NHS: Evidence-based Medicine
Earl Howe Excerpts(12 years, 9 months ago)
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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, 9 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, 9 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, 11 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, 11 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, 11 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.
NHS: Primary Care Trusts
Earl Howe Excerpts(12 years, 11 months ago)
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what action they will take to prevent primary care trusts inappropriately restricting access to patient treatments.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is inappropriate for a primary care trust to impose blanket bans on treatments, or to restrict access to treatments on the basis of cost alone. The department will ask strategic health authorities to investigate any examples of such behaviour, and appropriate action will be taken.
Lord Hunt of Kings Heath
My Lords, in thanking the noble Earl, I remind the House of my health interests in the register. The noble Earl will be aware that there is now abundant evidence that some primary care trusts are restricting treatments that are deemed appropriate, in some cases against the guidelines issued by NICE. Given that, will he go further and seek to ensure that he and his ministerial colleagues intervene in the NHS where this is happening so that we can be satisfied that the NHS will still provide a comprehensive service?
Earl Howe
My Lords, yes, we will intervene if ever it is demonstrated that primary care trusts are restricting treatments on a blanket basis or on a cost basis unrelated to clinical need. Any arbitrary restriction on access to treatment of that kind is unacceptable. We have made that clear repeatedly, as has Sir Bruce Keogh, the NHS medical director, on a number of occasions. However, that is not the same as saying that the NHS should be unconcerned about value for money. It should be very concerned about it. It should not spend money on treating a patient when that patient is unlikely to derive clinical benefit from the treatment. Therefore, we need to distinguish that kind of case from the kind cited by the noble Lord.
Baroness Masham of Ilton
My Lords, will the noble Earl find out to how many cases the PCT in North Yorkshire has denied treatment in the past year? Is he aware of how distressing it is for very ill patients to have to appeal?
Earl Howe
My Lords, I do not have the figures for North Yorkshire in front of me but, as the noble Baroness is aware, there is a process for patients to make an exceptional case application to their primary care trust where the circumstances are deemed to be exceptional. We had a short debate about this matter the other day. However, there will inevitably be variation around the country in the extent to which treatments are seen as a priority for the local population in a given area.
Lord Winston
My Lords, it is a question not just of treatment but of investigations for treatment. Only last week, I saw a couple complaining of long-standing infertility who were refused a laparoscopy or an X-ray of the uterus on the grounds that they were not permissible as investigations under the National Health Service. It was limited by their primary care trust. Would the noble Earl care to comment on that?
Baroness Brinton
My Lords, given that there is no consistency in the name that PCT committees are calling themselves to make these judgments about treatments and pathways, and often these matters are reported or hidden in longer performance reports, can my noble friend ensure that PCTs are open and transparent in their decision-making on these treatments, including referencing how their decision reflects NICE guidelines, and also insist that the appeals process is equally accessible?
Earl Howe
Yes, my Lords, we emphasise this principle at every opportunity. Indeed, transparency is a central principle, as my noble friend will be aware, in the way that the NHS constitution instructs the health service to make decisions rationally and transparently so that patients can see the basis on which those decisions have been arrived at. Again, if that is not happening in any area I should be very glad to hear about it.
Lord Walton of Detchant
My Lords, in relation to the point made by my noble friend Lady Masham, is the Minister aware that the particular primary care trust in North Yorkshire has refused the funding for an operation for a bright young lady doctor who is enrolled on a training scheme in that area and who turns out to have a rare hereditary form of pancreatitis? Three surgeons, two in Newcastle and one in Leicester, have agreed as a team to operate on her, otherwise the condition will be progressive and eventually fatal, but the primary care trust has refused funding for the procedure on the grounds that it is somewhat experimental, even though it has been carried out successfully on a number of occasions before. Is this not a case that ought to be referred to the Advisory Group for National Specialised Services?
