%. Returning to the question asked by my noble friend Lord Elton, the proportion of repeat abortions for all women having abortions in 2011 was 36%, which is slightly higher than the previous year; 26% of women aged under 25 undergoing abortion had had one or more previous abortions, which was slightly higher than the proportion in 2010.
NHS: Evidence-based Medicine
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Lord Taverne
To ask Her Majesty’s Government whether they will ensure that treatment provided by the National Health Service is founded on evidence-based medicine.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, evidence should be at the heart of modern medicine. The National Institute for Health and Clinical Excellence develops authoritative, evidence-based guidance that we expect the National Health Service to take fully into account in its decision-making. However, it is ultimately the responsibility of clinicians to determine the most appropriate treatments to prescribe, in discussion with their patients and taking account of individual clinical circumstances.
Lord Taverne
My Lords, the Secretary of State has announced his support for homeopathy and his opposition to research into hybrid stem cells. He has also stirred up the abortion debate. Would the Minister perhaps persuade the Secretary of State to make a public reassuring statement that he will not use his position as head of the health service to promote the kind of anti-science views and primitive social attitudes which are normally associated with the American Tea Party?
Earl Howe
My Lords, I would expect that my right honourable friend the Secretary of State is well aware of the public comment on his recent statements, but he is entitled to his personal views. The Government’s position remains that it is the responsibility of local NHS organisations to make decisions on the commissioning and funding of healthcare treatments, such as homeopathy, for NHS patients.
Lord Hunt of Kings Heath
My Lords, I refer the House to my interests in the register. Following up that point, does the Minister not think that the Secretary of State should at least show some discretion when he comes to make statements on these issues in the sense that he is also head of the Department of Health and the National Health Service? In relation to his response on NICE and guidance, is he satisfied that the technology appraisals that NICE issues are indeed implemented by the health service?
Earl Howe
My Lords, I do not think I can add to what I said previously as regards my right honourable friend. No doubt he will take the noble Lord’s comments into consideration. As regards NICE guidance, as the noble Lord will know, there are concerns that in certain parts of the health service NICE guidance is not followed as we would expect it to be. There are various initiatives in train to correct that, both as regards the NICE technical appraisals and also clinical guidelines.
Baroness Meacher
My Lords, the noble Earl knows very well that NICE has issued excellent guidance in relation to the increased access to psychological therapies, and these therapies are the best way, according to the evidence, to deal with depression and anxiety. Can the Minister explain to the House what actions he will take to make sure that these evidence-based therapies are available across the country? As the Minister knows, at present they are not.
Earl Howe
The noble Baroness will remember that one of the features of the Health and Social Care Act is a duty placed on the NHS Commissioning Board to promote the quality of care. In doing that, it will promulgate commissioning guidance based on advice received from NICE. In the mandate there is another means for the Secretary of State to ensure that instruments such as NICE clinical guidelines get traction within the health service.
Lord Walton of Detchant
The Minister has given a reasoned response to the Question posed by the noble Lord, Lord Taverne. I had the privilege some years ago of chairing the House of Lords Select Committee inquiry into complementary and alternative medicine. There is evidence that certain aspects of those disciplines may be of benefit to patients. I am a strong supporter of clinical freedom on the part of clinicians. Having said that, does the Minister not fully agree with the point made by the noble Lord, Lord Taverne, to the effect that the careful inquiries carried out by the National Institute for Health and Clinical Excellent have been influential, and importantly so, in indicating clearly which forms of treatment are effective in the management of illness and disease, which should be supported by the NHS and which, if they are not evidence based, should not be paid for by public funds?
Earl Howe
I agree with the noble Lord. He will know that the guidelines issued by NICE are condition specific. They bear in mind that if there is evidence to suggest that certain procedures may not benefit patients, it would be appropriate for commissioners to consider restricting access on grounds of clinical effectiveness.
