NHS: General Practitioners
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Lord Laming
To ask Her Majesty’s Government what steps they are taking to increase the public accessibility and range of services provided by general practitioners in the National Health Service.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, from April 2013 the NHS Commissioning Board will be responsible for commissioning primary medical services. As a single organisation the board will be able to ensure that a consistent approach is applied to defining and delivering accessible and high-quality GP services. Clinical commissioning groups will also actively seek to improve care delivered by general practice because of their inherent interest in enhancing the wider quality and cost-effectiveness of NHS care.
Lord Laming
My Lords, I am grateful to the Minister for that very helpful reply. He knows better than most that if the intentions of the new Health and Social Care Act are to be realised, locally based community health services will need to be transformed. Will he say a little about the process, and in particular whether the users of services—the patients—will be given an opportunity to contribute to that transformation?
Earl Howe
The noble Lord raises a central issue that is certainly a major part of the Government’s programme—to shift services in general out of acute settings, where appropriate, and into the community. We expect that clinical commissioning groups will wish to engage with health professionals from across the full range of disciplines to design care in better ways, and in particular to ensure that the shift goes on. The noble Lord mentioned patient input, which is another key responsibility of clinical commissioning groups—and a legal duty that we made sure was in the legislation.
Baroness Gardner of Parkes
Will the Minister tell me the position on homeopathic medicine? I had a lot of letters this week from patients who were concerned that they might no longer be able to benefit from it, and from GPs who practise homeopathy.
Lord Swinfen
My Lords, to what extent are general practitioners using telemedicine to cut down the time needed to obtain specialist medical advice for their patients?
Earl Howe
My Lords, this is a very exciting area. I have seen some extremely good examples of telemedicine that will deliver not only greater efficiency within the health service, sometimes enabling clinicians to diagnose conditions in patients from a remote standpoint, but also greater safety and effectiveness of care for patients. For example, I saw a demonstration of stroke diagnosis that can be done remotely by laptop. This is an area on which the department is focusing a lot of attention, not least through the 3millionlives initiative, through which we hope over the next few years to ensure that 3 million people benefit from telecare and telemedicine.
Baroness Jolly
My Lords, what role should practice-based patient participation groups have in moulding the services that their GPs offer?
Earl Howe
My noble friend is extremely familiar with this area. I have also come across some extremely effective practice-based patient groups that are enormously valuable, and are valued by the GPs and other primary care staff with whom they interact. It is very much part of the world of the NHS today and we wish to see it continue.
Baroness Wheeler
My Lords, at the conference this week we heard the growing concern of GP leaders and delegates that grass-roots GPs were being excluded from involvement in clinical commissioning groups. How will the Minister address this, and will he ensure that CCG guidance includes best practice on how their involvement can be ensured?
Earl Howe
My Lords, each GP practice will have a GP or other health professional who will represent the practice in dealing with the CCG. Other GPs may be involved in the clinical design of local services, building in some cases on existing GP involvement in practice-based commissioning. Most day-to-day commissioning activities are likely to be undertaken by staff within CCGs, but part of the rationale for this is clinical engagement and involvement. I would be very concerned to hear of instances where GPs felt that they were being shut out of the process of development that is now under way. If the noble Baroness could draw my attention to any such instances, I would be grateful.
Baroness Deech
My Lords, the Minister will know that a very large number of GPs are women. I chaired a committee on this for the Department of Health. To increase their availability, what steps is he taking to ensure that there is proper maternity leave provision for GPs, and assistance with childcare? These two issues have definitely restricted the availability of women GPs.
Earl Howe
The noble Baroness is correct: these are important issues and my department is in regular contact with the Royal College of General Practitioners, talking about those issues among others. The number of GP trainees has increased in recent years, as she will know, both men and women. The Centre for Workforce Intelligence, which is our independent advisory body on workforce planning, recommends that we should increase the number of entry-level training posts by 450 to around 3,250, phased over the next four years. I am afraid that I have not got the split of figures between men and women GPs but I shall write to her to let her know exactly what we are doing to address the areas of concern that she has raised.
Greater London Authority Act 1999 (Amendment) Order 2012
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the order before the Committee gives the Greater London Authority the ability to spend money on activities that protect or promote improvements in public health in London.
The Health and Social Care Act 2012 confers important new public health duties on upper-tier and unitary local authorities in England. They include London borough councils and the City of London but not the GLA. From April 2013, those authorities must take appropriate steps to improve the health of their populations. The Act also confers on the Secretary of State for Health the new duty of taking steps to protect public health, and allows him to delegate his functions to local authorities either by prescribing them in regulations or by entering into other arrangements. Local authorities will be supported in their duties by a new grant, based on the current NHS spend on the equivalent activity, ring-fenced exclusively for public health. They will employ directors of public health and other specialist staff who will act as local champions for health improvement both within their authorities and beyond.
It is fair to say that the Act’s provisions pave the way for the most fundamental reform of public health services for some decades. They were broadly welcomed by both local government and the public health community. There is widespread recognition that in many ways local authorities are the natural home for action on public health, given their closeness to their local communities, their direct democratic accountability and the responsibility they share already for a wide range of services that have an impact on health, such as social care, leisure and education among many others.
The public health challenges in Greater London are exceptional. London has a complex population that is ethnically diverse, relatively young, mobile and transient, with pockets of high levels of poverty, crime and social exclusion cheek by jowl with great wealth. London rates below the national average on 18 key health indicators, including mental illness and deaths from heart attacks and strokes, while childhood immunisation rates are lower than in other large cities.
Individually, the 33 boroughs are ready and able to address these challenges. There is, however, currently no agency with the power to plan and act across borough boundaries, and to take an overview of what can be done most effectively and efficiently for London as a whole. We believe that such an agency would have considerable potential. For example, it could be asked to commission pan-London services for smaller minority groups which may otherwise be at risk of slipping beneath the radar in some boroughs. We have consulted organisations representing minority groups in London, which agree that this would be a significant benefit.
A cross-London agency could reduce administrative costs and obtain economies of scale, freeing up more resources for public health services. If, for example, the boroughs agreed that it would be appropriate for them to run cancer awareness campaigns, it would be far more effective, and less costly, to commission one campaign for London than 33 separate campaigns each confined to a single borough.
The Government propose to fill this gap. In the gracious Speech on 9 May, Her Majesty announced that we will publish a draft Bill to modernise adult care and support in England. Subject to parliamentary approval, we also intend to use this Bill to require the Greater London Authority to establish a London health improvement board, bringing together the GLA, the mayor and the boroughs to produce and implement an annual plan for public health in London, funded by the boroughs from their ring-fenced grants.
