National Health Service (Clinical Commissioning Groups) Regulations 2012
Earl Howe Excerpts(12 years, 4 months ago)
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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(12 years, 4 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(12 years, 4 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(12 years, 4 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
Earl Howe Excerpts(12 years, 4 months ago)
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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
Earl Howe Excerpts(12 years, 4 months ago)
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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.
Health: Diabetes
Earl Howe Excerpts(12 years, 6 months ago)
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Lord Harrison
To ask Her Majesty’s Government what actions they are taking to ensure effective treatment of diabetes in minority-ethnic communities.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government are aware of the growing issue of diabetes in minority-ethnic groups. The NHS is taking a range of actions to ensure effective treatment. The recent publication of clinical guidance on type 2 diabetes by the National Institute for Health and Clinical Excellence identifies those at high risk and how best to manage the risk. It specifically mentions ethnic minorities and identifies pathways to ensure effective management.
Lord Harrison
My Lords, given that the worrying rise of type 2 diabetes among our ethnic communities is absorbing an ever increasing share of 10% of the NHS budget, which itself is shrinking for diabetes care, will the noble Earl institute an increase in the number of diabetes nurses, who are at the heart of communities, support the Diabetes UK campaign for ethnic-community champions and, finally, heed the advice coming from the dedicated research team at the University of Warwick that matching health professionals tutored in the cultural knowledge and understanding of our ethnic communities can give enormous benefits?
Earl Howe
My Lords, I agree wholeheartedly with the thrust of the noble Lord’s question. As he will know, Diabetes UK has pioneered a programme of diabetes community champions from ethnic-minority communities to raise awareness of the condition in their communities. The Department of Health has awarded Diabetes UK a grant through the volunteering fund national awards for the programme to be rolled out across 12 English cities over the next two years. I gather that 111 community champions have already been recruited in London. This is exactly the sort of initiative that we need if we are to reach those who are most at risk of developing or, indeed, being diagnosed with diabetes.
Lord Singh of Wimbledon
My Lords, for many years, the Network of Sikh Organisations has been active in working in clinics in gurdwaras, or Sikh temples, to promote an understanding of health issues and to do checks for blood sugar and raised cholesterol. These tests and other health advice have been very effective. Will the Minister consider ways of giving impetus to such initiatives and perhaps extending them to other faith groups and centres in order to combat the evil of bad genes and the subcontinental taste for sweetness and sugars?
Earl Howe
My Lords, I am aware of several local initiatives that are doing great work in accessing those in both black and minority-ethnic communities along the lines mentioned by the noble Lord. We have made important progress in strengthening our approach to promoting equality in health and social care and in tackling these inequalities that exist. That is especially important in relation to the Asian community. I am thinking in particular—the noble Lord mentioned the need to roll out initiatives—of the NHS Heath Check programme supported by the guidance on prevention issued by NICE and the Change4Life Programme, which now has a bespoke element to it targeted specifically at ethnic-minority communities.
Baroness Gardner of Parkes
My Lords, are separate statistics kept about ethnic groups? If not, would it not be an advantage to do so in terms of research, particularly as type 2 diabetes is very much dependent on diet and might be quite different in different sections of the community? What is the prevalence of diabetes in the ethnic community as opposed to other communities and what is the prevalence of type 1 diabetes as opposed to type 2 diabetes?
Earl Howe
My advice is that type 1 diabetes is not a particular issue in ethnic-minority communities. We are talking about type 2 diabetes, which is five times more common in black and ethnic-minority groups, six times more common in south Asian ethnic groups, and three times more common in areas of social deprivation than in the rest of the population. There are particular clinical risks associated with those from ethnic minority communities who have diabetes. Complications include particularly heart disease—south Asian people are 50% more likely than the general population to die prematurely from coronary heart disease—and the prevalence of stroke is also much higher in African, Caribbean and south Asian men.
Baroness Masham of Ilton
My Lords, can genetic problems be a cause? Are not exercise and getting fit an important part of stopping diabetes?
Earl Howe
Exercise is recommended under the Change4Life programme and under the advice given by NICE. However, the noble Baroness is absolutely right to mention a possible genetic cause. The cause of diabetes is not fully understood and is multi-factorial. Healthy eating, weight control and exercise can help reduce the risks, but that is not the full picture. It is suspected that there is a genetic component in the case of black and ethnic-minority communities.