Baroness Williams of Crosby
Does the Minister agree that in situations where the mandate is to be issued—of course, it has just concluded its consultative period—the emphasis should be placed clearly on the need to recognise that mental health is of similar importance to physical health in the whole of the NHS’s projections? Could this also perhaps be an opportunity to underline the significance of NICE advice to GPs and others?
Earl Howe
My Lords, my noble friend makes an extremely important point which was of course the subject of debate during the passage of the Health and Social Care Act. She will know that, in the draft mandate, there was considerable emphasis on mental health. I shall take her views firmly into account as we go forward into finalising the text of the mandate.
Lord Patel of Bradford
My Lords, the UK is blessed with an excellent evidence base on the treatment of drug misusers. Can the Minister reassure the House that government policy around illegal drug use and treatment for drug users is based on that evidence base and not on what appears to be a policy direction of abstinence only and punishment for drug users?
Baroness Wall of New Barnet
My Lords, I am surprised that in his response to the noble Lord, Lord Taverne, the noble Earl did not remind him of the health and well-being boards which make decisions now about what is happening locally. Certainly, from my experience, homeopathy has been one of the issues that the health and well-being board in Enfield has been looking at. Obviously, the evidence base is important, but should not that direction on what is locally required be made a priority?
Earl Howe
The noble Baroness makes an important point, and of course she is right that health and well-being boards will be very important forums for establishing the clinical priorities in geographic regions and then setting strategies to meet those priorities. However, in the end, it is for commissioners and individual clinicians to decide what is best for patients in a particular area.
Health: Cancer
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking my noble friend for tabling today’s debate and for her excellent speech. I am aware that this is a very important issue for her, for everyone who has had a diagnosis of cancer of the head and neck, and for their families and friends.
The incidence of head and neck cancer in England rose from over 8,300 to over 9,600 between 2007 and 2010, while the incidence in the under-65s rose from just over 4,800 in 2007 to over 5,600 in 2010. We know that for most cancers death rates are set to fall significantly in the coming decades. This is encouraging and highlights the impact of changes in lifestyle, particularly reductions in smoking, and improvements in the speed of diagnosis and the treatment of cancer. As noble Lords have pointed out, there are a number of risk factors that can increase the chances of developing cancer, including oral cancer. Cancer Research UK has recently estimated that over a third of all cancers are caused by smoking, unhealthy diets, alcohol and excess weight.
Let me look first at smoking. The Tobacco Control Plan for England, published in March 2011, sets out three new national ambitions to reduce smoking prevalence—among adults, among 15 year-olds and in pregnancy—and sets out a comprehensive range of tobacco control actions at all levels to achieve these ambitions. The Committee will also be aware of Stoptober, a new and innovative campaign that encourages smokers all to start their quit attempt together on 1 October. As for alcohol, the Government’s alcohol strategy includes a strong package of health measures. These build on the introduction of the ring-fenced public health grant to local authorities and the new health and well-being boards, giving local areas the powers to tackle local problems.
Most people know that smoking causes lung cancer and sunburn causes skin cancer. However, far fewer people know that a poor diet, obesity, lack of physical activity and high alcohol consumption are also major risk factors for getting cancer. To deliver on improved outcomes, public health services will provide people with information about these risk factors so that they can make healthy choices.
We know that HPV is associated with around a quarter of head and neck cancers. The National Institute for Health Research Clinical Research Network is currently hosting four trials focusing on the link between HPV and head and neck cancers. The Medical Research Council is also currently supporting two studies relating to the links between HPV and head and neck cancers.
Late diagnosis is also a cause of avoidable deaths from cancer in England. Generally, as my noble friend Lady Gardner pointed out, the earlier a patient is diagnosed with cancer, the greater the chance of being successfully treated. In order to achieve earlier diagnosis, we need to encourage people to recognise the symptoms of cancer and seek advice from their doctor as soon as possible. We also need doctors—and, where appropriate, dentists—to recognise these symptoms as possibly being cancer and, where appropriate, refer people urgently for specialist care. The Government have committed over £450 million over this spending review period to improve earlier diagnosis. Through the national awareness and early diagnosis initiative jointly led by the department and Cancer Research UK, we are working to improve earlier diagnosis by raising public awareness of the symptoms of cancer and encouraging earlier presentation. We are developing a “constellation of symptoms” campaign during January to March 2013 which will highlight symptoms that might be the result of a number of cancers, including rarer cancers.
