NHS: Definition of Exceptional Case
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Baroness Masham of Ilton
To ask Her Majesty’s Government what is the definition of an exceptional case needing surgical and medical care through the National Health Service, and who makes the decision.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the department has not issued definitive guidance on this difficult issue. Indeed, there is a paradox in the whole concept of defining an exception. However, good practice in the NHS suggests that a patient can be considered for treatment which is not normally provided locally if the patient has exceptional clinical need or is likely to derive exceptional clinical benefit. The decision is made by the local commissioner.
Baroness Masham of Ilton
My Lords, I thank the noble Earl for that reply. However, is he aware that there is a young doctor in Northallerton, North Yorkshire, whose PCT has denied her a vital operation for a genetic pancreatic condition? If she does not have this operation, she will remain in excruciating pain all the time, she will not be able to work, and there will be a risk of cancer.
Earl Howe
My Lords, I hasten to reassure the noble Baroness that I have every sympathy with the individual in question, and I was aware of this particular case. The chief executive of the NHS will shortly be writing to her clinical tutor to suggest a possible way forward. However, I should put on record my view that the commissioner is acting reasonably in insisting that its decision on exceptionality should depend solely on the clinical need of the patient, and not on any broader social factors. If there is now good clinical evidence to support the use of this particular treatment, commissioners should be considering whether to make it available to all patients with similar clinical needs, and not just to a few individuals.
Lord Ribeiro
Is my noble friend aware that the pancreatic unit at Leicester is not able to do any islet cell transplantation operations because the PCT refuses to fund them? The excuses used to justify not funding these operations are that these may be “procedures of limited value” and “experimental surgery”. There are, in fact, four clinical units throughout the UK doing islet cell transplantation, with good records and good outcomes. I want to know whether the PCTs are not funding these operations in order to present a clean sheet to the incoming CCGs in April 2013, or whether there is another reason.
Earl Howe
My Lords, no, that is not the reason. My noble friend is quite right that this treatment has been around for a little while. However, it is not yet in mainstream practice. It is expensive, it is not routinely available in the NHS, and indeed NICE has published interventional procedure guidance which concludes that it,
“shows some short term efficacy, although most patients require insulin therapy in the long term”.
That does not seem to me to be a resounding endorsement of this treatment.
Lord Winston
My Lords, will the Minister be kind enough to help us by defining what is meant by exceptional clinical needs?
Earl Howe
There is no clear-cut answer to that question. A patient might be suffering unusually severe symptoms from a given condition, or they might suffer from some comorbidity, with the result that in the absence of treatment his or her quality of life would be unusually severely affected. The underlying principle should be that the patient has some exceptional characteristic which would justify more favourable treatment being given to them than to the average patient with that condition.
Baroness O'Loan
Given the vulnerability of the patients, the exceptional nature of the illness in such cases, and the consequential problems in terms of access and capacity to appeal, will the Minister tell the House what arrangements exist to scrutinise the fairness and consistency of decisions by PCTs and by their exceptional cases review processes?
Earl Howe
My Lords, under the NHS Constitution, all patients have the right to an individual review of a decision not to fund a particular treatment if they and their doctor believe that it would be appropriate. They also have the right to an explanation of the basis of the decision. The commissioner must in turn have a process to enable such individual funding requests to be considered, so the watchwords here are transparency and publishing an explanation.
Baroness Gardner of Parkes
Does the Minister agree that there are other decision-making bodies? I refer in particular to the UK National Screening Committee. Is he aware that, probably correctly, it makes its decisions only on research results? Why does it claim that it does not have the money to spend on research into Streptococcus B infections, when international research shows a clear choice for screening as opposed to risk assessment? That change that has been made in other countries has resulted in reductions of strep B infections in children of 80% in the USA, 60% in Spain, 82% in Australia and 71% in France. The screening of pregnant mothers could prevent that very serious condition, which can be fatal, being passed to a small number of babies.
Earl Howe
My Lords, the UK National Screening Committee advises Ministers and the National Health Service in all four UK countries on all aspects of screening policy, including for group B Streptococcus carriage in pregnancy. The committee is currently reviewing the evidence for screening for that condition in pregnancy against its criteria. It will take into account the international evidence and a public consultation on the screening review will be opening shortly.
Lord Collins of Highbury
My Lords, the Minister said that this treatment is not routinely carried out. The doctor concerned, who works in the NHS, is aware that pancreatectomy is carried out in other PCTs. Can the noble Earl explain where it is being carried out so that we can understand what is routine and what is not?
Earl Howe
My Lords, I hope that my earlier answers gave a clear indication of the definition of exceptionality, which should demonstrate to the House that something that is exceptional is not routine. Our advice is that that treatment is not routinely available in the NHS. There is a handful of centres in England with doctors who are trained to carry out the operation, but although the technique has been in use since 1977, it is available only in a few centres worldwide, which does not suggest to me that other countries are ahead of us in this area.
Dementia
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by congratulating the noble Lord, Lord Touhig, on securing this debate and thank him for his compelling speech. As all noble Lords have emphasised, dementia is one of the most important health and social care issues that we face as a society. The statistics are staggering. The 670,000 people with dementia in England will double over the next 30 years, and the current £19 billion cost will inevitably spiral.
Dementia affects not only health and social care but all of society, and the speeches today have brought that dimension graphically to life. We need to be better prepared. Dementia is a priority for this Government, and we are working to ensure that it becomes a priority for every part of our society—communities, banks, supermarkets and transport. All need to become dementia-aware and dementia-friendly. That is why, on 26 March, the Prime Minister set out the Government’s challenge on dementia, to go further and faster in implementing the national dementia strategy in three key areas: driving improvements in health and care, creating dementia-friendly communities and improving research into dementia.
I was grateful to my noble friend Lady Barker for what she said about the challenge. We do mean business in this important area. Nationally, three champion groups are driving delivery. The first meetings of the three groups have already taken place and work is well under way to make progress on the challenge. The champion groups will report their progress in September 2012 and again in March 2013.
People with dementia, their families and carers have told us what is important to them and what will help them to live well with dementia. They want to receive an early diagnosis and timely, good-quality information that will help them to make informed choices about their care. I listened with dismay to the story the noble Lord, Lord Wills, told us about his own mother in that context. They want the treatment and support they receive to be the best for their dementia and their life, regardless of whether they are cared for at home, in hospital or in a care home. They want the care they receive at the end of their life to be compassionate and appropriate and to support their exercise of choice.
Early identification of those who care for people with dementia is crucial so that they can be directed to the information, advice and support that will help them in their caring role. The NHS operating framework requires the NHS to work more closely than ever before with local carers’ organisations and councils to agree plans, pool their resources and make sure that carers get the support and breaks they deserve.
However, there are other reasons why change is so important. The challenging economic context, as noble Lords have emphasised, makes it even more important for new and more efficient models of service delivery. That is why we have launched an innovation challenge prize of £1 million for NHS organisations to develop ideas for transforming dementia care. Through the dementia care and support compact, the social care sector is committing to leading initiatives to improve the quality of care for people with dementia. That includes work to ensure that people with dementia are clear about what they have a right to expect of care services.
The noble Lord, Lord Wills, asked about the funding for all this. The Government have already made increased funding available to the NHS and many of the aims of the challenge should deliver savings. For example, the CQUIN goal of improving the recognition of dementia in hospital should lead to people with dementia spending less time in hospital, and ensuring that people with dementia are diagnosed early should stop them going into crisis. The Prime Minister’s challenge is about the NHS and social care making better use of the resources already available to them.