I am delighted to say that the idea for this proposal came from the boroughs and the GLA themselves, in response to an invitation from the Secretary of State, which I think sends us a very positive message about their commitment and enthusiasm. In fact, the board is already up and running, albeit in a limited and non-statutory way.
This brings us directly to the matter of today’s debate. The boroughs will acquire new duties and the related funding from April 2013. The NHS in London is keen to work with the London health improvement board on public health right now. However, it will not be possible to establish the board on a statutory basis before 2014 at the earliest.
Eager as the Board is to make its full contribution as soon as possible, it faces one particularly severe constraint during this intervening period. The GLA is currently prevented by Section 31(3)(d) of the Greater London Authority Act 1999 from spending money on providing any health services that can be provided by a local authority or other public body, such as a primary care trust.
This means that even if funds are contributed voluntarily by the boroughs or the NHS, the GLA and therefore the board cannot currently use them to commission public health services or campaigns. It is easy to understand the rationale for that constraint—it is the need to prevent wasteful duplication of activity. We have no intention, either now or in the future, of giving the GLA a standing statutory duty for public health that would overlap with the duties that the boroughs have for their populations.
The objective we want to achieve now, ahead of more comprehensive primary legislation, is simply to allow London boroughs to work in partnership with the board from the outset as one way of effectively fulfilling their duties. This order removes the obstacle that the 1999 Act presents. It is made under Section 31(9) of that Act, which provides that the Secretary of State may make an order to remove or restrict any prohibitions or limitations imposed by Section 31.
The order inserts a new Section 31(5A) into the Act, which from July will allow the GLA to spend money on providing services or facilities that protect or promote improvements in public health. This new power will be exercised consistently with the GLA’s principal purposes as set out in Section 30(2) of the Act.
With this new power, the GLA will also be able to spend funds on public health activities that it raises from external sponsors other than the borough councils and, until April 2013, allow it to work with primary care trusts and the strategic health authority in London if they commission the GLA to deliver public health services on their behalf.
Lord Hunt of Kings Heath
My Lords, I thank the noble Earl, Lord Howe, for explaining the intention of the order to the Committee. I declare an interest as chairman of an NHS foundation trust and as a consultant and trainer in NHS and health issues. As the noble Earl explained, this will enable the GLA to spend money on improving or protecting public health in Greater London. It has a specific relevance to the London Health Improvement Board, and is consistent with the enhanced role to be given to local authorities in the rest of England and in the London boroughs. We believe that local authorities can make a major contribution to public health and support the general thrust of the order.
The case the noble Earl put forward for a pan-London approach to public health is persuasive. My understanding is that—as he said—it will tackle the major health problems in the capital, including cancer, childhood obesity and alcohol abuse. I particularly note the comments of Dr Simon Tanner, NHS London regional director of public health, who explained that:
“Health issues in London are both complicated and specific to the city. The capital’s biggest health problems such as obesity, cancer and alcohol abuse are often interrelated and cannot be tackled in isolation”.
On behalf of the NHS, he said,
“we want to draw on the diverse skills and experience we have to tackle these areas through the London Health Improvement Board”.
This clearly receives support from the NHS, as well as the London boroughs and the GLA.
I listened carefully to the noble Earl’s explanation of the relationship between the London boroughs, the GLA and the improvement board. He was careful to make clear that the London boroughs are the principal public health bodies for London. In essence, the LHIB will depend on the support of the London boroughs to be able to take the necessary action. I entirely understand that, but I will ask the Minister a question. He mentioned the issue of campaigns. He said that it would be much better to co-ordinate a public health campaign across London, and that the board could have an important role to play, which is self-evident. However, I imagine that it would depend on all the London boroughs signing up to a particular programme and committing a budget to it.
What will happen if the board is not able to get all the London boroughs to join a campaign? When statutory legislation is brought to Parliament, will it enable the board to take account of that in some way? Presumably, one would not want one borough to be able to veto an action that all the others had agreed to. I would be grateful if the noble Earl would also indicate when he thinks legislation will be brought forward to put the board on a statutory basis. I do not know whether it will be primary or secondary legislation. It would be helpful if he could explain that, too.
My final question is slightly outwith the issue, but I hope that the noble Earl will not mind me asking it. We are all agreed that local authorities, whether inside or outside London, should have a stronger role in public health. The appointment of a director of public health by first-tier local authorities, and the establishment of public health departments in those local authorities, is clearly very important. Noble Lords will be aware that there has been concern in the public health community about the extent to which the ring-fencing of budgets will actually hold. If the noble Earl is not able to explain this, perhaps he might write to me in due course.
I am also picking up some concerns that local authorities are being less than sensitive to the debates that we had on the Health and Social Care Bill about the status of the director of public health and the right of direct access to the local authority chief executive. I realise that local government structures have changed since 1974 and that direct access for the DPH could present some problems to local authorities, but it is widely accepted within government that the Chief Medical Officer must have direct access to the Prime Minister and senior Ministers—for obvious reasons in view of the importance of that office. Surely the same applies at local level.
There are some signs that local authorities have not taken that message on board. It would be a great pity if local authorities, almost at the starting gate of assuming greater responsibility, did not recognise the need to ensure that public health has a very strong voice at the top table. Frankly, local authorities are on trial. There is no guarantee that the arrangement will stay for ever if they are not able to accept the responsibility that is placed on them. I realise that this matter goes slightly wider than the order, but any words of comfort would be much appreciated.
Earl Howe
My Lords, I am very grateful to the noble Lord, Lord Hunt, for his support for the order. He asked me a number of questions. First, he asked whether, if the London borough councils cannot unanimously agree on a plan, that would affect their ability to commission services from the GLA or through the board. The board can and will be able to deal with the boroughs individually if necessary. The draft Bill that we are bringing forward will make clear in primary legislation how the board will agree plans on a statutory basis. For example, if a group of boroughs wished to get together, excluding other boroughs, there is no reason why they should not do so and commission the GLA to deliver services solely on their behalf.
As I said, the establishment of the board as an NDPB will require primary legislation. Unfortunately, I cannot tell the noble Lord when that will be brought forward, but the draft legislation will be published soon. We published baseline allocations based on the NHS spend for public health, and our intention is to move gradually to a more needs-based formula over a period of years. To move more suddenly would prove destabilising, as I am sure the noble Lord appreciates. That addresses his point about the ring-fencing of budgets, and whether they will hold. I was not aware of concern about that. Of course, some boroughs wish that they had more money than they do, but it is necessary to start from a logical place, and we believe that the baseline allocations reflect current reality.