We will hold the NHS to account for improvements in outcomes through the NHS outcomes framework. As the noble Baroness, Lady Morgan, mentioned, we are working with the London School of Hygiene and Tropical Medicine to develop a composite survival rate indicator which covers all cancers to ensure that performance on rarer cancers can be monitored effectively. In addition, there is a cancer mortality indicator that is shared between the public health outcomes framework and the NHS outcomes framework, which is designed to improve prevention—to reduce incidence—as well as improve diagnosis and treatment.
The balance between composite and tumour-specific cancer survival indicators always needs to be considered. It is currently being considered. I would say to the noble Lord, Lord Hunt, on the composite indicator, that these are complex measures requiring linkage of ONS population statistics with cancer registry data and attribution to clinical commissioning groups as well as testing the robustness of the measures. It is likely to take some months to complete the work that is currently in train. The commissioning board will decide, of course, on the content of the commissioning outcomes framework. It is expected to publish a list of measures for 2013-14 in the autumn. If the composite indicators are not included in the 2013-14 framework, the board may choose a separate publication route for the data that exist to ensure that the information is available transparently to the public.
I know that there is concern on the part of Macmillan Cancer Support, among others, around proxy indicators. I understand that the NHS Commissioning Board Authority is now engaging with clinical commissioning groups and other stakeholder organisations to discuss the shape of a commissioning outcomes framework, as I mentioned, for 2013 and beyond.
We recognise that there is a role for dentists in the early detection of some head and neck cancers, including mouth or oral cancers. We are working to ensure this, and the new patient pathway currently being trialled in 70 practices provides dentists with decision support based on current best practice. Patients receive comprehensive oral health assessments at regular intervals under this pathway. Those assessments require dentists to systematically assess the soft tissue as part of the clinical examination and include a social and medical history which, through the questions on smoking and drinking, allow the dentist to assess the patient’s level of risk for oral cancer and, if appropriate, offer advice on lifestyle changes. The pathway is being piloted as part of the work to design a new dental contract. The Government are committed to introducing a new contract based on capitation and quality. Supporting dentists to systematically provide high quality care through the pathway is a key part of this. I can tell both my noble friends that the General Dental Council has recently confirmed that improving early detection of oral cancer is to be included as a recommended topic in its continuing professional development scheme. More generally, the department supports the British Dental Health Foundation which sponsors annually a mouth cancer action month; officials work closely with the foundation as well.
Once head and neck cancer is diagnosed, patients need to have access to appropriate and consistent treatment, delivered to a high standard, across the board. Improving Outcomes in Head and Neck Cancers, published in 2004, set out recommendations on the treatment, management and care of patients with head and neck cancers. We have made a commitment to expand radiotherapy capacity by investing around £150 million more over four years until 2014-15.
My noble friend Lady Gardner raised the issue of public awareness of oral cancer. Work is underway on the third edition of Delivering Better Oral Health, a toolkit for the dental team. This will update the section on tobacco and oral health. A patient-facing version is also in development which will seek to make the public more aware.
My noble friend Lady Jolly spoke about vaccination and asked why boys, indeed all teenagers, were not vaccinated. The Joint Committee on Vaccination and Immunisation did not recommend the vaccination of boys because high coverage of the vaccination among girls means that it is not cost-effective to vaccinate boys to prevent cervical cancer. However, as with all vaccination programmes, the JCVI keeps its recommendations under review. The HPV vaccine is offered free each year under the national programme to girls aged 12 to 13 in school year eight. That is because the HPV vaccination is best given before the onset of sexual activity. Routine immunisation started in 2008, and a phased catch-up of girls aged up to 18 years of age was also implemented. However, scientific evidence is constantly coming forward and the JCVI will no doubt take account of that as necessary.