The noble Lord, Lord Touhig, asked about the eligibility criteria for care. The imminent White Paper on care and support—I stress that it is imminent—will set out our plans to transform the care and support system for everyone, including people with dementia. The noble Baronesses, Lady Pitkeathley and Lady Wheeler, asked me for further and better particulars on our plans for publishing the White Paper and indeed for reforming the funding of social care. The care and support White Paper and the progress report on funding reform for social care will be published simultaneously and, I hope, very shortly. I believe that I can go no further than I did the other day in responding to the noble Baroness, Lady Wheeler, but I can reaffirm the Government’s intention to legislate on both funding reform and the reform of the law on social care as early as possible in this Parliament. Clearly, following the publication of the White Paper and the draft Bill that will go with it, we will wish to hear from all sides of the House and indeed from all sectors of the community about the direction of travel and the detail of our ideas.
The noble Baroness, Lady Pitkeathley, asked about the role of GPs. As part of the Prime Minister’s challenge, we are actively working with the royal colleges to identify how best to improve early diagnosis through awareness, education and training at GP level. Early and accurate diagnosis is, as the noble Baroness and others emphasised, very important in ensuring that people with dementia can access the support and information that everyone needs when they receive the dismaying news of this dreadful condition.
My noble friend Lady Barker spoke about adaptations for those with multiple disabilities. I agree with what she said. It is important that designers think about people with dementia when designing products for older people. The department provided funding to the Design Council to run a project to encourage design for people with dementia. There were 185 entries, which shows that designers take this seriously and that the design community is very definitely rising to the challenge.
The noble Lord, Lord Wills, spoke about the Swindon project and innovation. I can tell him that we very much want to see good, innovative practice spread out across the NHS and social care. That is why we have launched the innovation challenge prize for dementia, to which I referred. We are very much looking at innovation as part of the implementation of the Prime Minister’s challenge. Incidentally, the dementia challenge is to achieve a dramatic reduction in the proportion of people who have undiagnosed dementia, with evidence of a step-change in the diagnosis rate and a strong service response. The challenges in this and other areas will be open for a minimum of three years, which should encourage health communities and organisations to confirm their intention to apply for a prize.
The noble Lord, Lord Wills, also referred to human rights. We very much welcomed the publication of the report of the EHRC inquiry into human rights in home care for older people. The report found evidence of mixed practice. While we should be positive about those who deliver good-quality care services—and there are many—there is no excuse for bad practice. We believe that the report performed a valuable service by shining a light on the care and support provided in that most private of spaces—people’s own homes. We cannot tolerate poor quality in any of our care services. I completely agreed with what the noble Baroness, Lady Greengross, said about training. Care and support that respects human rights must be the foundation on which we build to make a reality of our vision of better health and well-being and better care for all. We will continue to work with the EHRC, the Care Quality Commission, local authorities and care providers to ensure that poor practice is rooted out.
The noble Baroness referred, quite rightly, to workforce issues and training. We know that two-thirds of people in care homes have dementia, so it is vital that the workforce is trained in dementia care. Indeed, 10 leading care home and home care providers have already signed the dementia care and support compact to which I referred, and we aim to have 50 organisations signed up by September this year. The compact sets out the organisation’s commitment to deliver high-quality, relationship-based care and support for people with dementia. I think that that statement of intent gets the process off to the right start.
The noble Baroness, Lady Pitkeathley, rightly reminded us of the vital contribution that carers make to society, a theme taken up, very perceptively, if I may say so, by the noble Baroness, Lady Wheeler. The Government have taken strong action to support carers. We set out our priorities in Recognised, Valued and Supported: Next Steps for the Carers Strategy, published in November 2010, and we are providing additional funding of £400 million to the NHS between 2011 and 2015 for carers’ breaks. As we set out in Innovation Health and Wealth, published last December, from April 2013 access to all CQUIN rewards will be dependent on commissioning support for carers in line with NICE and SCIE guidelines.
Furthermore, the 2012-13 NHS operating framework requires the NHS to work more closely than ever before with local carers’ organisations and councils to agree plans, pool their resources and make sure that carers get the support and break that they deserve. I very much hope and believe that that will have a positive effect on the thousands of carers of people with dementia in England.
Although dementia can be a crushing condition, we must not lose sight of the fact that people do live well with it. We need a profound shift in culture and behaviour if we are to reduce the stigma of dementia. All too often dementia is ignored, and the work of carers and other professionals goes unrecognised. Business and civic organisations are part of the solution. They can help to create dementia-friendly communities where people with dementia and their carers can remain and do the things that we all take for granted, such as travelling around and shopping. As so often, my noble friend Lady Barker was completely right in what she said on this theme. We need to create communities in which people are not ashamed of or embarrassed by dementia.
As we have a few minutes in hand, with the leave of the House I will continue a little longer. We need to create communities that show a high level of public awareness and understanding about dementia, communities where people with dementia and their carers are encouraged to seek help and where people know enough about dementia to be able to help someone with the condition. By 2015, there will be at least 20 places recognised as working towards being a dementia-friendly community. Places and organisations that meet the criteria being developed as part of the Prime Minister’s challenge will be awarded dementia-friendly status. I can say to my noble friend Lady Barker that, as part of the dementia-friendly communities strand of the challenge, we are working with banks to ensure that they and their staff understand the needs of people with dementia and that staff are dementia-aware.
The noble Baroness, Lady Greengross, mentioned an important part of the Prime Minister’s challenge, dementia research, spanning basic research through to living well with dementia and increasing capacity and capability across the entire research system. It commits the National Institute for Health Research, the Medical Research Council and the Economic and Social Research Council to increasing funding for research into dementia from £26.6 million in 2009-10 to an estimated £66.3 million in 2014-15.
Over the next three years, the NIHR will support the four new NIHR biomedical research units for dementia, projects resulting from the recent NIHR-themed call for research on dementia, and additional work depending on the volume of high-quality applications received. In addition to the increase in funding for dementia, the MRC will spend over £3 million to support the UK brain banks network. This connects all the UK brain banks for the benefit of donors, researchers and future patients. This money includes £500,000 a year to improve the process for donating brain tissue by meeting the costs of collection through the NHS. The ESRC is making £5 million of additional funding available to fund research into the prevention of dementia and interventions to maximise the quality of life for people with the condition.
There is much that the Government are doing and much more yet to be done. To address the challenges of dementia, we need a response not only from the NHS but from society as a whole.
Lord Wills
My Lords, as there is a little time—this is not my intervention—I want to place on record how enormously heartening I found the Minister’s response to the debate. I feel inspired by much of what he said and I want to put on record my thanks to him for his response.
My question is this: are there any milestones in place to measure progress in meeting the Prime Minister’s challenge and, if so, what are they?
Earl Howe
My Lords, if the noble Lord will allow me, I shall write to him on that. The answer, broadly, is yes, we want to see progress made by certain steps of time. However, time does not permit me to spell that out now.
There are already significant signs of progress up and down the country. The Prime Minister’s challenge is about mobilising not only the NHS and local authorities but all the resources that our communities have to offer. A great deal of good work is already going on and is beginning to lead to a steady increase in diagnosis rates, which is promising. The result of that will, of course, be that many more people will get the treatment and care that they need and that their loved ones deserve. Long may this continue.
Care Homes
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Baroness Wheeler
To ask Her Majesty’s Government what action they will take in the light of the finding of the Care Quality Commission’s recent unannounced inspections of care homes and treatment centres for people with learning disabilities, that around half of those inspected were not meeting essential standards of care.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the CQC’s findings show unacceptable levels of care. On Monday a Department of Health report set out 14 national actions to improve care and support for people with learning disabilities or autism and behaviours that challenge. All parts of the health and care system have a role to play in driving up standards, stopping abuse and transforming local services.