I was concerned to hear what the noble Lord said about the status of directors of public health and the extent to which they will or will not have access to their respective chief operating officers within a local authority. I will take that concern away with me, and I am grateful to him for flagging it up. If there is anything I can say to him in writing, I will be very happy to do so.
Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2012
Earl Howe Excerpts(12 years, 6 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the regulations that are before us today make a number of changes to the registration system for providers of health and adult social care services operated by the Care Quality Commission.
The changes that we are proposing fall into three broad categories. First, they make some changes to the extent of registration, removing some providers from registration where the risk to service users does not justify regulation by the commission, or there is little or no potential for regulation by the commission to mitigate these risks. Secondly, they make some slight technical amendments to the regulations; and thirdly, they make some clarifications to the regulations. I shall say more about the purpose of the instrument a little later, but I would like to reflect on the progress that the commission has made since it was set up three years ago.
As the independent regulator of health and adult social care services in England, the commission plays a key 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. This includes, in the most extreme cases of poor care, closing down services. The commission has registered around 22,000 providers in a number of waves. The final round will be the registration of 8,000 providers of NHS primary medical services in April 2013.
During the passage of the Health and Social Care Act 2012, we made it clear that we would strengthen the role of the commission. As our reforms to health and social care services are implemented, the commission’s focus will remain on its core function of registering providers against the essential levels of safety and quality, and taking action against those providers that do not meet these standards.
The commission has taken on a challenging workload in bringing a large number of new providers into a new registration system in a short period of time, and in merging the work of three former regulators. I believe that it should be commended on the progress that it has made. The early years of the commission’s operation have been comprehensively reviewed over the last year. This has included reviews by the Public Accounts Committee, the Health Select Committee and the performance and capability review undertaken by my own department.
The regulations before us now were consulted on and drafted before the findings of those reviews were available. I assure the Committee that my department will consider whether further changes to the regulations that underpin the registration system are required in the light of these several reports. We are now commencing a further review of the regulations and aim to consult on any further changes, if they are needed, at the end of the year.
Earl Howe
My Lords, I am grateful to the noble Lord for his comments. I begin by thanking him for the expressions of support that he gave to Dame Jo Williams and Cynthia Bower. I am sure that they will read those with gratitude.
The noble Lord made a number of points around the capability of the CQC to undertake the duties placed on it. The performance and capability review found that in its early stages the CQC was understandably focused on operational priorities. However, the achievements of the CQC should not be underestimated, and I was glad to hear the noble Lord acknowledge that. The review also acknowledges that the CQC leadership could have done more to manage operational risks and provide better strategic direction. We are clear that the CQC leadership is now demonstrating greater confidence and challenge. The recommendations are aimed at building on performance over the last 12 months, which I think has been noticeable, to further strengthen capability and improve accountability, including within the department.
We were very frank in our assessment of our own role—that is to say, the role of the department—in this. The capability review recognised that the department and the CQC underestimated the scale of the task of combining three regulators into one organisation while developing and implementing the new regulatory model. Even so, the review found that the CQC could have done more to manage the difficulties that it faced in its first few years.
We need to address those points but, at the same time, to look ahead. The department is committed to supporting and strengthening the CQC. We are clear that the CQC should continue in the future to focus on its core role of assessing whether providers meet the essential levels of safety and quality through its registration function. We have every confidence in the CQC’s ability to provide effective regulation of providers of healthcare and adult social care in England. The performance and capability review found that the CQC has made significant progress in the last nine months and is clearly focused on its core tasks.
The review has already made recommendations to strengthen the board and the board’s structures, which was a matter raised by the noble Lord, including changing the board so that, instead of comprising only non-executives, it becomes a unitary board of majority non-executives, with senior executives on the board where they can be better held to account. It also recommended that the CQC reviews and reinstates the board’s support and development programme and strengthens capability at executive team level with greater strategic capability and more and wider sector-specific expertise. The department will oversee the implementation of those recommendations.
Lord Hunt of Kings Heath
I am grateful to the noble Earl, Lord Howe. Perhaps I may make just a couple of points. On the consultation on the HFEA, all I should like to say to him is that it might be useful if there were some time for parliamentary discussion in your Lordships’ House around the consultation—not to second-guess the consultation process but, I should have thought, in view of our previous debates, to allow for some discussion among parliamentarians about the consultation document.
Secondly, as regards Kay Sheldon, I fully understand that the noble Earl is not prepared to comment on any individual case. He went on to make the point that the department was concerned to ensure that the board of the CQC was well functioning and effective. One could take that both ways. I understand, in a sense, the ambiguity of the noble Earl’s expressions in relation to that. All I would say to him is that I would ask the department to walk very carefully in this area. I know that he has debated the issue of whistleblowing many times in the past few years, and he has always upheld the rights of whistleblowers. Although it might be argued that a board member is a little different from a member of staff, there will sometimes be circumstances when board members themselves can become frustrated that they have raised concerns that are not then dealt with. Taking action against a board member who has actually given evidence to a public inquiry will send unfortunate signals to the NHS about how strong collectively we are in supporting whistleblowers. I do not expect the noble Earl to respond to that but hope that it will at least encourage the department to think very carefully about their actions in this case.
Earl Howe
My Lords, on the noble Lord’s first point, I would be very willing to take part in a debate on the issue involved in our proposals to transfer the functions of the HFEA and the HTA to the CQC. I can only say that I will ensure that the noble Lord’s suggestion is fed into the usual channels.
On the second issue that he raised, I appreciate his understanding that it would not be appropriate for me to comment on the position of individual members of the board. I am sorry if my remarks appeared ambiguous; that was certainly not my intention. All I intended to say was that the CQC will be facing significant challenges over the coming months, as we have been discussing, and the department is committed to ensuring that its board has the skills and capabilities it will need to meet those challenges.
NHS: Risk Register
Earl Howe Excerpts(12 years, 6 months ago)
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Lord Hunt of Kings Heath
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and, in so doing, I declare an interest as chair of an NHS foundation trust and as a consultant and trainer on the NHS and health issues.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the transition risk register will be published when the balance of public interest favours disclosure. We will continue to be open about risk. Last week we published a document containing information on all risk areas in the register, along with a scheme of publication for future review and release of information on risk.
Lord Hunt of Kings Heath
My Lords, I am extremely grateful to the noble Earl for that because he said that it would be published when the balance is in favour of the public interest. Can I take him back to the judgment of the First-tier Tribunal, which concluded that risk registers,
“would have provided the public with a far better understanding of the risks to a national institution”,
on which millions depend? Surely the public interest and parliamentary scrutiny actually depended on that risk register being published, and it should have been published when the Bill was in this House.