Baroness Howells of St Davids
My Lords, I have some of the statistics that have already been mentioned. We now know that manifestations of diabetes are three times higher among the Afro-Caribbean people who came to Britain to assist after the war than among the majority population. We also know that deaths are three times higher and 40% are at a higher risk of morbidity, kidney failure and blindness. As a result, they really do put a higher cost on the NHS. Some who have returned home have to come back here for treatment because this is where they paid their way. I would like to know whether Her Majesty’s Government have really taken on board the NICE recommendations that health programmes should be culturally appropriate and that cooking guidance should be given and tailored to the needs of people and to what they eat at home. We believe that educators are necessary to inform sufferers of their needs, so that they can make a choice, not only about what they eat but also about how they prepare it. I ran classes for a group of people and I can assure your Lordships that there has been a change in the way they respond. If the Government have not taken up that particular part of the NICE recommendations, why not?
Earl Howe
My Lords, the advice given by NICE makes 20 specific recommendations, many of which are highly relevant to the population group mentioned by the noble Baroness. She is absolutely right that there is a need to educate those in black communities about a healthy diet. There is a lot of work going on in that area, which is too detailed and complicated for me to mention at the moment, and in the area of self-education to enable patients to understand their own condition and to manage it better.
NHS: Health Workers
Earl Howe Excerpts(12 years, 6 months ago)
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Lord Crisp
To ask Her Majesty’s Government what steps they are taking to promote changing the roles and skills mix of health workers in the National Health Service to improve access and quality, and reduce costs.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, local healthcare providers must be free to manage the composition and skills mix for their workforce so as to best meet the demands of the communities they serve. We are working together with the professions and partners on key initiatives that will help healthcare providers make more informed decisions on the shape of their workforce to achieve better outcomes in both patient care and value for money.
Lord Crisp
I thank the Minister for that reply. As he knows, changing job roles in the health service can be done well to great benefit or it can be done badly and be detrimental to services. Given that a recent report from the All-Party Parliamentary Group on Global Health has provided the evidence for what works, can I ask him, first, how will the Government make sure that Health Education England and other national bodies give this a much higher priority and provide the support that local organisations need to make this happen? Secondly, to avoid the problems of failure, how will the Government ensure that the Care Quality Commission and other national bodies provide the leadership needed to make sure that failures do not happen?
Earl Howe
My Lords, the noble Lord’s Question addresses the central issue facing the NHS, which is how to deliver the best outcomes for patients and do so in the most cost-effective way. He is right to single out the role of Health Education England because I believe that, in conjunction with local providers who will be feeding in their view of what the workforce priorities are in their local areas, together with the Centre for Workforce Intelligence, which has a horizon-scanning capability, we can at last crack a nut that has been so difficult to crack in the past, that of good workforce planning in the NHS to make the workforce as productive and effective as we can. He is also right to single out the CQC because in areas such as staff ratios, the commission has a role in making sure that providers have thought about the right way to deliver care in individual settings.
Lord Winston
My Lords, in order to produce a skilled workforce with wide diversity in the health service, one of the real needs is that of attracting more young people into this very large workforce. At the present time, as I think the noble Earl may be aware, there is massive resistance to having young people on work experience in the health service. All sorts of barriers are put up—risk of infection, lack of privacy and so on—most of which are absolute nonsense. Could the Minister do more to encourage the university trusts in particular to ensure that more young people can gain work experience in our hospitals?
Baroness Sharples
Can my noble friend tell us how many matrons are in hospitals now?
Earl Howe
My Lords, I cannot give my noble friend the precise figures for matrons, but what I can tell her is that in all NHS trusts there is now an emphasis on nurse leadership, however defined, so that at ward level and indeed at board level the input from nurses is heard and taken into account. That is important if we are to achieve what I think everyone wants, which is to drive the quality of care at the bedside.
Lord Howarth of Newport
My Lords, as Ministers review the skills needs of the health service, will they take into account the significant contribution that can be made in healthcare settings to recovery and well-being by the arts—music, poetry and reading aloud, for example? Will they signal to healthcare professionals and commissioning bodies that it is legitimate to invest certain resources in the arts and, of course, design in order to promote good health?
Earl Howe
One of the features of the reforms that we have enacted is the ability for allied health professionals, including those mentioned by the noble Lord, to have a say in the planning of services at a local level—health and well-being boards. The value of those activities, rightly emphasised by the noble Lord, will I hope in time be more greatly appreciated as the outcomes framework takes effect, and the patient experience of care becomes more prominent in the way that we assess services.
Lord Kakkar
My Lords, how will clinical leadership be developed to secure the appropriate culture and values essential for delivery of safe, effective and dignified care for all NHS patients?
Earl Howe
There is a clear role here for the professional bodies. Training should be done in the right disciplines and numbers and in the right way. I am sure I do not need to tell the noble Lord that in virtually all the medical royal colleges and through the Royal College of Nursing, there is an increasing emphasis on leadership backed by resources from the Department of Health. We are seeing a drive forward for innovation and the breaking down of professional barriers, which is another aspect of this issue.