Lord Soulsby of Swaffham Prior
Thank you, my Lords. This is an unfortunate Question in that it tends to imply that this system is widespread. However, my experience, admittedly only in one hospital in Cambridge —Addenbrooke’s Hospital—is quite the contrary. I do not know just how much my noble friend can comment on whether access for patients has been restricted nationally, but I would very much like to ask him to make sure that this Question is not a common reflection on the National Health Service and hospital service. I do not think that it is.
Earl Howe
My Lords, I agree with the noble Lord. The Co-operation and Competition Panel undertook a review of restrictions on patient care last year, and although it uncovered quite a number of examples of arbitrary rationing, those were cases that took place under the previous Government. We have banned all such cases. We do not believe that this kind of arbitrary restriction is at all widespread, and we have yet to receive any firm evidence that it is taking place at all.
Lord Bach
My Lords, I wonder if the Minister is aware of the widespread feeling of disgust and disappointment at the Government’s decision to close the ECMO cancer unit for children at the world-renowned Glenfield Hospital in Leicester. Is he aware that the quality of work done at that hospital has been praised internationally, and that many thousands of people in Leicester, Leicestershire and beyond are just appalled at the Government’s insensitive and brutal decision?
Earl Howe
My Lords, I am aware of the concern that the noble Lord has reflected in his remarks, but I think that it would be wrong of me to comment. That particular decision flowed directly from a review which was conducted by the NHS, quite consciously at arm’s length from Ministers. The matter is currently under scrutiny and I would not wish to pre-empt any decision that my right honourable friend the Secretary of State wishes to take.
NHS: Mental Illness
Earl Howe Excerpts(12 years, 11 months ago)
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Baroness Thornton
To ask Her Majesty’s Government what is their response to the report How mental illness loses out in the NHS, published by the London School of Economics and Political Science on 18 June.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we agree with the report’s insistence on both the importance of investment in mental health services and on the necessity of treating mental ill health as seriously as physical ill health. Our mental health strategy, No Health Without Mental Health, makes our commitment to these principles clear, and we are soon to publish an implementation framework that will help to embed them in NHS practice.
Baroness Thornton
I thank the Minister for that Answer. I remind the House that during the passage of the Health and Social Care Bill it was agreed that mental health should have the same, equal status as physical health. In that light, at present the 50 outcomes of the NHS outcomes framework include no health outcomes for the millions of people with clinical depression or crippling anxiety disorders. Do the Government have any plans to change that and, if so, when will they change it? When will we see mental health outcomes appear in the outcomes framework?
Earl Howe
My Lords, we have deliberately taken a generic approach to the NHS outcomes framework. That said, the framework for 2012-13 contains three improvement areas relating specifically to mental health: premature mortality in people with serious mental illness; employment of people with mental illness; and patient experience of community mental health services. Therefore, the noble Baroness is not quite right in what she has just said. Many of the indicators in the outcomes framework relate to all patients, including in relation to safety incidents, for example, or experience of primary care. Improving outcomes for people with mental health problems will be a crucial element of success.
Lord Alderdice
My Lords, five out of the six recommendations of this excellent report by the noble Lord, Lord Layard, and his colleagues emphasise the importance of IAPT, an excellent initiative begun by the previous Government, which is being built on by the coalition Government. However, from the time of the previous Government to now, I continue to receive reports that psychotherapy departments, particularly those that provide non-cognitive behaviour therapies such as art therapies, psychodynamic psychotherapy, group analytic psychotherapy and family therapy, are closing down or are unable to get contracts. Can my noble friend help me to understand why that might be the case since, while CBT is valuable and helpful in many circumstances, it is not the only approach to treatment that has been demonstrated to be helpful in those who need psychological therapies?
Earl Howe
I am very happy to take the advice of my noble friend, who is of course an expert in this area. Historically, it is true to say that access to talking therapies in the broadest sense has been very poor. That is why we have invested £400 million in rolling out the IAPT programme, which makes available a range of NICE-recommended therapies to a much larger cohort of people. However, I will take my noble friend’s point away and, if I can throw any light on the issue that he has raised, I will gladly write to him.