Earl Howe
My Lords, we do not agree with that. We have, as I have mentioned, published a document setting out a summary of all the risks in the register and the mitigating actions associated with each category, but we resist publishing the risk register itself at present. It is essential that officials are able to formulate sensitive advice to Ministers, making frank assessments and using direct language, without the fear of causing unnecessary embarrassment for the Government or damage to their area of policy. That is the essence of the reason.
Lord Naseby
Is my noble friend aware that there is nobody more passionate about the NHS than I am, but that a great many people outside want civil servants and other advisers to Ministers to point out the whole extremity of risks in any policy, whether it is policy A, B or C? At the end of the day, they expect Ministers to look at those risks and take appropriate decisions. Against that background, therefore, the strategy that my noble friend is following is understood outside by the ordinary public. It may not be understood by the lobby groups; nevertheless, it is the public whom we serve.
Earl Howe
My Lords, I am very grateful to my noble friend, and he is right. The risk assessment process, carried out by civil servants and detailed in these registers, is an integral part of the formulation and development of government policy. It is in the public interest that this process be as effective as possible. We are clear that where policy is sensitive, that necessitates confidentiality.
Lord Martin of Springburn
My Lords, I take it that the decision that was made was a government decision, which was collective. I recall that the Deputy Prime Minister, before he became Deputy Prime Minister, was very keen on transparency. Was he therefore comfortable about the withholding of this information? If the noble Earl does not know, perhaps he could come back and let the House know.
Earl Howe
My Lords, the decision to exercise the veto, which is a decision provided for under the Freedom of information Act, was made by my right honourable friend the Secretary of State for Health. However, he would not have been able to exercise the veto without the collective approval of the Cabinet, and that approval was secured.
Lord Brooke of Alverthorpe
My Lords, last Thursday I asked the Minister a question that he answered in part. The part that he did not answer was whether the transitional risk register drew to the Government’s attention the risk that patients would have to wait longer to see their GP. Speaking as someone who uses the NHS and as part of the British public, I fear that the delays are getting longer and will continue to do so. Could he please now answer the question about whether or not this was in the risk register?
Earl Howe
I acknowledge that I did not answer that question and apologise to the noble Lord for not having done so last week. The whole issue of stakeholder support is one that the risk register addresses, as he will see from the document that we published. I do not recall the specific issue of waiting times to see one’s GP arising in the risk register for the simple reason that, although I acknowledge that it is currently a problem in some parts of the country, particularly London, that is not a direct result of anything that the Government are doing in our reform programme.
Lord Tebbit
My Lords, would my noble friend decline to take lessons in these matters from those who supported former Prime Minister Blair in not publishing a full and frank assessment of the intelligence reports on which he committed this country to a war?
Baroness Jolly
My Lords, risk registers are a tool to inform policy-making, so is the department currently working on a risk register for the implementation of the social care Bill, including the risks around the failure to reform the funding of social care?
Earl Howe
In answer to that characteristically helpful question from my noble friend, the department will put in place thorough programme-management arrangements as it takes forward the draft care and support Bill and plans for its implementation. That will include monitoring and assessing risks as they arise, to ensure smooth passage through to implementation.
Lord Peston
My Lords, I repeat what I said last time: it really is about time that the Liberal Democrats recognised that they are part of the government side. Everyone is getting quite fed up with this demand to be treated separately.
Is it not trivially obvious that all decision-making involves risks and therefore the Government’s refusal to publish this register would cause a reasonable person outside to come to the conclusion, much as the Minister might dislike this, that the Government really are trying to hide something that was damaging to them?
Earl Howe
My Lords, I cannot answer for those who see something suspicious in what the Government are doing. All I can say is that we are absolutely clear that the circumstances in this case were exceptional. The FOI request from Mr Healey was made at a particularly sensitive time when the need for a safe space for civil servants and Ministers was especially high. The Freedom of Information Act was drafted specifically to allow for the ministerial veto. It is not just about the specific content of the risk register; it is also about preserving risk registers in general as frank internal working tools in the interests of good government.
Greater London Authority Act 1999 (Amendment) Order 2012
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Health Transition Risk Register
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
Mr Speaker, I shall now repeat a Statement made in another place earlier today by my right honourable friend the Secretary of State for Health on the subject of risk registers. The Statement is as follows:
“Mr Speaker, with permission, I would like to make a Statement on the publication of the Department of Health’s strategic and transition risk registers check.
In November 2010, the right honourable Member for Wentworth and Dearne submitted a freedom of information request, asking for the publication of the transition risk register relating to the planned Health and Social Care Bill. A similar request by Nic Cecil, a journalist with the Evening Standard, for the publication of the Department of Health’s strategic risk register, followed in February 2011.
The Government refused both requests on the grounds that the risk registers related to the formulation and development of policy and, as set out in the Freedom of Information Act 2000, were not required to be published. Appeals were then made by the applicants to the Information Commissioner. In both instances, the Information Commissioner ruled against the Government, arguing that the balance of the public interest lay in public disclosure. The Government’s view, to the contrary, is that the public interest is best served in this instance by officials and Ministers being able privately to consider such issues, including any risks. We therefore appealed the decision of the Information Commissioner, under the terms of the Freedom of Information Act, to the First-tier Tribunal. The tribunal was asked to consider whether the Information Commissioner was correct to find that, on balance, the public interest required disclosure of the risk registers.
On 5 April, the tribunal made public the reasons for its decision. For the department’s strategic risk register, it found in favour of the Government and so did not order its disclosure, but it came to the opposite conclusion with regard to the transition risk register. I have carefully considered the tribunal’s decision and have discussed it thoroughly with Cabinet colleagues. Following these discussions, I have decided to exercise the ministerial veto, as allowed by the Freedom of Information Act, in relation to the disclosure of the transition risk register. This decision represents the view of the Cabinet.
I have decided to veto, rather than appeal, the decision to the Upper-tier Tribunal, because the disagreement is on where the balance of the public interest lies and is a matter of principle and not a matter of law, as would be the focus of any further appeal. I recognise that this is an exceptional step. It is not one that is taken lightly.
There is no doubt that reform of the NHS has attracted huge public interest. But my decision to veto, while an exceptional case, is also a matter of wider principle and not just about the specific content of the transition risk register. In all departments, Ministers are required to balance the public interest in terms of disclosure with the need properly to consider complex areas of public policy. Good government demands that the analysis and management of risk is thorough and robust, whichever party is in power.
It is an essential aspect of good government, in the formulation and development of policy, that officials have a ‘safe space’ within which to formulate sensitive advice to Ministers, and that they feel free to use direct language and make frank assessments—and that the Government should, in exceptional circumstances, have the ability to reserve such privacy absolutely.