Baroness Wheeler
My Lords, in its inspection of care homes and assessment centres in the light of the serious abuse and appalling standards of care at Winterbourne View hospital for people with learning disabilities, the CQC found that of the 150 inspections it carried out, independent healthcare providers were twice as likely to fail to meet the required standards as NHS providers. How does the Minister account for that? Can he say specifically what steps he will be taking to ensure that clinical commissioning groups tackle the problems the commission found over lengths of stay in services, failure to review care plans so that residents can be moved on to community-based services, and the very worrying overuse of restraint of patients?
Earl Howe
My Lords, it is true that CQC inspectors found that for the kind of services they inspected, there was more non-compliance in services run by the private sector. But the information the CQC gathered for its report does not enable it to analyse the reasons for that. I would simply say that all providers of services, whether in the independent sector or the NHS, need to ensure that they comply with essential standards. The noble Baroness summarised a number of the areas where the CQC found failings and I endorse her view that there is a fundamental failing across the system, not just in providers but in terms of commissioning as well. The examples of poor care show up a fundamental need for commissioners to review commissioning plans and care plans, and make sure not just that the providers are capable of offering and providing care to the right standards but that they are actually doing so at the right level for the patients and service users they look after.
Baroness Campbell of Surbiton
My Lords, in 2008 the Joint Committee on Human Rights produced a shocking report which highlighted some of the most degrading experiences endured by adults with learning disabilities in health and residential care settings. Four years on we are debating the same human rights abuses—this time highlighted by the CQC report, which shows excessive use of restraint and seclusion in assessment and treatment facilities. Will the Minister assure us that he will return to the JCHR and CQC reports and tell us what measures the Government will take now to protect the liberties and safety of this highly vulnerable group so that we do not sit here again in four years debating how we have failed for a third time?
Earl Howe
The noble Baroness’s remarks will resonate with many noble Lords. We have been here before. One of the emerging issues from the review is around poor practice on the use of restraint, as she rightly mentioned. CQC inspectors found that only 73% of locations met requirements on physical intervention or restraint. There was ineffective monitoring of restraint data and learning from incidents. Staff were not always trained and restraint was not always delivered in line with the care plan. There are real lessons to be learnt by providers about the use of restraint. We have flagged this up as one of the actions that we will take in the department to work with the Department for Education, the Care Quality Commission and others to drive up standards and promote best practice in the use of positive behavioural support and ensure that physical restraint is only ever used as a last resort. The report published on Monday is an interim report and we will be publishing a final report later in the year.
Baroness Barker
My Lords, does the Minister agree that this report calls into question the role of local safeguarding adult bodies? What are they doing now while people are being mistreated in a way that the CQC has uncovered? Does the Minister think that it is time to revisit the legal bases of those organisations?
Earl Howe
My Lords, my noble friend is right to call that matter into question. My department will be working with the NHS Commissioning Board Authority to agree by January next year how best to embed quality of health principles in the system using NHS contracting and guidance. Those principles will set out the expectations of service users in relation to their experience. We are taking a range of other action—the 14 national actions to which I referred in my initial Answer—which I would suggest my noble friend looks at. We are clear that there is a need not just for providers but for everybody in the system to focus on their responsibilities and to work together to drive up standards in the way that we all wish to see.
Baroness Browning
My Lords, given the number of years that have passed since we saw the Mencap report Death by Indifference, and the fact that these reports show an inadequate level of improvement, I find myself in the strange position of asking my noble friend if he would please reconsider a proper register, professionally supervised by those working in the care industry?
Earl Howe
My Lords, as my noble friend knows, we committed in the Health and Social Care Act to facilitate a voluntary register for care workers and health workers. We believe that the system should be tried before we think about any statutory regulation. However, I understand the urgency and strength of feeling around this issue and it is a matter that we will keep under regular review.
NHS: Dental Care
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Baroness Gardner of Parkes
To ask Her Majesty’s Government how many dentists are now providing NHS dental care under the general dental services contract introduced in 2006; and what is the annual cost of the care provided and the amount generated in patient charge revenues towards funding this care.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the latest figures published by the NHS information centre show that 22,799 dentists provided NHS primary dental care in 2010-11. The net allocation for primary dental care in 2010-11, the latest year for which figures are available, was £2,200 million. Patient charge revenue for 2010-11 was £617 million.
Baroness Gardner of Parkes
It is good to have the updated figures, but is the Minister aware that the two major concerns for patients now are transparency and availability? Availability is something that we look to the health service to provide. However, the transparency issue has become very important, not only to patients but to other dentists, who are very dissatisfied that dentists are able to put up notices saying, “National Health Service treatment available”, yet after a patient goes to them it emerges that the treatment is very limited. Does the Minister not think that, in the interests of warning the consumer, the present NHS fee charts should show that conditions may apply?
Earl Howe
My Lords, I absolutely agree with my noble friend about the importance of transparency of information for NHS patients. NHS Choices, which is the department’s public-facing website, already displays a lot of information about fees, the treatment that should be received and how to make a complaint about NHS dentistry, but more work is being done in this area to improve information on patients’ ratings of different practices, and we are updating the patient leaflet as well. What a dentist should not do is mislead a patient or induce a patient to access the surgery and then not provide the treatment that the patient thought they were going to get. If they cannot provide NHS treatment for whatever reason, they should point the patient in the direction of a practice that can, or else refer him or her to the primary care trust helpline.
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interests in the register. Following on from the noble Baroness’s Question, can the Minister refer specifically to the OFT report, which showed that thousands of patients, after being told by their dentist that they could not have a certain treatment on the NHS, were persuaded to go private? That is and was inaccurate information. Are the Government going to take action in this area?
Earl Howe
My Lords, the OFT report on the dental market was published last month and we very much welcome that study. We note that it found that the vast majority of patients were happy with their dental treatment and that the vast majority of dentists behave ethically. There should be, and are, clear penalties for the small minority who mislead patients, but the noble Lord is right to draw attention to that aspect of the OFT report. It is an area that we are taking extremely seriously and we are looking at what more we can do.
Lord Colwyn
In view of the Minister’s comments on patient charge revenues and the fact that NHS dentists are not allowed to do competitive pricing, has he any idea why the recent OFT report to which he has just referred revealed that 1% of regular NHS patients chose their dentist because, they said, the practice had competitive prices? Why do his colleagues at the department still refer to the NHS as being free at the point of delivery?
Earl Howe
My Lords, my noble friend is correct. Treatment provided on the NHS carries only one pricing tariff, which cannot be varied. The OFT report found that only 1% of NHS patients and 2% of private patients chose a dentist on the basis of price. I stand to be corrected, but I do not believe that it made any suggestion that NHS charges were uncompetitive; they are, and always have been, a subsidised contribution to NHS costs—they are not a market price. Therefore, I imagine that the OFT report reflected the fact that patients were comparing private charges with NHS charges. Of course, the NHS is in general free at the point of use, but my noble friend is right. It is important that we are clear that some charges exist, as they have in dentistry for 60 years.
Baroness Jolly
My Lords, some may avoid the dentist because they cannot find one, others for fear of high costs, and others just for fear. Have the Government carried out any work to determine what proportion of the population does not attend a dentist, and the reason why?
Earl Howe
I am pleased to tell my noble friend that since May 2010 over 1.1 million more patients have been seen by an NHS dentist, which is very good news. Nevertheless, we are clear that access is a priority—56.6% of the population has seen an NHS dentist within the past two years. We wish to design the new dental contract, which is currently being piloted, in a way that encourages access.