The noble Baroness, Lady Morgan, spoke about outcome measures for rarer cancers. Of course, she is quite right that early diagnosis is important in rarer cancers as it is everywhere else; we are addressing that, as I have mentioned. It is also important to improve treatment, and the recent announcement on radiotherapy means that access will be improved for specialised radiotherapy treatments such as stereotactic radiosurgery, used predominantly for brain tumours. Proton beam therapy is also an area that we are looking at closely. We are developing two proton beam therapy facilities, in Manchester and London, to be operational by the end of 2017. This treatment improves outcomes for a number of rarer cancers, including those which affect children.
My noble friend Lady Jolly asked what plans the Government have to address the issue of underage drinking while in the home. The new “Change for Life” programme helps people check if they are drinking above the lower-risk guidelines or not, and offers tips and tools to cut down. Dame Sally Davies, the Chief Medical Officer, will be overseeing a UK-wide review of the alcohol guidelines so that people at all stages of life can make informed choices about their drinking.
The noble Lord, Lord Hunt, and my noble friend Lady Jolly spoke about clinical networks. The final number of strategic clinical networks, and therefore the number of doctors, nurses and others who will support them, will be determined locally to meet the needs of patients. The full structure for strategic clinical networks will be published shortly. The establishment of clinical networks, hosted and funded by the NHS Commissioning Board, will ensure that patients everywhere in England benefit from dedicated clinical networks for four priority conditions and patient groups: cancer, cardiovascular disease, maternity and children’s services, and mental heath, dementia and neurological conditions. These networks will receive £42 million of national funding in the next financial year. We anticipate that these strategic networks will be supported and funded through the 12 network support teams. These teams will be hosted, again, by the NHS Commissioning Board local area teams. We anticipate an arrangement that would see support teams employing their skills across different networks as needed, but one that would also involve designated subject experts such as those with expertise in cancer commissioning.
The noble Lord, Lord Hunt, asked about research, which I agree is important in reducing deaths from cancer. The National Institute for Health Research health technology assessment programme is currently commissioning a feasibility study for assessing the clinical and cost effectiveness of photodynamic therapy for the treatment of locally recurrent head and neck cancer. The National Institute for Health Research Clinical Research Network is currently hosting 33 trials, including the four I mentioned earlier, and other well designed studies into head and neck cancer.
To conclude, the Government have set out an ambition in Improving Outcomes: A Strategy for Cancer to save an additional 5,000 lives each year by 2014-15. This means halving the gap between England’s current survival rates and those at the European best—and our aspiration is to be among the best in Europe. As my noble friend Lady Gardner has made clear, it is not just about saving lives after a diagnosis, it is also about preventing the cancers to start with. The Government’s strategies for prevention are designed to tackle increasing incidence.
NHS: Mental Health Services
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by congratulating my noble friend Lord Alderdice on securing this debate, and on raising the important issue of strengthening mental health in the NHS.
This is a timely debate. Wednesday is World Mental Health Day, a day which sends an important message across the global community: mental health is everyone’s business. As the noble Baroness, Lady Young, rightly emphasised, it is appropriate to turn the spotlight on mental health services at a time of huge structural and service reform across health and social care, when a lot of the attention has been focused on primary care and clinical commissioning groups. It is vital that mental health is woven in to the fabric of these reforms.
Before I respond in detail to the remarks made by my noble friend and other noble Lords, I want to take this opportunity to thank him and the noble Lord, Lord Layard, in particular for their lobbying, research, advice and support, which have done so much to set the standard for mental health services and drive system reform.