As the right honourable Member for Blackburn said in his evidence to the Justice Select Committee only last month, on 17 April:
‘There has to be a space in which decision makers can think thoughts without the risk of disclosure, and not only of disclosure at the time, but of disclosure afterwards’.
He also said there have been,
‘some rather extraordinary decisions by the Freedom of Information Tribunal, in which they suggested that it’—
by which he meant the exemption—
‘can apply only while policy was in the process of development but not at any time thereafter. That is crazy and it is not remotely what was intended’.
The Freedom of Information Act was drafted specifically to allow for a safe space for the development of policy, and I have acted throughout in strict accordance with the provisions of the Act.
The risk assessment process, carried out by civil servants and detailed in these registers, is an integral part of the formulation and development of government policy. It is strongly in the public interest that this process be as effective as possible. At the time the request for the transition risk register was made, many aspects of the policy were still at an early stage of their development. The Command Paper responding to the consultation had not been published. The Bill had not been published. It is therefore incorrect to say that the transition risk register does not relate to the development of policy as it fed, and continues to feed, directly into advice given to Ministers.
The Bill may have become an Act in March of this year but we are still in the process of policy development at the next level of detail. The value of risk registers is directly linked to the form and manner in which they are expressed, with the use of direct language. They do not, however, show the benefits of a policy. They are not, as impact assessments are, intended to reflect considered calculations of both costs and benefits. They are simply about identifying possible risks, in order to stimulate action to mitigate them.
If such registers are disclosed at sensitive times in relation to sensitive issues—as would have been the case here—it is highly likely that they would have been open to misinterpretation and misuse. The impact of this would be that future risk registers become anodyne documents of little use. Potential risks would be more likely to develop without adequate mitigation. That would be detrimental to good government and very much against the public interest.
Reflecting this, a detailed statement of reasons for my decision to exercise the ministerial veto in this case has been laid before Parliament. This decision to veto the disclosure of the register is not in any way a criticism of the Freedom of Information Act. The Act always envisioned that there would be times when the Government would need to protect the process of policy development, and this is one of those times. The Government’s right to make just such a veto is written into and is a proper use of the Act.
We have always been as open as possible about the risks and issues engaged in the modernisation of the NHS. First, there was the full public consultation, then the thorough examination by the NHS Future Forum, and the 50 days of detailed debate in both Houses, in addition to the detailed risks published in the impact assessment. Very few pieces of legislation have ever received this degree of public and parliamentary scrutiny. And on Tuesday, I went further and published a separate document that includes the risk areas covered in the transition risk register. This document also includes the actions taken to mitigate those risk areas. I have also published a scheme for publication, which sets out our proposals for reviewing and releasing material relating to the transition programme in future. Both of these documents are available in the Library and on the Department of Health’s website. These documents further confirm that the purpose of the veto was not in any sense to restrict public access to relevant information. It is to establish that publication of the risk register in December 2010 would have been contrary to the public interest.
This Government, more than any other before them, are committed to openness and transparency. Across government we publish business plans, departmental staffing and salaries, full details of departmental contracts and summaries of departmental board meetings. In the NHS, we have published more information about services than was ever previously the case—information that is not only shining a light on poor performance, but actually helping to root it out.
We now publish the NHS Atlas of Variation, exposing the variations in outcomes across the country. We have published data on mixed-sex accommodation, leading to a dramatic 95% fall in breaches. We have invested in new information collections—on A&E performance, on ambulance performance, and on clinical audits.
The decision to veto is about long-term principle and good government, not about limiting in any way scrutiny of NHS reform. Information relating to much of the content of the risk registers is now in the public domain. However, the important principle of the right not to publish has been maintained. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I begin by welcoming the noble Lord, Lord Hunt of Kings Heath, to his new responsibilities with the health portfolio. It is very nice to see him in that post but I pay tribute to his predecessor, the noble Baroness, Lady Thornton, whom I think we would all agree fulfilled the expectations and requirements of her office with great distinction.
First, perhaps I may make a very emphatic statement. The use of the veto by my right honourable friend was not in any way an act that indicated political embarrassment. The reasons for the use of the veto were those that I read out in the Statement. Furthermore, the noble Lord’s point that this represents a fundamental change of policy is quite invalid. As he knows, the veto was used by the previous Government in matters of cross-government importance. In this instance, the Cabinet considered that the principle of “safe space” for civil servants was a matter of cross-government importance. Had it not taken that view, my right honourable friend would not have been able to exercise the veto.
The previous Government took a very similar stance in relation to risk registers. Indeed, they refused to release the Department of Health’s strategic risk registers in response to three requests under the Freedom of Information Act. Therefore, I suggest to the noble Lord that the position adopted by the Government of whom he was a member was not at all dissimilar to the one that we have taken.
The noble Lord asked why the Government consider the current circumstances to be exceptional. He himself read out a section of the tribunal’s reasons which uses the word “exceptional”. The tribunal and indeed the Information Commissioner regard this case as exceptional, as do we. It is important for me to say that the reasons why those views are taken may be different in each case. Nevertheless, both sides classified this as an exceptional matter. From our point of view, it is exceptional not only because these were highly sensitive issues for which a request for disclosure was made at a very sensitive time—namely, when policy was still in the process of formulation—but because of the wider considerations that I mentioned that run across government. For those reasons, above all, we believe that this is an exceptional case.
It is not true that the Government have said that the transition risk register will never be published. All documents, as long as they form part of the national archive, are published in the end but, quite apart from that, we have undertaken to review at regular intervals the sensitivity of this document and to judge whether the current circumstances still pertain. That is right and proper. It is very interesting that over the past few months my department has received no fewer than 546 requests for release of the transition risk register. I think that that is an indication of what departments would have in store for them had the veto not been exercised. I repeat that it must be possible for civil servants and Ministers to have private discussions without the fear that literally every week, or even more frequently, the public would wish to be told the exact nature of those conversations.
Do we consider the tribunal’s decision to be reasonable? I will not criticise it on grounds of reason but we fundamentally take issue with its conclusions. We believe that the balance of public interest most definitely lies in non-disclosure in this case. It is interesting that the noble Lord has given the House to understand that the Government are not keeping a close eye on the performance of the NHS. Of course, we are doing that. Indeed, as I hope the noble Lord knows, the performance of the NHS has not only been maintained since the 2010 election; in many respects it has improved. We have made efficiency savings through the Nicholson challenge. We have maintained financial control and low waiting times for elective treatment. The transition is being managed very effectively. I say that with great tribute to those in the National Health Service who have had a considerable burden of work to undertake to ensure that these changes take place in a structured way. It is proceeding well. The noble Lord failed to acknowledge that the NHS is basically in very good heart indeed.