Baroness Knight of Collingtree
My Lords, does my noble friend recall that last month he told the House that he was giving attention to the possibility of access online to dental prices. Has he anything to report since he said that?
Earl Howe
My Lords, I referred earlier to NHS Choices, the website that patients and the public can access. It contains the most up-to-date information on dental treatment costs and entitlements. The dental section of NHS Choices was updated at the end of February following suggestions and comments submitted by the public through the website itself and these changes include new pages that clearly explain dental charges and exemptions and inform patients how to get help with dental costs.
The Countess of Mar
My Lords, am I right in my understanding that children and young people get all NHS dental treatment free of charge? If so, what improvements have there been in dental health among this group?
Earl Howe
The noble Countess is quite right. The oral health of children, particularly those from disadvantaged families, is one of the biggest challenges we have and one of the main priorities in this policy area. While two-thirds of five year-olds are now caries free, the remaining one-third have an average of 3.45 decayed, missing or filled teeth. We are piloting new ways of supporting dentists to identify children at risk of tooth decay to get them the care and preventive advice they need, including engagement through schools, the wider community and local authorities.
Care Quality Commission (Registration and Membership) (Amendment) Regulations 2012
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Earl Howe
My Lords, I am most grateful to noble Lords who have spoken and shall endeavour to cover the questions and points they have raised in a moment. However, before I do so, perhaps I may briefly take the Committee through the purpose of this instrument.
The regulations before us today make changes to two areas of the legislation that affect the operation of the CQC. The first component of this statutory instrument makes two small amendments to the Care Quality Commission (Registration) Regulations 2009 to replace references to the National Patient Safety Agency, the NPSA, with references to the NHS Commissioning Board Authority. The second relates to the make-up of the commission’s board. I shall say more about the purpose of these changes in a moment but I should like to reflect on the importance of the Care Quality Commission as the independent regulator of health and adult social care services in England.
The commission plays a vital role in providing assurance that patients and service users receive the standards of care that they have a right to expect. All providers of regulated activities in England, regardless of whether they are public, private or voluntary sector organisations, are required to register with the commission. Providing a regulated activity without being registered is an offence. In order to be registered, providers have to comply with a set of registration requirements that set the essential levels of quality and safety. Where providers do not meet these essential levels, the commission has a range of enforcement powers that it can use to protect patients and service users from unsafe care, including, in the most extreme cases of poor care, closing down services. The changes to the commission effected through the Health and Social Care Act 2012 are to strengthen the CQC as the quality regulator of health and adult social care services.
I shall now explain why we need to make these changes to the regulations included in the instrument under debate. Under Regulations 16 and 18 of the CQC registration regulations, registered providers of regulated health service activities have been required to notify the CQC of unexpected deaths of service users or other serious incidents, except where such providers have already reported the death or incident to the NPSA. This exception was designed to reduce the reporting burden on providers, preventing the duplication of reporting to both the NPSA and the CQC. Notifications to the NPSA were processed through the national reporting and learning system, the NRLS, and notifications made in the circumstances described in Regulations 16 and 18 of the registration regulations were passed on to the commission by the NPSA. However, from 1 June, responsibility for oversight of the NRLS transferred from the NPSA to the NHS Commissioning Board Authority. Therefore, the amendments to which I referred were needed to reflect the changing ownership of and responsibility for the NRLS and to update the exception and allow it to continue from 1 June.
Relevant notifications to the NRLS will continue to be passed to the CQC under the new arrangements. To set this in context, as noble Lords are aware, the arm’s-length bodies review in 2010 recommended the abolition of the NPSA, and provision is made for the recommended abolition in Section 281 of the Health and Social Care Act 2012. Provision in the Act is also made for the NHS Commissioning Board to have responsibility for the patient safety functions formerly carried out by the NPSA. I shall briefly reiterate why we believe this to be entirely sensible and in the best interests of patients. Patient safety has to be the key priority for all those working in the health service. It can never be allowed to be seen as an add-on or an afterthought.
For that reason the Act puts safety at the heart of the NHS, not at arm’s length. Safety is, of course, a central part of quality and we believe that the board, as a body legally responsible for ensuring continuous quality improvement in the NHS, will be best placed to drive a powerful safety agenda throughout the NHS. Embedding safety across the health and social care system is vital. That is why oversight of the patient safety function has been conferred on the shadow body—the NHS Commissioning Board Authority—from 1 June. The NPSA did not have the authority or position to fully exploit the information gained from the NRLS. In contrast the board will have the necessary authority and, being positioned at the very heart of the system, will be better placed to lead and drive improvements. Patients rightly expect that all NHS services will be safe. We believe that by making the board responsible for safety, we are placing that responsibility at the centre of the NHS.
The second part of the regulations makes changes to the regulations setting out the composition of the Care Quality Commission’s board. These changes are in response to the recommendations of the Department of Health’s review into the performance and capability of the commission. The review recommended that the department should take steps to strengthen the board, including changing its structure to that of a unitary board, so that instead of comprising only non-executives, senior executives can also be appointed and held to account by the non-executive members. The model of a unitary board also potentially offers strength in combining the strategic views of the non-executives with the organisational knowledge of the executives. In addition, the performance and capability review recommended that the Secretary of State should strengthen the board by appointing new non-executive members to existing board vacancies. The regulations, therefore, remove the bar in the commission’s existing regulations stating that the Secretary of State cannot appoint an employee of the commission to the board, so allowing for the creation of a unitary board. The regulations also extend the number of members who can be appointed to the commission’s board so as to accommodate the senior executives. The upper limit is currently set at 10, and these regulations extend that to 12. That allows flexibility in the appointment of new executive and non-executive members to strengthen the board’s capability.
I was very grateful for the comments of the noble Lord, Lord Hunt, on the appointment of David Behan as chief executive of the commission. I am sure he will agree that David’s wealth of experience around adult social care and local government system reforms at the department as director-general for social care, local government and care partnerships will stand him in excellent stead for his new role as chief executive of the CQC. David’s previous experience as the first chief inspector of the Commission for Social Care Inspection and as president of the Association of Directors of Adult Social Services, as well as his other front-line experience, will also be a great advantage to the commission.
All noble Lords who spoke asked about resources and funding. It is important to recognise that the CQC recovers fees from providers to cover the cost of registration. In addition, it receives grant in aid to cover its other functions. Every year, the CQC agrees its business plan with the Department of Health and its financial position is kept under constant review. We have agreed that the CQC will receive additional funding for staff recruitment in 2012-13.
Allied with the question of resources was that about the CQC’s capability. We have every confidence in the CQC’s ability to provide the effective regulation of providers of health and adult social care. I welcomed what the noble Baroness, Lady Wall, had to say about that. As the noble Lord, Lord Hunt, has acknowledged, huge improvements are being made in the delivery of its core task of providing assurance that services for patients and service users are safe and of appropriate quality. The CQC leadership is now demonstrating greater confidence and challenge. The recommendations that we made in the performance and capability review are aimed at building on performance during the past 12 months to strengthen capability further and to improve accountability, including accountability with the department.
We are committed to supporting and strengthening the CQC. We are clear that the CQC should continue to focus on its core role of assessing whether providers meet the essential levels of safety and quality through its registration function. The department is assured that the CQC is delivering its core functions and learning from its implementation of the registration system, improving the way in which it carries out its core business to provide a better service. We have emphasised to the CQC the importance of ensuring that providers continue to comply with regulations and safety and quality requirements. The CQC continues to monitor closely the information on service providers that it receives and takes regulatory enforcement action if it finds the safety and quality of services to be lacking in any case.