Baroness Jolly
My Lords, we now accept nurse prescribing as perfectly normal and sensible, and these changes were implemented when the NHS was the major provider of health services. Therefore, what challenges or opportunities does the Minister think that the new diverse health economy will pose to task shifting?
Earl Howe
My noble friend poses an extremely complex question. She is right that regulatory improvements such as nurse prescribing are making a difference and we are looking to see what other professions can also share in that sort of freedom. As the NHS gets more plural, we are able to drive the consistency and quality of practice through the NHS standard contract, through regulation, as the noble Lord, Lord Crisp, emphasised, and also through the clinical leadership referred to by the noble Lord, Lord Kakkar. That applies not only in NHS settings, but in private and independent settings as well.
NHS: Specialised Services
Earl Howe Excerpts(12 years, 6 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, perhaps I may begin by congratulating my noble friend Lady Jolly on securing this short debate on the future of the Advisory Group for National Specialised Services. This is undoubtedly an important area for discussion, not only for the members of the advisory group who have worked hard to provide Ministers with advice but for patients and families who have benefitted from the national commissioning on which it leads.
At the outset I would like to say, in particular to my noble friend Lord Palmer and the noble Baroness, Lady Hollins, that in working up plans for the reform of the NHS, we absolutely recognised the needs of people with very rare and rare conditions. We wanted to make sure that we honoured the commitment in the NHS constitution that no one should be “left behind” because of the rarity of their condition. For these reasons, the legislation reflected our view that specialised and highly specialised services were best commissioned at a national level. Services will be set out in regulations, making it very clear what we are expecting the Commissioning Board to directly commission. I can assure my noble friend Lord Palmer that patients with rare conditions, depending of course on their clinical needs, will continue to have access to specialised services and expert treatment. I would say to the noble Baroness, Lady Masham, that the NHS Commissioning Board will retain money centrally to directly commission these services, including services for very rare conditions.
When the coalition Government were formed in 2010 we endorsed the previous Government’s proposal and established AGNSS as an independent stakeholder advisory group, bringing advice and funding together into one body. We also gave AGNSS the specific role of considering whether certain very high-cost, low-volume drugs should be included in the national arrangements for specialised commissioning. In developing this role, AGNSS worked very closely with NICE and developed its own decision-making system.
Under the Health and Social Care Act 2012, this situation will change from April 2013. Instead of highly specialised services being commissioned nationally by the National Specialised Commissioning Team and specialised services being commissioned on a regional basis by specialised commissioning groups, the new NHS Commissioning Board will take responsibility for commissioning all these services. That will all be under a national commissioning policy which will be sensitive to local requirements so that the needs of people with rare and very rare conditions are met.
Ministers will still be responsible for deciding what services the board should be asked to commission, but it will be the responsibility of the board to decide how it commissions those services. The functions of AGNSS cut across both the “what” and the “how” so I do not see a role for AGNSS in its current form from April 2013 and it will cease to be an advisory group offering advice to Ministers.
I would like to set out the current functions of AGNSS and consider in turn where each would sit in the future. The first function of AGNSS is to advise Ministers on which highly specialised services, products and health technologies should be nationally commissioned. That will be expanded to cover all specialised services and not just the highly specialised. Ministers will need to receive advice on whether services can be defined by the rarity of the condition, the cost of providing the service or facility, the number of centres able to provide the treatment, and financial implications for clinical commissioning groups. We are currently considering an appropriate advisory mechanism for Ministers that will keep the list of services directly commissioned by the board under review, ensuring that services are commissioned at the right level. In time, some services might be more appropriately commissioned by clinical commissioning groups, but I emphasise the words “in time”.
The second function of AGNSS is to advise Ministers on which centres should be designated providers for nationally commissioned services. In the new reformed NHS, this is rightly the role of the Commissioning Board in carrying out its commissioning of services. It is no longer for Ministers to decide upon. Therefore, advice to Ministers is no longer required. The same is true for the third function of AGNSS: advising on the annual budget for new and existing nationally commissioned services and the contribution required from PCTs. The fourth function is to advise on funding of the management function of the NSCT as hosted by NHS London. That will no longer be needed. The Commissioning Board will manage one single specialised services budget and commissioning function. So, again, Ministers would no longer need that advice, and it will be a matter for the Commissioning Board.
Whether commissioning a cataract operation or the most highly specialised and long-term treatment, the most important thing is quality of care. We must prioritise good-quality clinical advice on highly specialised services over the structure of a group for its own sake. Work on developing an advisory mechanism for the board on highly specialised services is ongoing. The chair of AGNSS, Professor Michael Arthur, is working with the NHS Commissioning Board Authority on such an advisory mechanism that would build on the skills and expertise of current arrangements. Within the board, there will be a clear focus on specialised services, organised around programmes of care to make sure that services are always top-notch. Commissioning teams will make sure that contracts with providers reflect the needs of people with rare and very rare conditions. On top of that, there will be specific links to innovation, including a specialised services innovation fund. The board will also manage stakeholder engagement.