I hope that that answers the noble Lord’s questions. I know that he will come back to this subject, perhaps even next week, but I do believe that the Government’s decision is the right one and, indeed, the only one.
Lord Falconer of Thoroton
My Lords, whether this is a discreditable attempt to cover up something that is embarrassing for the Government, I do not know; that is for others to decide. The Statement represents quite a significant change in the Government’s position towards the use of the veto. Everybody in this House would agree with the noble Earl that there needs to be a safe space in which policy is formulated. Safe space means that you can talk to your civil servants, they can talk to you, and it will not be disclosed. That was fully reflected in the Freedom of Information Act, which allowed for that safe space. Again, as the noble Earl rightly says, there is a balance to be struck between preserving that safe space and the interests of openness.
The importance of the Freedom of Information Act was that, instead of it being decided by the Government or officials, it would be decided in accordance with the law and enforced within the courts. I understood the noble Earl to say that the Government have no complaint with the application of the law by the First-tier Tribunal and that is why they are not appealing. The position, therefore, is that the law was properly applied by the tribunal and the statute said that it would be the courts that determined where the limits were to be drawn. Everybody recognised that, in very exceptional circumstances, the veto would be used. Ministers at the time referred to such circumstances as, for example, when an informer would be inadvertently named if there was disclosure or if our foreign position would be damaged in a way that people could not work out. What has happened here—the noble Earl was frank about this—is that the Government simply disagree with the courts about where the balance should be struck. What does the noble Earl feel that that says about the Government’s view of the rule of law?
Earl Howe
My Lords, the law governing the release of government documents is the Freedom of Information Act 2000. The Act specifically recognises that the Government are entitled to consider all aspects of policy formulation in private. It provides an exemption to allow that, but it also allows Ministers to exercise a veto on the release of information if they have reasonable grounds for doing so. We believe that we do have reasonable grounds for doing so.
Lord Mawhinney
My Lords, will my noble friend accept that, in trying to find a balance between disclosure and transparency on the one hand and long-term good governance on the other, he has made the right judgment? Will he accept that good governance cannot be traduced or undermined in any way because it is at the very heart of the legitimacy and credibility of what happens here and in another place? Will he accept, finally, from a noble friend, who was occasionally—only occasionally—a constructively critical friend during the passage of the Health and Social Care Bill that the openness with which he handled that Bill will add credence to the judgment that he has announced today?
Earl Howe
I can do little but thank my noble friend for his kind remarks. Indeed, if I may say so, during the passage of the Health and Social Care Bill, I always attempted to be as open as I possibly could with the House on all the matters that we debated. I think that that resulted in a much better Bill. I hesitate to do this, but it is instructive to look at the evidence given to the Justice Select Committee in another place last month by Jack Straw. He put the case that we are making in very graphic terms with which I agree. He said:
“If you talk generally about risk registers, it has to be possible for officials to say to Ministers that there are these risks without these going public. Given the assiduity of the British press, if you publish a raw risk register without any more information, you will set all sorts of hares running, but the document was not designed or prepared in that way. You have to say, ‘We think that we could be at risk here. We think we could be at risk there. Have you thought about this?’ In my view, that sort of information must be protected”.
I could not have put it better.
Lord Harries of Pentregarth
My Lords, I thank the Minister very much for his helpful Statement. The whole House agrees totally with the noble and learned Lord, Lord Falconer, that officials must have their private space to make their frank comments. Does the Minister agree that you have to draw a distinction between those frank comments and the risk register itself, which is something of a more formal document? The risk registers that I have seen lay out formally whether the risk is high, medium or low, and you could publish the risk register without at the same time publishing any frank advice that was given. Because the risk register has not been published, does that not itself give rise to possible misrepresentations? There is always the possibility of misrepresentation. If it is published it will possibly be misrepresented; if it is not published, it could also be misrepresented. Finally, I ask for further clarification about the noble Earl’s remark that if the risk register had been published that would set a precedent for the future so that advice would all be anodyne. That was the word the Minister used. Would not the opposite be the case? Officials who were trying to make their judgment about possible risks would be more likely to exaggerate the risks. If the risk register was published and it was discovered that proper risks had not been identified, those officials would be held responsible for not identifying those risks and weighing them with due seriousness. I was slightly surprised by the use of the word “anodyne”.
Earl Howe
If you talk to any Permanent Secretary in any department I guarantee that they would take issue with the noble and right reverend Lord on his final point. It is firmly the view of departments across government that if civil servants believe that what they say will reach the public domain immediately, they will not wish to embarrass either themselves or their Ministers by expressing their concerns in graphic language. I understand the noble and right reverend Lord’s point, but I disagree with it for that reason.
He made a distinction between certain parts of the risk register—between the nature of the risks described, their ratings and so on. He was perfectly right to make that distinction. We reviewed the content of the transition risk register following the tribunal’s decision and decided that it would be possible to publish material taken from the register to inform both Houses, and members of the public, about as much of the content of the register as we could. That is why the document that we published on Tuesday, which I commend to the noble and right reverend Lord, included key information relating to the risk areas in the register, an explanation of why we considered that to be a material factor, and the actions taken to mitigate those risk areas. We were as candid as we could be, given the decision of principle that I outlined.
Lord Campbell-Savours
My Lords, perhaps I may take a stage further the point of the noble and right reverend Lord, Lord Harries. Is there not a converse argument that where civil servants feel strongly, one way or another, about whether there is a risk inherent in a policy initiative, there should be a mechanism whereby that view can enter the public domain so that the public should be informed of strong divisions of opinion, even between civil servants? Is not the risk register on this Bill precisely one of those areas where strong views may have prevailed?
Earl Howe
The noble Lord may correct me, but he seems to be advocating a world where all disagreements in private between civil servants become public property. With respect, I disagree with that point of view, which would be the consequence of his position. Section 35 of the Freedom of Information Act explicitly allows for those disagreements to be kept private. There is no doubt about that. Both the Information Commissioner and the tribunal agreed that Section 35 was engaged in this instance, and was there for a reason.
There are several other reasons why we felt that there was a need to withhold information. The need for candour was one. I referred to the risk that publication of the content of the risk register would distort rather than enhance public debate. Another reason was that disclosure could in some instances—including in this case—increase the likelihood of some of the risks happening. Some risks in the register were theoretical rather than real. If people had thought that the risk was real, they might have taken action that would have made the risk a self-fulfilling prophecy. Nobody wanted that.