We are committed to developing the role of the CQC as the quality regulator of health and adult social care services in England. The functions that the CQC will gain as a result of the Health and Social Care Act 2012—joint licensing with Monitor, information governance monitoring and hosting Healthwatch England—and the potential transfer of functions from the Human Fertilisation and Embryology Authority and the Human Tissue Authority, subject to consultation, are all aimed at strengthening its role in assuring the safety and quality of health and adult social care services.
I emphasise that these changes will not happen overnight. For example, the delivery of joint licensing is not expected until 2014, and any transfer of functions from the HFEA or the HTA will not happen until 2015. The CQC will have a number of years to prepare for these functions, including assessing the resources needed to carry them out. During this time, the department will work with the CQC to ensure that it is ready to take on the functions at a pace that avoids distracting the commission from its core responsibilities and placing the delivery of its current functions at risk.
The noble Lord, Lord Hunt, spoke about the CQC’s methodology and in particular the “generic model of regulation”. Professional regulation, as he knows, conducted through the GMC, the GDC and other professional regulators, focuses mainly on the competence of the individual professional. However, the way in which organisations are managed and their systems work, together with factors such as the suitability of premises, also affects the safety and quality of the services provided. CQC registration will ensure that competent individuals meet the needs of their patients without putting them at risk from potential system or premises weaknesses. It is encouraging that both the General Practitioners Committee and the Royal College of General Practitioners have issued joint statements with the CQC illustrating the profession’s acknowledgment of the need for CQC registration and the light-touch approach that the CQC is taking to bringing providers into registration.
I argue that there is a generic element to the regulation process, but that does not mean that the CQC approaches its task on a one-size-fits-all basis. I have accompanied CQC inspectors when visiting a dental practice, and I know that there are non-generic elements of its methodology that apply only to dentistry. The CQC has worked with stakeholders and trialled its processes to keep these to a minimum, but it is important that it has the capacity to take action where services do not meet essential standards.
NHS: Liverpool Care Pathway
Earl Howe Excerpts(12 years, 7 months ago)
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Baroness Knight of Collingtree
To ask Her Majesty’s Government whether use of the Liverpool care pathway in NHS hospitals is consistent with the outcome of parliamentary debates and votes on euthanasia.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Liverpool care pathway is an internationally recognised framework to guide the delivery of high-quality care for people in their last hours or days of life. It is not a means of euthanasia and is therefore entirely consistent with the outcome of parliamentary debates and votes on the subject. The Liverpool care pathway helps to ensure that people die with dignity, respect and minimum distress.
Baroness Knight of Collingtree
My Lords, is my noble friend aware, however, that although the Liverpool care pathway is certainly not intended to be a tool for euthanasia, that is what a growing number of people now believe it to be, judging by their own experiences? Is he aware that consultants are not always informed that their patients have been put on this pathway, and that invariably neither those patients nor their relatives are told? Will he look into what is happening, since the very name “pathway” indicates that they are shortly to face induced death, as indeed they do?
Earl Howe
My Lords, I recognise that some people who have been on the Liverpool care pathway have received poor care. The pathway is not of itself a guarantor of best-quality care. It has been consistently made clear in the guidance for the implementation of the Liverpool care pathway that it is in no way a replacement for clinical judgment and should not be treated as a simple tick-box exercise. Rather, it should be seen as a useful framework to guide the delivery of care in a way that complements the skill and expertise of the practitioner using it.
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interests in the register. Does the noble Earl agree that the noble Baroness, Lady Knight, has done sterling work in bringing to the attention of Parliament issues to do with the appropriate feeding and nutrition of patients in hospitals, but that on this issue she is wrong? Will he confirm that the national care of the dying audit shows that in fact the vast majority of patients on the care pathway in the last 24 hours of their life were reported to be comfortable and receiving good clinical care, and that his department will continue to recommend the care pathway as good practice?
Earl Howe
My Lords, we will continue to do so. The Liverpool care pathway has sometimes been accused of being a way of withholding treatment, including hydration and nutrition. That is not the case. It is used to prevent dying patients from having the distress of receiving treatment or tests that are not beneficial and that may in fact cause harm rather than good. The noble Lord was right that the recent national care of the dying audit of hospitals, run by Marie Curie in collaboration with the Royal College of Physicians, notes that in 94% of documented cases discussions explaining the use of the LCP were held with relatives or carers. That audit process gives clinicians an opportunity to feed in their views about how well, or not so well, the pathway is working in practice.
Baroness Finlay of Llandaff
My Lords, given that the Government have recognised that the Liverpool care pathway has been designed to bring the best of hospice care into other care settings, such as hospitals, nursing homes and patients’ own homes, and that it is a tool—and a tool is often only as good as the person using it—will the Government ensure that Health Education England includes in its remit comprehensive education around the appropriate care of dying patients?
Earl Howe
Yes, my Lords. To ensure that it is used properly, the Liverpool care pathway emphasises the importance of staff receiving appropriate training and support in its use as well as accessing relevant end of life training and education programmes. A range of activity has been undertaken to support staff education and training and end of life care by the national end of life care programme and others. That includes the development of an extensive package of e-learning, which is free to access for health and social care staff.
Baroness Browning
Will my noble friend tell the House whether there is ongoing monitoring of patients who are sedated but not hydrated? Looking at people who are dying can take a long time. My noble friend mentioned a few hours or a few days. If you are not hydrated for days on end, inevitably death will come. What analysis is there?
Earl Howe
My Lords, one key feature of the Liverpool care pathway is regular monitoring of the patient—every four hours at a minimum, I believe. That regular monitoring process gives clinicians and nursing staff an opportunity to reassess the patient’s condition to see whether they are in fact responding to treatment, whether they require a different form of treatment or whether the treatment they are being given is unduly burdensome. That regular monitoring should, I think, take care of the point my noble friend raises.
The Lord Bishop of Liverpool
My Lords, I have some contact with the Liverpool care pathway in Liverpool. Does the Minister agree that not just palliative care professionals but all healthcare professionals should receive education and training in caring for dying patients? Would he also agree that in the relationship between the two, trust is paramount?
Earl Howe
My Lords, the right reverend Prelate is absolutely right. Audits that have been carried out, particularly the recent audit published in December last year, provide us with important information about the current quality of care provision. The recent audit makes a series of recommendations, including mandatory training in the care of the dying for all healthcare staff involved and a seven day, nine to five, face to face palliative care service.
Baroness Crawley
My Lords, is the Minister aware that my own dear mother spent her last days on the Liverpool care pathway? Is he further aware that our family experience was of extraordinary care and sensitivity on the part of all the healthcare professionals involved, enabling us to be with my mother peacefully at home at her death? Confusion reigns over the title. A family friend, hearing that Mum was on the Liverpool care pathway, thought that a miraculous recovery had taken place and that she was taking a leisurely stroll in one of our great northern cities.
Earl Howe
My Lords, I am pleased to hear that the noble Baroness’s mother was well looked after with the benefit of the Liverpool care pathway. I take the point about the name. Indeed, the noble Baroness, Lady Finlay, can probably give us some instructive examples from Wales, where the word “pathway” has not been adopted and the process has, I believe, been refined.
Baroness Masham of Ilton
My Lords, is the noble Earl aware that some relatives and loved ones have to fight to stop their loved ones being on the Liverpool care programme? Can he think of anything worse than dying of thirst?