Baroness Hollins
My Lords, I, too, commend the report. What action would the Minister expect in response to two of the recommendations that relate to training? First, there is the recommendation that an automatic component of general practice training in future should include mental health. Only a minority of GPs currently receive any training in mental health. Secondly, with respect to the current recruitment crisis in psychiatry, it is recommended that we recognise that psychiatrists have an essential leadership role to play in mental health care.
Earl Howe
My Lords, as regards GPs, the Royal College of General Practitioners has identified improved care for people with mental health problems as a priority within its enhanced GP training programme, which forms part of the college’s proposals for a new evidence-based four-year programme of training.
As regards the workforce issues, I am aware that there is concern about recruitment into psychiatry. My department and the Royal College of Psychiatrists are looking into this matter. The royal college has established a task force to make recommendations to improve recruitment, and it is investigating the factors before medical school, during medical school, during foundation training and in core and higher psychiatric training so as to get to the bottom of the issue as best it can.
Lord Hunt of Kings Heath
My Lords, one of the important recommendations in the LSE Centre for Economic Performance report, which led to this Question, concerns the attitude of other doctors to psychiatrists and the issue that that has in relation to recruitment. The report says that,
“it is routine for”,
surgeons and physicians,
“to make derogatory remarks about psychiatry, which affects not just psychiatrists but also their patients”.
I wonder whether the noble Earl has any answer to that.
Baroness Greengross
My Lords, is the noble Earl able to deal with two blatant forms of age discrimination? The first is that the talking therapies are very often denied to older people; pharmaceutical alternatives are cheaper. The other is that, when a diagnosis of dementia is made, the way in which services are organised now means that those services have to be funded by local authority social care rather than the NHS. Given that dementia is a terminal disease, does the noble Earl not feel that this is unfair?
Earl Howe
My Lords, yes, and we have laid great emphasis on the need to bear down on unreasonable discrimination against elderly people. The noble Baroness is aware that the requirement to reduce inappropriate anti-psychotic medication for the elderly is a key part of the Prime Minister’s dementia challenge. Therefore, I identify completely with the remarks of the noble Baroness on that issue.
Social Care: Sustainable Funding
Earl Howe Excerpts(12 years, 11 months ago)
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Lord Warner
To ask Her Majesty’s Government when they will announce their plans for sustainably funding adult social care.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government set out their plans for the funding of adult social care at spending reviews. The date of the next spending review has yet to be announced. At the last spending review the Government prioritised money for adult social care, announcing an additional £7.2 billion over four years. When combined with an ambitious efficiency programme, this will provide enough funding to enable local authorities to maintain current service provision.
Lord Warner
I thank the Minister for that Answer. However, is he aware that publishing a White Paper about adult social care without a funding plan is as much a work of fantasy as Fifty Shades of Grey, but without the fun of sex? Do the Government recognise that the longer they delay implementation of the Dilnot commission’s proposals—and here I declare my interest as a member of that commission—the greater will be the social care cost that shifts to the NHS, which has its own funding problems? Starting that implementation will cost around one-thousandth of annual public expenditure, as Andrew Dilnot has repeatedly said. Is it not time that the Prime Minister and the Chancellor engaged with this issue within cross-party talks to try to sort out the funding problems of adult social care?
Earl Howe
My Lords, we look forward to a continuation of the constructive cross-party talks that have taken place. We have been clear that we accept the principles of the Dilnot recommendations, including financial protection through capped costs and an extended means test. They are the right basis for any new funding model. That sets out, if you like, our high-level view on what a new funding system should look like, but there will be many questions to answer—such as on the level of the cap and whether the funding system should be voluntary, universal or opt-in—before we can make any firm decisions. It is right that we take time to work through this, including engaging with stakeholders to make sure that any reform is the right one. That means that the next spending review is the appropriate time to take those decisions.