Lord Walton of Detchant
My Lords, having been heavily involved in debates on the Health and Social Care Bill—a Bill of extraordinary complexity and vast in its range—I find it very easy to see how civil servants involved in the handling of the Bill might well have been able to identify substantial potential perceived risks of proceeding with it at earlier stages of its development. However, as the noble Earl said, it is perfectly clear, first, that the Government had the right to keep information of such a nature confidential, even though at the end of the day it appeared that they were flouting a legal decision in order to do so. It was absolutely right that the Secretary of State had the right to impose a veto. In the circumstances, it was absolutely acceptable. Therefore, it is right that the matter should proceed as the noble Earl said.
However, will he not express just a little surprise, in the light of the massive clamour by the public and professional bodies during the passage of the Bill—which has all settled down now that the Bill is an Act—that there are those who perceive in this government decision the possibility of a slightly Machiavellian desire to suppress information that could in the ultimate be somewhat embarrassing? Having said that, I believe that the decision was obviously correct in the circumstances.
Earl Howe
I am very grateful to the noble Lord for his support—as I was throughout the passage of the Health and Social Care Bill. It would be wrong not to acknowledge that, to the outside world, the decision to employ the veto looks suspicious. Of course, Governments of whatever party are the subject of suspicion. I am sure that it is well known to noble Lords who served in government that there is very little one can do to dispel impressions of that kind, other than to stand up in Parliament and in public to tell the world what is true. I can only say to the noble Lord that I recognise that those who might take issue with the Government’s decision are entitled to a measure of disappointment, considering that we proclaimed from the rooftops our commitment to transparency. We believe in transparency, and this is apparently an instance where we are not doing what we said we would do. However, there are overriding reasons why it was important for us to take this position.
Lord Armstrong of Ilminster
My Lords, I support my noble friend Lord Walton. As I understand it, the Government’s position on the disclosure of risk registers is a matter of principle. It is clearly crucial that an assessment of risk or a risk register should be comprehensive and candid if it is to be of any use. If it is not comprehensive and candid, and if those who compile it are prevented or discouraged from making it comprehensive and candid by having to look over their shoulders in the fear of premature publication, the risk register’s value will be reduced—and there will be a further risk that the Minister will say later, “Why wasn’t I told?”.
Earl Howe
The noble Lord, Lord Armstrong, with his immense experience at the top of government, is very familiar with decisions of this nature, and I am grateful for what he said. Perhaps I should make it clear that the decision the Government took was not a blanket decision about all risk registers. The law requires the Government to look at each case on its merits. We believe that a risk register of this particularly sensitive kind is an exceptional matter. The noble Lord, Lord Hunt, pointed out instances of risk registers that might be less sensitive. He mentioned the one relating to Heathrow’s extension. I suggest that that was a less sensitive case. The matter was clearly on a smaller scale; it was less political; and it became an issue after the project had been closed down. Therefore, the release of the register was perhaps not altogether a surprising decision by the then Government.
Lord Marks of Henley-on-Thames
My Lords, I apologise to the House for not being in my place when my noble friend read the Statement. However, I read the Secretary of State’s Statement in full. My noble friend mentioned that the previous Administration refused freedom of information requests for disclosure of risk registers on three occasions. Will he tell the House how many times risk register disclosure has been refused by both this and the previous Administration? Does he know that in Wales the Labour Administration have also refused disclosure of a Department of Health risk register? Does he discern any difference of approach to the disclosure of risk registers between this and the previous Administration?
Earl Howe
I am grateful to my noble friend. The answer to his final question is no, I do not believe that there is a difference of approach. I do not have data relating to all government departments but, as I said earlier, the previous Administration refused to release the Department of Health’s strategic risk registers in response to three freedom of information requests. Indeed, one of those was responded to by the right honourable gentleman Mr Burnham in language not dissimilar to that which I have used today. A search of my department’s freedom of information database indicates that, since the Act came into force in January 2005, the department has received six specific requests for risk registers. In no case was the request granted. My noble friend also referred to the Welsh example, which is a very interesting one. In April of this year the Labour Assembly Government in Wales refused to disclose a risk register, and it was a health register. The reasons given for withholding that register mirrored exactly those that we are using currently.
Lord Brooke of Alverthorpe
As the legislation focuses so much on GPs, can the noble Earl say whether the risk register made an assessment that there would be increasing delays for patients in getting to see their GPs during the transitional period and that those patients would be put at risk? Given that the Government abandoned the previously set targets for the time limit in which GPs have to see their patients, is he aware that patients in London have faced longer waits to see a GP, let alone the GP of their choice? Is that point covered in the recently published documents in the Library? If not, will he make sure that it is?
Earl Howe
There are two points in answer to that. I am aware that in London, in particular, there is an issue for some patients wishing to see their GP; indeed only two days ago I had a useful conversation with the Royal College of GPs about that very matter. However, that particular issue has nothing to do with the reforms that the Government have just enacted, but relates to the supply of GPs. We have many more GPs than we had 10 years ago. Unfortunately, however, we need more. There is a target every year for recruiting GPs but we have not quite reached that target in the past three years. We need to do something about that. Action is in hand to address the issue that the noble Lord has raised. However, I would impress on the House that it is not a reflection of the reforms. The reforms have only just been enacted, and we are only now just rolling them out.
Health: Clinical Commissioning Groups
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Lord Hunt of Kings Heath
My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In so doing, I remind the House that I am chairman of the Heart of England NHS Foundation Trust.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in February the NHS Commissioning Board Authority published Towards Establishment which set out general safeguards that clinical commissioning groups (CCGs) should have in place to manage conflicts of interest. More specific guidance outlining safeguards for when CCGs are commissioning services that could be provided by GPs will be published shortly. We expect that both of these will inform the guidance the NHS Commissioning Board must provide for CCGs once it is established.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for his response. He will be aware of research published at the end of March which showed 22 clinical commissioning groups where the majority of GPs on the board of those groups actually had a financial interest in companies that are in receipt of NHS funding. Given that decisions on future contracts will fall to clinical commissioning groups, can the noble Earl assure me that those GPs will not take part in any discussions or decisions about future contracts? Will he also acknowledge that the problem arises from the weakness of the corporate governance arrangements, because in some CCGs there will be no one left to make the decision?
Earl Howe
My Lords, I do not accept that. CCGs will be subject to rigorous safeguards that prevent conflicts of interest affecting their commissioning decisions. Each CCG has to maintain registers of interest. They must have a governing body with lay members on it and other non-GP clinicians who will oversee the arrangements for governance. Each CCG must make arrangements set out in their constitution to manage conflicts and potential conflicts of interest. And the NHS Commissioning Board, as part of its overseeing role, will be responsible for making sure that every CCG has arrangements to manage potential conflicts of interest. So we do not see these problems arising in practice.