Tobacco: Control
Earl Howe Excerpts(12 years, 7 months ago)
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Lord Naseby
To ask Her Majesty’s Government whether they will meet representatives of non-governmental organisations, the tobacco industry and retailers to discuss tobacco control issues, publishing the minutes of such meetings, in line with both the requirements of Article 5.3 of the World Health Organisation Framework Convention on Tobacco Control and the practice of the European Commission and other member states.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, Health Ministers consider all meeting requests carefully. Article 5.3 of the Framework Convention on Tobacco Control requires the Government to protect the development of public health policies from the vested and commercial interests of the tobacco industry. The tobacco industry is welcome to share its views on tobacco control issues with us in writing at any time.
Lord Naseby
My Lords, that is a depressing Answer. How is it possible that in a country that believes in freedom of speech, a highly regulated and legitimate industry employing thousands of people and providing millions of pounds of revenue for Her Majesty's Government can be treated quite so shabbily when the Government are developing new regulations affecting plain packaging, which affects intellectual property, and are involved in consumer safety? I ask my noble friend to think again and to receive representations. The Government may not want to agree with those representations, but surely it is the legitimate right of every elector and every employer in this country to make their representations in person to Her Majesty’s Government.
Earl Howe
My Lords, we welcome the views of tobacco companies, retailers and all those with an interest in tobacco-related policy. Ministers in other departments may have legitimate reasons to meet the tobacco industry—I understand that, from time to time, they do—but Health Ministers and Department of Health officials would have a good reason to meet tobacco companies only if a specific matter, as opposed to general issues to do with tobacco control, demanded that. We would have to think carefully whether there was a good reason.
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interests in the register, in particular as president of the Royal Society for Public Health. I ask the noble Earl to continue his efforts to keep those companies at some distance from him and the Department of Health. Will he confirm that it is the view of the Government, as it was of the previous Government, that the tobacco industry promotes a product that has been described by the WHO as being proven scientifically to be addictive and to cause disease and death, and that we should have very little to do with those companies?
Earl Howe
My Lords, I can only agree with the noble Lord, Lord Hunt, that tobacco is extremely damaging to public health. There is no safe level of smoking, and as a party to the Framework Convention on Tobacco Control, the UK has an obligation to take its undertakings very seriously—which means to develop public health policy free from influence from the vested commercial interests of a very powerful industry. However, that does not mean that we close our ears to what the tobacco industry may have to say: we are very happy to hear from it in writing. That promotes transparency, which I think assists everybody in a freedom of information context.
Lord Stoddart of Swindon
But is it not hypocritical of a Government—not only this one but previous Governments—to refuse to meet the tobacco industry, which is their tax-gatherer to the extent of £10.5 billion a year? If they had any honour and really believed that tobacco is such a bad commodity they would ban it. If they believe that, why do they not?
Earl Howe
My Lords, across government we recognise the need for Ministers or officials from other government departments to meet the tobacco industry within the parameters set under the framework convention. There may be legitimate operational reasons why such meetings might be necessary—for example, Her Majesty’s Revenue and Customs sometimes meets the tobacco industry to discuss measures to reduce the illicit trade in tobacco. So it is not as if all government departments have closed their doors, but there is a very specific issue to do with Health Ministers and health officials.
Lord Rennard
My Lords, I declare my interest as an unpaid director of Action on Smoking and Health. Does the Minister recognise that any dealings he has with the tobacco industry will be with an industry that is responsible for the deaths of around 300 of its own consumers every day in this country alone, and that any claims that that industry makes must be treated with very great scepticism given its knowledge over many years of the connection between smoking and lung cancer and the addictive properties of nicotine—facts which it well knew but denied for many decades?
Earl Howe
My Lords, my noble friend makes some very powerful points and he is right. Smoking is the biggest preventable cause of death in England. It causes more than 80,000 premature deaths every year. Tobacco use is a significant cause of health inequalities in the UK. One in two long-term smokers will die as a result of smoking. That demands that we take this issue very seriously indeed.
Lord Faulkner of Worcester
My Lords, is the Minister aware that his answers this afternoon will give a great deal of satisfaction to those of us who care about public health and the pernicious effect of the tobacco industry in its attempt to subvert it? As other questioners have said, this is a unique product: it is the only legal product that kills if it is used as the manufacturers intend. Does he share the views of his Secretary of State, who told the Times last month that he wanted the tobacco companies to have “no business” in the United Kingdom? If he does, he can be assured that he will certainly have the support of many Members of this House.
Earl Howe
My Lords, if we are successful in our strategy to reduce smoking rates significantly, an inevitable consequence will be that, over time, less and less tobacco will be sold. It is smoking that we aim to reduce, which will have consequences for the sale of tobacco products. For the good of public health we are trying to arrive at a point where there is no smoking in this country, and that would mean no retail sales of smoking tobacco. Hence I fully support the remarks of my right honourable friend the Secretary of State.
Lord Ribeiro
My Lords, I am grateful to my noble friend for acknowledging the harm and damage that smoking does. Can he assure the House that the Government are equally determined to ensure that smoking will not have an adverse effect on children and children’s health in the future?
Earl Howe
The need to reduce and, we hope, eliminate the uptake of smoking by young people is one of our top priorities. I would like to thank my noble friend for his Private Member’s Bill, which will certainly enable this issue to benefit from a wide airing. We would all like to see smoking in cars with children eradicated—the health of people can be harmed by second-hand smoke. The key question for us at the moment is what is the most appropriate and workable way of protecting children from second-hand smoking. No doubt we will debate that matter when we come to my noble friend’s Bill.
Lord Foster of Bishop Auckland
Does the noble Earl ever speak to one of the best Ministers of Health that his party ever had—and, indeed, probably the best leader that they were never intelligent enough to elect—namely Kenneth Clarke, who they tell me used to get £150,000 a year from British American Tobacco? Perhaps I may just add that Rothmans was one of the best employers that I ever encountered. It was good with the employees, good with the trade unions and good with the community. It was just that its product happened to kill people—like arms dealers’.
Older People: Health and Social Care
Earl Howe Excerpts(12 years, 7 months ago)
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Baroness Finlay of Llandaff
To ask Her Majesty’s Government how they plan to implement the recommendations in the report Delivering Dignity.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government welcome the report from the dignity in care commission and will consider carefully all the recommendations addressed to government. We will respond to the commission in detail in due course. Many of the solutions to the issues in the report lie with the local NHS, social care providers and other key stakeholders. The Government will encourage the sharing of best practice by bringing people together and putting in place the right system incentives to enable providers to increase the quality of their services to older people.
Baroness Finlay of Llandaff
Following the report, Delivering Dignity, which was published today, will the Government instruct Monitor and the Care Quality Commission to require all authorised providers to seek, monitor and act on feedback from patients and their families, and will the Nursing and Care Quality Forum be widened to look at all aspects of care home staffing, root out poor care and ensure that action is taken so that respect of the individual is an “always” event in the delivery of care?
Earl Howe
My Lords, the NHS outcomes framework contains two domains that are highly relevant to this area. The NHS Commissioning Board will be in prime position to monitor those areas of the domains that relate to the patient experience. However, I have no doubt that the CQC will continue to do its work in maintaining essential standards of quality and safety. The Nursing and Care Quality Forum is an independent group and it is therefore for the forum itself to consider how to take forward the issues raised in the recommendation, but I understand that its chair, Sally Brearley, was already planning to consider care homes as part of the next phase of the forum’s work. She has already approached a number of individuals to strengthen the forum’s membership and add further expertise in that area.
Baroness Cumberlege
My Lords, one of the most important levers for change in the Health and Social Care Act is the mandate that has been agreed between the Secretary of State and the NHS Commissioning Board. Does my noble friend consider that one could include some of the principles that are established in this very good report within that mandate?