Baroness Campbell of Surbiton
My Lords, is the noble Earl aware that while these complex funding matters are being considered, many local authorities are severely reducing the levels of support provided to disabled people in ways that can curtail their independence, prevent them from working and participating in public life and, in some cases, force them into residential care? Is he aware, for example, that Worcestershire County Council proposes to radically restrict the maximum value of an individual disabled person’s care package, offering them no other choice than to enter residential care if they cannot meet the shortfall? Surely the Minister agrees that this runs entirely counter to the White Paper and government policy?
Earl Howe
My Lords, I am not aware of the Worcestershire example. What I will say is that the best local authorities are those that enter into a two-way dialogue with service users to see what is best and most appropriate for them in their circumstances. I recognise that this is a challenging settlement for local government, but if local authorities are prepared to reform their services and drive down costs, we believe that the additional investment from the NHS to social care, which we announced in the spending review, will enable local authorities to protect the care that people receive. Many councils are making the necessary changes to ensure that there is no drop in eligibility criteria.
Baroness Gardner of Parkes
My Lords, in view of the answers to the previous supplementary question and to the first Question, which stated that decisions should never be made purely on grounds of cost, is the Minister aware of a case in one of the London boroughs where a woman who has had multiple sclerosis for years and has been cared for by a very loving husband has now been told that she may be obliged to go into a care home because providing her care package at home is costing £79,000, while a care home could be provided for £71,000? That would perhaps not destroy, but put a terribly unfair strain upon, her marriage after all these years. Can the Minister assure us that in the Government’s plans for health and social care, factors other than cost will be considered?
Earl Howe
It would not be right for me to comment on an individual case such as the one mentioned by my noble friend, but I would say that local authorities have a duty to meet people’s eligible needs, and they should take account of a person’s resources as they do so. If a local authority were to change someone’s personal budget, we would expect it to consult and discuss with the service user how their needs and goals could best be met within the new budget. It should not, in most cases, descend to forcing any options on anybody.
Baroness Pitkeathley
My Lords, I was happy to give way to the noble Baroness, especially on her birthday. The Minister’s words may be comforting to many families when contemplating the future, and may provide comfort that the Government have plans for the future. However, what comfort will he give to my neighbour Margaret who is caring for her husband, who is in the last stages of Alzheimer’s, and is in despair with his and her physical and mental distress? Today—now—they face huge costs for care that is intermittent and often of very poor quality. How does the Minister address the poor-quality issue in the face of such a shortage of funds?
Earl Howe
My Lords, as I made clear, the Government and my department have made a very significant sum of money available to local authorities to bolster their social care funding. In the announcements we made last week we said that we were directing additional money to local authorities to support integrated care. I regret the instance that the noble Baroness cites, but it is part of the reason why, in our White Paper and in the announcements we made last week, there is a particular focus on quality and on ensuring that the tick-box approach—which I am afraid some local authorities have taken—should be a thing of the past.
Drugs: Prescribed Drug Addiction
Earl Howe Excerpts(13 years ago)
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The Earl of Sandwich
To ask Her Majesty’s Government whether they plan to develop separate treatment programmes for those suffering from acute symptoms of addiction to and withdrawal from legally prescribed drugs, distinct from programmes for illegal drug addiction.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, treatment should be based on individual need, not the legal status of a drug. The Health and Social Care Act places responsibility for commissioning services to treat dependence at the local level. My honourable friend Anne Milton is leading work to improve the prevention and treatment of addiction to medicines, and has visited local areas where support for dependence on prescription drugs is an integral part of the local treatment system.
The Earl of Sandwich
My Lords, I thank the Minister and I know that he and his fellow Minister are fully aware of the problem. However, there are only a handful of voluntary organisations and one or two primary care trusts dealing with this. The basic question is surely the control of prescription drugs. Does the Minister recognise that the British National Formulary guidelines are being routinely breached? Is there nothing that the Government can do effectively to control and monitor these prescription drugs, separately from illegal drugs?
Earl Howe
My Lords, the report commissioned by the Department of Health from the National Addiction Centre brought together published evidence on the scale of the problem. That report suggested that while some GPs prescribed for longer than the recommended period, most prescribing in fact falls within current guidelines. I say to the noble Earl that what matters most in these circumstances is that patients should be treated according to the level of their need, regardless of what the dependence is and where it has come from.