The recent report from the London School of Economics’ Centre for Mental Health, How Mental Illness Loses Out in the NHS, makes a compelling case for prioritising investment in mental health services and for treating mental ill health as seriously as physical ill health. Although we take issue with some of the content, we are in full agreement on these two central tenets of the report. Mental health simply cannot be an add-on or an afterthought. It costs £105 billion per year, to say nothing of the emotional toll that it takes on individuals, families and carers, so it must always be in the foreground when we think about health and social care. The messages are clear from people with mental health problems and their carers. They want to see a real difference in the range, quality and choice of services available. They want everyone to benefit from our mental health strategy, “No health without mental health”. This includes people with severe and enduring mental illness, those from minority ethnic communities and individuals who have offended.
They also want us to recognise the importance and expertise of family carers, who have so long occupied a shadowy position ill-served by legislation. This Government have committed themselves to fulfilling those wishes. Our new mental health implementation framework, coproduced with five leading mental health charities, sets out how we will do that. The framework translates the strategy’s vision into practical action for specific organisations. It outlines what the new health and care system will mean for mental health; and it shows how the mental health strategy fits with the three outcomes frameworks for the NHS, social care, and public health, and how each will help to deliver the other.
On top of that, the draft mandate to the NHS Commissioning Board, published for consultation on 4 July and mentioned by my noble friend Lady Tyler among others, also emphasises the importance of a new focus on mental health. This is reflected both in a dedicated objective on mental health, and in objectives for improving performance against the NHS outcomes framework. Overall the mandate suggests a culture-change on mental health throughout the NHS.
I simply say to the noble Lord, Lord Layard, that the Commissioning Board is discussing future arrangements with Ministers, but in the end, as he will recognise, it will be up to the Commissioning Board to deliver its commitments, and not for the department to second-guess the board. The noble Lord, Lord Layard, has said that the outcomes framework contains almost nothing on mental health. This is simply not the case. The 2012 framework contains three improvement areas which relate specifically to mental health—
Lord Layard
I was referring only to it containing nothing about the outcomes from IAPT, which is a very big service. There is nothing about recovery from depression and anxiety.
Earl Howe
I am grateful, and I will come on to that point. It is just worth rehearsing that there are three improvement areas: premature death in people with serious mental illness, the quality of life of people with mental illness, and the experience of healthcare for people with mental illness. In addition, many of the indicators relate to all patients and therefore apply equally to mental health patients. We are keen to strengthen the outcomes framework in relation to mental health in general, and recovery from mental illness in particular. We have recently begun work to define what good recovery from mental illness looks like, recognising that for some people this will mean the effective management of symptoms rather than a cure, and to develop proposals for how this might be measured. Our aim is develop measures that are suitable for inclusion in the NHS outcomes framework.
I know that some, like the noble Lord, Lord Layard, have been concerned that not enough is being done to meet the needs of people with long-term physical health conditions who also have mental health needs. We are addressing that. One of the measures by which we will gauge the success of the NHS Commissioning Board will be its ability to improve care for people with long-term conditions. This obviously includes people who have both physical and mental health problems.
Moving on to IAPT, we are also addressing the criticism that psychological services are too difficult to access in the first place. The operating framework for the NHS in England clearly states that the NHS should carry on expanding access to psychological services as part of the improving access to psychological services or IAPT programme. The noble Lord, Lord Patel of Bradford, said that change on the ground was hard to discern. The coalition Government have overseen a big increase in the number of people benefitting from IAPT services: 528,000 people entered treatment in 2011-12, more than double the number in 2009-10.
These new services are achieving recovery rates of more than 40% and are on track to meet recovery rates of at least 50%. We are investing £32 million this year in training new therapists to meet the demand. More than £400 million will be channelled towards talking therapies so that adults with depression and anxiety across England can get access to NICE-recommended psychological therapies. That investment will also help to fund the expansion of psychological therapies for children and young people—I shall say a bit more about that in a moment. We are also looking at how older people, carers, people with long-term physical health problems and those with severe mental illness can get better access to evidence-based psychological therapy.