Earl Howe
My Lords, decisions about the content of the mandate will be made on the basis of a full public consultation, which will take place in the summer. More details on that score will follow in due course so there is a limit to what I can say at the moment. However, as I indicated during the passage of the Health and Social Care Act, the mandate is likely to include expectations for improving healthcare outcomes for patients, based on the NHS outcomes framework. That framework reflects the Government’s ambition for an NHS that provides high quality, safe and effective care, treating patients with compassion, dignity and respect.
Baroness Jolly
What measures will be taken by the national Commissioning Board to ensure that clinical commissioning groups always pay proper attention to dignity when commissioning services for older people?
Earl Howe
I come back to the point that I made to the noble Baroness, Lady Finlay. Domain 4 of the NHS outcomes framework is about ensuring that people have a positive experience of care and reflects the importance of providing that positive experience, including treating patients with dignity and respect. Domain 5, which is about treating and caring for people in a safe environment and protecting them from avoidable harm, also relates to that area. These areas will be centre stage in the way that the NHS CCGs in particular are monitored by the board.
Baroness Wheeler
My Lords, the recommendations of the Delivering Dignity report focus on tackling the underlying causes of poor care in hospitals and residential care. As the Minister knows, there is widespread concern among key stakeholders, including voluntary organisations, care professionals and care providers, about the serious impact that the growing crisis in social care funding is having on providing good-quality care in residential homes. Does this not make it even more vital for the Government to stand by the Prime Minister’s pledge to deal with social care funding and with the recommendations of the Dilnot commission in this Parliament?
The Lord Bishop of Exeter
Given that Delivering Dignity recommends that,
“All hospital staff must take personal responsibility for putting the person receiving care first”,
and that staff “should be urged” to challenge practices that they believe are not in the best interests of residents, what measures have Her Majesty’s Government taken to support staff who whistleblow in this respect?
Earl Howe
My Lords, the right reverend Prelate draws attention to an area that we have focused on quite hard in recent months, and the NHS constitution has been changed to strengthen the areas around whistleblowing. In the care home context, often the care home is looking after someone who is not publicly funded and the arrangements there are often ones that the care home itself has put in place. We believe that the CQC needs to focus carefully on the arrangements in the care homes that it inspects to ensure that staff feel free to speak up if they are aware of any problems of maltreatment or anything of that kind.
Baroness Greengross
My Lords, does the Minister agree with the final recommendation in the report that we need a major cultural shift if we are to get this right? A very simple and straightforward way of ensuring that would be if every person receiving care was protected under human rights legislation. That would simplify this and make it work straightaway.
Earl Howe
The noble Baroness is right. This is about a culture shift and nothing unfortunately can happen overnight. To extend the Human Rights Act to apply to private providers in purely private arrangements in which there is no involvement by a public body would be a radical extension of the Act. The Ministry of Justice leads on humans rights but we will be discussing this recommendation with it and will consider whether further action is needed. However, we need to remember that everyone in a care setting is already protected by the law. I have mentioned to the right reverend Prelate the Care Quality Commission’s registration requirements which set essential levels of safety and quality in the provision of services. Those cover, in a nutshell, the care and welfare of service users, safeguarding service users from abuse and respecting and involving service users. The CQC has extensive enforcement powers to ensure that those standards are met.
Health Research Authority (Amendment) Regulations 2012
Earl Howe Excerpts(12 years, 8 months ago)
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Lord Patel
My Lords, my apologies to the Minister. I was not quick enough to get up. First, I welcome this order, which establishes the Health Research Authority. Like the noble Lords who have already spoken, I ask when we will have further legislation defining all the roles of the Health Research Authority. Can the noble Earl also confirm that this new authority will be required to give ethical approval to all research, no matter how it was funded? I am particularly keen to find out whether research that might be funded by individual trusts or, for that matter, by the department will also come under the ethical scrutiny of the Health Research Authority. Will the authority at this point be promoting research from the NHS, as the new NHS Act requires the foundation trusts and the commissioners to do?
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I start by thanking the noble Lord, Lord Hunt of Kings Heath, for setting out so helpfully the intended roles for the Health Research Authority, which, I think by common consent, is a very positive move forward. It has got off to a solid start. I am grateful to him as well for giving us the opportunity to debate these instruments. They are the second of three steps in the establishment of the Health Research Authority. They amend instruments, laid last year, that established the Health Research Authority in December 2011 as a special health authority with an executive board. That was the first step in fulfilling the Government’s commitment in the March 2011 Plan for Growth to create a new body to streamline the approvals for health research, following an independent review of health research regulation and governance by the Academy of Medical Sciences.
The Health Research Authority was initially constituted with an executive-only board to allow it to begin work quickly on its important agenda. We were able to make suitable interim ex officio appointments from among the initial staff who transferred in.
The instruments that we are debating today provide for the Health Research Authority to have a chair and non-officer members as well, so that it has greater independence and credibility to perform its functions for the purpose of protecting and promoting the interests of patients and the public in health research. That is the second step.
Baroness Emerton
My Lords, the conversation today has been limited to medical and health research. During the passage of the Bill, we had long debates about multiprofessional involvement being included in the research. I am very concerned that the conversation has been very much geared towards medical and health research and has not mentioned the fact that there are healthcare professionals other than those involved with medicine.
Earl Howe
The noble Baroness is right to draw attention to that omission in my coverage of these instruments. Of course, she is right that there are many different kinds of research that will involve the HRA in one form or another. I have emphasised only the medical and pharmaceutical elements of the HRA’s remit, because these matters were high up on the agenda of the Academy of Medical Sciences when it produced its report in the context of UK plc.
However, the noble Baroness should bear in mind my remarks about joining up health research and social care research. The HRA will co-operate with various bodies for the purposes of creating a unified approval process, not just for health research but to promote a consistent national system for research governance generally. Where this includes a social care or nursing element, the HRA will work closely with the relevant bodies to promote processes and standards that are consistent with the NHS and social care elements.
Lord Hunt of Kings Heath
My Lords, I thank the Minister for his positive response. I also thank the noble Baroness, Lady Emerton, the noble Lord, Lord Patel, and my noble friend Lord Turnberg for taking part in this interesting debate. I believe that the appointment and development of the HRA is a positive move forward, and of course we support the appointment of a majority of non-execs. The Minister mentioned the appointment of a chair. I do not know whether that is yet in the public domain or whether he has the name to hand, but it would be helpful to know.
I welcome the publication of draft clauses on the establishment of the HRA as a non-departmental public body in due course.
Earl Howe
My Lords, I am happy to inform the Committee, for noble Lords who were unaware of it, that Professor Jonathan Montgomery was appointed chair of the HRA on 11 June, that interviews for non-exec directors will be held on Friday, that interviews for the substantive chief executive were held on 11 June, and that the other executive members will be appointed by the rest of the new board as soon as possible.
Lord Hunt of Kings Heath
My Lords, that is very helpful. On the question of the reduction of the regulatory burden and the Minister’s reference to improving the cost-effectiveness of the whole process of approvals, that of course is welcome so long as patient consent and confidentiality are maintained and research is ethical. There is common agreement on that. I welcome his commitment to streamlining the approach in general for health research. I also welcome the decision by the devolved Administrations to encompass some of the work within the HRA, particularly the work of research ethics committees, which I assume will mean that cross-UK multi-centre trials will be subject to the streamlined process that the Minister has referred to.