Lord Patel of Bradford
My Lords, while there certainly is a focus on recovery for illegal drug users, does the Minister agree that the journey from being a drug user to becoming “recovered”—that is, to abstinence—is very complicated? It may require that person to have treatments, including methadone, Subutex and other drugs. It is not simply a matter of someone becoming abstinent, especially in the current economic climate. Does he agree that that is still the direction of travel?
Lord Taverne
Will the Minister ensure that whatever else is done, nothing shall prejudice the treatment of illegal drugs and of alcoholism, which is the greatest problem? Will he also take note that in the distant past, when I was a Home Office Minister and Roy Jenkins was Secretary of State for the first time, the use and possession of drugs such as heroin was not a crime and that this greatly facilitated the possibility of access to treatment?
Earl Howe
There are no plans to revert to the former situation as regards heroin, but my noble friend makes the point that alcohol addiction is an extremely important issue. The commissioning of services to treat addiction will in the future architecture of the system be devolved to local areas. The all-party group on benzodiazepines on which the noble Earl sits has done some important work in exposing those areas where services are not as good as they should be.
Baroness Meacher
I applaud the Minister’s comment that treatment must be based on need rather than on whether a substance is legal or illegal. Is he aware of the excellent work being done to treat heroin addicts in Switzerland, where a third of people are in employment and two-thirds of people are living legally within 18 months? Will he consider introducing to this country these highly cost-effective approaches?
Lord Howarth of Newport
My Lords, does the noble Earl think, as I do, that if the Department of Health were to be the lead department for the Government’s policy on drugs we would get better results than we have been getting with the Home Office as the lead department?
Earl Howe
My Lords, the Home Office has a particular responsibility for drugs which is distinct from my department’s responsibility, which is to do with ensuring that those who are addicted to drugs get the proper treatment. The two are distinct and it would not necessarily be helpful to blend them together.
Baroness Finlay of Llandaff
Will the Government ensure that the recommendations from the Royal College of General Practitioners for increased training in psychiatry is implemented in workforce planning after the new Act is in place? The inappropriate initiation of prescriptions is a major problem for those becoming dependent when alternative therapies, such as cognitive behavioural therapy, or simply better social support, would have avoided the inappropriate prescription of a drug on which physical dependence then develops.
Earl Howe
The noble Baroness is absolutely right, and I am very pleased that both the Royal College of General Practitioners and the Royal College of Psychiatrists have been keen participants in the round table group on addiction to medicines convened by my colleague Anne Milton. The actions agreed by the group have included greater recognition of the risk and the treatment of dependence on prescription drugs within the core competencies of psychiatrists and the further development of training and guidance on this issue for GPs and other healthcare practitioners.
Lord Brooke of Alverthorpe
My Lords, does the Minister agree that one of the biggest obstacles to recovery for people with addictions to alcohol and drugs is stigma? Will he confirm that there is no thought in mind of moving down the avenue suggested in the Question because that would lead to greater stigma?
Earl Howe
I am well aware of the point that the noble Lord appropriately raises. Stigma is an issue and we need to take account of the risk of it. That means that quite often when treatment services are provided to those who are addicted to medicines, they take place in a different setting from those administered to addicts of illegal substances.
Lord Crisp
Will the Minister recommend that, given that withdrawal from legally prescribed drugs is every bit as dangerous as withdrawal from illegal drugs, more should be done, for example, to print warnings in bolder lettering on packaging, to put notices in doctors’ surgeries and to make the public and the patient more aware of this issue as well as making doctors more aware?
Earl Howe
I agree that dependence on prescription medicines can be just as devastating and debilitating as dependence on illegal drugs. The round table on addiction to medicines has agreed actions to improve public and professional awareness of the risk of dependence. They include a review of the updated warnings on prescription painkillers by the Medicines and Healthcare products Regulatory Agency and the development of further materials for GPs and other healthcare practitioners to support patients in understanding the risks.