I mentioned one important aspect of the work of AGNSS, in assessing very high-cost, low-volume drugs, but so far I have not explained where this function will sit in the new system. We have looked at several potential options. I am pleased to announce that, on the basis of a detailed proposal and discussions, we have asked NICE to take on the assessment of very high-cost, low-volume drugs from April 2013. I am aware that some noble Lords may have concerns about NICE taking over this work, as the current cost per quality-adjusted life year that NICE operates for its appraisals of drugs would rule out highly expensive drugs for small numbers of people with rare conditions. We have explored this issue thoroughly with NICE and it has developed a process for assessing such drugs. It will build on the decision-making framework that AGNSS uses at the moment. That framework balances health gain, best clinical practice, societal value and reasonable cost. In addition, recommendations from NICE will not be based solely on a cost per QALY figure.
NICE proposes setting up a dedicated expert panel to produce an assessment of a new drug, usually within six months. Given that we wish the new process to commence in April 2013, NICE will develop interim methods for the first few assessments. The institute plans to subject these processes and methods to a consultation in 2013-14 alongside the assessments it will carry out. NICE’s work will make sure that we have a robust, transparent and consistent process in place for assessing very high-cost, low-volume drugs. We have a number of points of detail that Department of Health officials are still exploring with the institute. I will be able to say more about the detail of this proposal in the coming weeks, but, in the mean time, I thought it important to provide a progress report to the House.
The noble Lord, Lord Turnberg, asked about the mandate. I can tell him that the consultation on the draft mandate, which was launched on 4 July and on which we welcome views and comments, emphasises the importance of driving improvements in the £20 billion- worth of services commissioned directly by the board, including specialised services for people with rare or very rare conditions. One of our proposed objectives in the draft mandate asks the board to put in place arrangements to demonstrate transparently that these services are of high quality and represent value for money.
The noble Lord, Lord Hunt, expressed his dissatisfaction that, as he sees it, Parliament will not have a say in which services are commissioned by the NHS Commissioning Board. The consultation on the mandate provides Parliament and, indeed, others with the opportunity to express views on that matter. I would also reassure the noble Lord, Lord Turnberg, and my noble friend Lord Palmer that within the board there will be a clear focus on specialised services, including experts on highly specialised services, organised around programmes of care and with a national commissioning policy for specialised services that is sensitive to local needs, as I mentioned. Clinical leadership will be the responsibility of Professor Sir Bruce Keogh and advisory mechanisms to the board are being developed. Within 10 of the 27 local area teams of the board, there will be expertise in highly specialised services.
The noble Earl, Lord Listowel, asked about children with specialist mental health issues and whether they would have access to appropriate treatment. I can give the assurance that such services will be available once the board is responsible for commissioning them. Specialised services relating to mental health was the theme taken up by the noble Baroness, Lady Hollins. We are not yet in a position to announce the full list of the services that the board will be commissioning. However, a great deal of work has been going on to draw up that list. The chairs of 60 clinical reference groups have been working on the matter. They are all leading clinicians in their fields. The CRGs hold a broad membership and an assurance process was established that looked at the work of the CRGs. The findings of the CRGs were considered by the CAG in May of this year and Ministers expect to set out the list of services over the summer.
In answer to the noble Baroness, Lady Masham, I am of course very sorry to hear about the child she mentioned who has neuroblastoma. Obviously, for reasons of patient confidentiality, it is not appropriate to comment on individual cases. At the moment the decision for funding treatments for neuroblastoma rests with PCTs. In the future, commissioning decisions for patients with rare conditions will, as I have mentioned, rest with the board. I cannot say definitely whether that will be one, but the noble Baroness may like to draw her own conclusions. I am informed that the evidence base for stem cell-based therapy for neuroblastoma is not yet sufficiently robust despite the comments she made.
The noble Lord, Lord Walton, asked for an assurance that molecular patches will not be subject to constant regular testing. Molecular patches that are found to be safe by the regulatory process can be used on the NHS. My noble friend Lady Thomas spoke eloquently about research. She is absolutely right in the importance she attaches to that. The Government will invest £800 million over five years from April this year in NIHR biomedical research centres and units. Most of these centres are conducting leading-edge research on rare diseases that will benefit patients with these conditions. The NIHR has joined the International Rare Diseases Research Consortium and is actively involved in pursuing the consortium’s goals.
Time is now against me. I beg leave to write to noble Lords who asked me questions that I have not had time to answer. Once again, I express my gratitude to my noble friend for raising this important subject.