On the role of the National Health Service in encouraging research, I take the noble Lord’s point about the NHS Commissioning Board’s statement of intent. I have no doubt that at that level Sir David and his colleagues will wish to support research. I am more concerned about the individual organisations in the NHS. I do not think that all NHS bodies quite realise the importance of research not only to patients but to UK plc. Anything that can be done to encourage the NHS to recognise that importance is vital. Sometimes that might mean the practicalities of recognising that their clinicians need time to take part in research activities. At a time when the NHS is having to find large efficiency savings, that may not always be welcome to chief execs of NHS organisations or to clinical commissioning groups. None the less, it would be disastrous if practising clinicians in particular were dissuaded or prevented from taking part in research activities. Again, messages on that matter from Ministers and the NHS Commissioning Board are vital.
Academic health science networks, particularly those outside London, are an important development. They will, I am sure, enhance research efforts. Again, the more support that can be given to them, the better. However, it is important that those networks focus on research—there has been some indication that almost everything about their intent is being put into the bath. One needs to come back to the fact that they are about enhancing our research capacity in the interests of the quality of patient services.
I agree with the Minister that the CPRD is a major step forward. We are uniquely attractive, but can we translate that into research money coming to the UK for what undoubtedly can be offered?
The Minister knows that I have always been sceptical about value-based pricing. He said that there was much to do. I urge him and his department to take their time on this matter. The PPRS allows industry flexibility to set the price within a profits cap. Although the UK is not a great purchaser of branded pharmaceuticals globally, the fact that it is able to set a price has an influence on price throughout Europe. My concern is that taking that away might have an impact on industry’s willingness to invest in R&D in this country, given that we so are slow to take up innovative new medicines. We developed NICE to encourage the health service to do that, and it is still a struggle because unfortunately the default position of the NHS and of clinicians is to be slow to invest in and agree to innovation.
If value-based pricing can encourage the NHS towards innovation in the way that the Minister suggests, that is of course to be welcomed. However, looking more generally at the impact of research, we do not seem yet to have a philosophy that goes hard on innovation where it can definitely improve the quality and outcome of patient care. That is to do partly with the conservative nature of clinicians in the UK and partly, probably, with the mindset of finance directors in the NHS. I know that the noble Earl is the Minister for Innovation and that he is wrestling with those issues. It is very important when we look at both research and value-based pricing that we encourage the NHS as both commissioner and provider to do everything that it can to take advantage of the huge amount of innovation that takes place in this country on the back of a fantastic resource in life sciences, in our universities and in the medical devices industry. Overall, we have had a very good debate and I am glad to support these statutory instruments.
NHS: Public Information and Advice
Earl Howe Excerpts(12 years, 8 months ago)
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Lord Sharkey
To ask Her Majesty’s Government whether they plan to review, after an appropriate interval, the comparative performances of public health information and advice campaigns under (1) the new, and (2) the former, NHS architectures; and, if so, when and whether the findings of that review will be made public.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the department continuously reviews the performance of its public health information and advice campaigns. Our investment in campaigns reflects evidence of their effectiveness. Summaries of campaign research are published online as part of our freedom of information publication scheme. Publication typically occurs six months to a year after receipt of the final research report. As evaluation is ongoing, we have no plans to review the impact of campaigns against specific changes to NHS architecture.
Lord Sharkey
I thank the Minister for that Answer. He will be aware that the country faces an epidemic of obesity, with predictions that nearly a half of all adults could be obese by 2030. He will also know that changing childhood eating habits is the key to addressing this problem. What long-term plans do the Government have for information and advice campaigns aimed at influencing childhood eating habits?
Earl Howe
My Lords, my noble friend is absolutely correct to highlight the importance of preventing obesity, particularly obesity in the young. He will be reassured to know that the Change4Life Campaign, which we have continued from the previous Government, will include this as a major focus into the future.
Baroness Gould of Potternewton
My Lords, in light of the fact that the Minister talked about having a review, have the Government given any reconsideration to the need for a specific national prevention campaign designed to reduce the number of HIV infections? Does he accept that there is a necessity to reduce the increasing level of transmission, not only because it is spreading into non-high-risk groups but also because of the cost of treatment, which is extremely costly indeed? It seems to me that there is no question that the long-term savings would be substantial compared to the cost of a national campaign. Can the Minister also clarify the future of the two current targeted HIV campaigns?
Earl Howe
My Lords, I share the noble Baroness’s concern. She has highlighted a major area on which Public Health England and local authorities will wish to focus going forward. This is the great advantage of the architecture that we have put in place, with health and well-being boards responsible for determining local needs and the way in which to address them. Public health awareness campaigns have their place but they are not the total answer. The noble Baroness has drawn attention to the importance of having sufficient treatment facilities, and access to them, available. So, with the support of Public Health England at a national level, local authorities should be addressing sexual health as one of their key areas.
Baroness Gardner of Parkes
My Lords, as the Minister has said, the situation is constantly being evaluated. Has he looked into the recent problems of patients who cannot see displayed the costs for National Health Service dentistry procedures? Would it not be a good idea to set up an online application so that patients can see the information for themselves, with a simple form to fill in that lets them know what they should be paying before they go? That would remove all the arguments about whether or not there is a notice in the waiting room.
Earl Howe
My noble friend is right. Many dentists are good at conforming to the terms of their contract, which means making it clear to patients what it will cost them to have a particular course of NHS treatment. Other dentists, I am afraid to say, are less scrupulous. It is part of the contractual arrangement that dentists should be open on that score and it is an area to which we are currently devoting a good deal of attention.
The Lord Bishop of Blackburn
My Lords, one of the most startling ways that deprivation is measured is by health inequalities. We are all aware that, under the Act, the responsibility for public health passes to local authorities. As I understand it, local authorities do not have a duty under the Act to prioritise the reduction of health inequalities. How will the Government use the non-legislative processes open to them to reduce inequalities, especially with regard to local authorities?
Earl Howe
The answer to the right reverend Prelate, who makes a good point, is that clinical commissioning groups do have and will have a duty to bear down upon health inequalities and to ensure that they look after not only the patients on GP lists but the unregistered patients in their catchment areas as well. What we expect to see emerging from the joint health and well-being strategies coming out of the health and well-being boards is account being taken of those hard-to-reach groups in society who may not be on the immediate radar of GPs, but whose needs are nevertheless extremely acute and will have to be factored into commissioning plans.
Lord Hunt of Kings Heath
My Lords, first, I declare my health interests which are set out in the register. Perhaps I may take the noble Earl back to the decision of his department to reduce the number of national campaigns in relation to public health. A survey by the Association of Directors of Public Health published at the weekend shows that, in the transfer to local authorities, there has been a loss both of capacity and of funding. Given that, how can he justify the emphasis on local campaigns at the expense of national focus programmes?
Earl Howe
My Lords, there will be national focus programmes led primarily by Public Health England, but we see those as complementary to the work going on at the local level. By no means are we abandoning national campaigns. Indeed, we have seen considerable successes. In 2010-11 we invested almost £11 million to support 59 cancer awareness campaigns around the country. In 2011-12 we provided £8.5 million to support a range of cancer awareness campaigns, and this year we hope to spend even more on cancer awareness than we have in previous years.
Baroness Oppenheim-Barnes
My Lords, what is the reaction of the NHS to the explosive headlines appearing daily in newspapers about new cures, magic pills and other things of that nature? Surely these are being trialled for the NHS, which must be creating new demands every day as a result. Does the service have a plan to deal with this?
Earl Howe
The key is to make available to the public accredited sources of information because there is an awful lot of unaccredited information available. Through mechanisms such as NHS Choices and NHS Evidence, people can now see online not only what best practice looks like, but what clinical trials are available for the latest drugs and treatments. My noble friend is right; we have to direct people to the right sources of information.