Contrary to the statements quoted by the noble Lord, Lord Patel, we have no evidence of underinvestment by the NHS in IAPT services. On the contrary, funding is going up. At present, 149 out of 151 PCTs commission an IAPT service, which is nearly 100 services across England covering more than 95% of the population. However, in order to secure consistently good services, there needs to be a fundamental change in the way our society views mental health. Both individuals and organisations need to change some views that on occasion are deeply entrenched. We have commissioned the Royal College of Psychiatrists to look at how we can encourage everyone to ascribe the same importance to mental health and physical health. The work involves many leading royal colleges, professional associations, charities and others. It includes concrete examples of positive changes that parity would help to bring about. The college has already begun to collect and develop examples of both good and bad practice, and its final report will be available shortly.
My noble friend Lord Alderdice mentioned skills. It is important to note the influence that the royal colleges can wield in improving mental health services. The Royal College of General Practitioners has identified improved care for people with mental health problems as a training priority. It has proposed enhanced training for GPs, designed to increase clinical, generalist and leadership ability. I welcome its suggestion that mental health should be a central part of that enhanced training.
The GP curriculum and examination system will be changed to accommodate the new system of training, so we can look forward to newly trained GPs with an extremely broad knowledge of mental health issues. That is an excellent example of the role that groups outside government can play.
There have been a lot of stories about spending on mental health services being cut, but spending on mental health has stayed broadly level in cash terms. Although this has meant a very slight reduction when compared with inflation, this is quite an achievement given the huge cost pressures on the NHS and quite a different picture from the one that is often claimed.
My noble friend Lord Alderdice and the noble Lord, Lord Patel, questioned how we know that the £400 million is being spent on IAPT. The NHS is accountable to the department for results, not for spending money in line with predefined pots; it is outcomes that count. We have made sufficient money available to the NHS to maintain the expansion of IAPT. We have made very clear what results we expect from that investment, but local commissioners must be in a position where they decide how to use their budgets to meet the health needs of their local populations. That is not something that we can decide in Westminster.
The noble Lord, Lord Layard, and the noble Baroness, Lady Emerton, spoke about the slowing down of this effort. Preliminary figures for the first quarter suggest that the expansion of talking therapy services is slowing in some parts of the country. We are looking at the data to make sure that we understand whether that is temporary or something more serious, but it is clear that the picture is very variable across the country.
I have just received a note to say that my time is running out. I say now that I will write to all noble Lords whose questions I have not covered, but I shall in the time available cover as many more as I can, in particular on children’s services, which was a theme of my noble friend Lady Tyler and the noble Baroness, Lady Young.
Children’s mental health is a priority for this Government. The Government’s mental health strategy takes a life-course approach, recognising that the foundation for lifelong well-being is already laid down before birth and that there is much we can do to protect and promote well-being and resilience through our early years and adulthood. We have invested up to £54 million over the four years from 2011-12 to 2014-15 in evidence-based practice, such as children and young people’s IAPT, undertaken work to introduce payment by results for CAMHS, which my noble friend Lady Tyler referred to, and announced plans for a children’s health outcomes strategy.
Children and young people’s IAPT is a service transformation project for CAMHS, extending training to staff and service managers and embedding evidence-based practice across services to make sure that the whole service, not just the trainee therapists, use session-by-session outcome monitoring.
My noble friend Lord Alderdice and the noble Baroness, Lady Meacher, questioned whether there was a bias towards IAPT to the detriment of other services. Although I agree that there are different approaches to providing psychological therapies, it is local commissioners and not central government who are responsible for determining which services should be funded. I am happy to write on that theme, about which I have further information—as I do about charities, a point raised by the noble Lord, Lord Wills, who also asked me about the mental health legislation resource. I have a note that I would gladly have read out, but time has eluded me. I will also gladly write to the noble Lord, Lord Patel, about prisoners’ mental health and to my noble friend Lord Alderdice about patients being locked in at night at Broadmoor, as well as any other points that I have not covered. I am very grateful indeed to all noble Lords who have spoken in what has been a most illuminating and helpful debate.