Baroness Gould of Potternewton
I should like to probe the Minister a little further in response to that. While he says that CCGs have to have a register of interest, how are they going to be monitored to make sure that actually happens? How will the register be kept up to date so that conflicts of interest cannot arise in the future? And what actions might be taken when a conflict of interest is proved?
Earl Howe
My Lords, the watchword in this context is transparency in that the governing body of a clinical commissioning group will usually meet in public. There will be provision for the health and well-being board of a local authority to challenge decisions made by the clinical commissioning group in its annual commissioning plans. In general, if anyone has a concern about a conflict of interest, or indeed a perceived one, it is open to them to refer the matter, first to the CCG and, secondly, to the NHS Commissioning Board itself.
Baroness Barker
My Lords, have the BMA and the royal colleges been involved in drawing up the guidance? And if a member of a CCG believes that there is no conflict of interest but a member of the public believes that there is, what mechanisms are available to resolve such a dispute?
Earl Howe
My Lords, we are involving all relevant stakeholders in drawing up the precise rules that we expect the NHS Commissioning Board to follow. As I mentioned in my initial Answer, part of that has resulted in guidance that has already been issued and the rest will follow shortly. As regards the second part of my noble friend’s question, the key is for CCGs to make arrangements to make sure that actual and potential conflicts of interest do not affect the integrity of the group’s decision-making process and do not appear to do so. Therefore, the CCG must not only be fair and open and honest, it must also be seen to be all those things, because a perceived conflict of interest which is not managed appropriately would be as damaging to the reputation of a CCG as an actual conflict.
Lord Clark of Windermere
My Lords, would the CCG’s workings and operations be subject to the Freedom of Information Act?
Lord Dykes
My Lords, will the Minister reassure the House that the nationality rule will be maintained to make sure that British people are on the boards and that American advisers do not get too heavily involved?
Earl Howe
As my noble friend may remember from our debates on the Health and Social Care Bill, we have undertaken to ensure that no member of a commissioning support organisation may also be a member of the governing body of a CCG. Having said which, it is important that CCGs have the freedom to take advice on back-office functions and other matters that will assist them in their clinical decisions.
Baroness Howarth of Breckland
My Lords, I have spent a great deal of time working in governance with professionals from many different groupings and, however experienced professionals are in their own trade, they are not always very clear about governance issues. This is often true of trustees in voluntary organisations as well as in clinical governance in the health service. What plans does the Minister have for training and advice to the new bodies in order to ensure that people who often believe that they know the answers really do know them?
Earl Howe
The noble Baroness makes an extremely important point, which is why we have laid great stress on training and ensuring that the NHS Commissioning Board will develop appropriate guidance on procurement, avoiding conflicts of interests and avoiding unfair competition entering the arena.
Lord Foulkes of Cumnock
My Lords, what is the estimated extra cost of all this extra bureaucracy?
Health and Social Care Act 2012
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Baroness Deech
To ask Her Majesty’s Government whether they have any plans for post-legislative scrutiny of the Health and Social Care Act 2012.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, all government Bills receive post-legislative scrutiny within five years of receiving Royal Assent. However, I can reaffirm the commitment that I made at the Second Reading and Committee stages of the passage of the Health and Social Care Bill. Although five years would normally elapse prior to the Department of Health undertaking post-legislative scrutiny of a Bill, we will bring that forward to three years for the Health and Social Care Act 2012.
Baroness Deech
My Lords, I am grateful to the Minister for his reply. However, does he agree that the reputation of this House rests largely on its ability to scrutinise, and that there is still insufficient capacity for this House, not a department, to carry out post-legislative scrutiny? Does he further agree that the Health and Social Care Act is very different in the end from what was proposed? It aroused huge concern and must be a number one candidate for monitoring, not necessarily by the department but by this House to ensure the appearance of total objectivity.
Earl Howe
My Lords, I am in tune with the sentiments that the noble Baroness has expressed. I am sure that she will be in no doubt that my department will be monitoring the implementation of the Act very closely. Of course Ministers will continue to provide information to Parliament—for example in response to Questions and in Select Committees and, indeed, in debates if noble Lords put down Motions. I am sure that we will provide a lot of information both on the implementation of the Act and on health and social care more widely in the months and years ahead.
Baroness McIntosh of Hudnall
I wonder if the noble Earl can explain a remark that he made early in his original Answer to the noble Baroness, Lady Deech, when he said that all government Bills are subject to post-legislative scrutiny within five years. I am sure that that is true in some way, but not in a way that I personally understand, and I am sure that it is not entirely clear to the House in what way such scrutiny is carried out. It certainly is not what is commonly meant by post-legislative scrutiny—that all Bills should be subject to it.
Earl Howe
My Lords, my understanding is that formal post-legislative scrutiny is a relatively new invention. It came in under the previous Administration in, I think, 2008. So until now there have been very few if any—there may have been one or two, a handful—formal post-legislative scrutiny processes. But we will, of course, see this as a more regular feature going forward.
Lord Mawhinney
My Lords, my noble friend has just reconfirmed that post-legislative scrutiny will take place in three years—that puts it in 2015. Can he tell your Lordships’ House whether the Government have a policy to have that scrutiny before or after the general election which is alleged to be taking place that year?
Lord Campbell-Savours
By whom is this post-legislative scrutiny on a five-year basis being conducted?
Earl Howe
My Lords, it will be conducted by the Health Select Committee of another place. The process is that the Department of Health will submit a memorandum to the Health Select Committee and that memorandum will include a preliminary assessment of how the Act has worked out in practice relative to the objectives and benchmarks identified during the passage of the Bill.
Lord Patel
My Lords, the noble Earl said in response to the Question of the noble Baroness, Lady Deech, that in the interim period the department will be undertaking scrutiny of the work of the bodies set up. Can he tell the House how the results of that scrutiny will be reported to Parliament?
Earl Howe
My Lords, the performance of the health service will be very visible as we go along: we will have the NHS Commissioning Board producing its annual report; each clinical commissioning group will be publishing an annual report; directors of public health must produce an annual report; the Secretary of State has to report annually on the overall performance of the health service; and HealthWatch England has to publish an annual report. So there will be no shortage of transparency along the way.
Baroness Jolly
My Lords, as for the Health and Social Care Act, scrutiny was, of course, done by this House. However, there is still more to be done, because there is quite a lot of secondary legislation still to come down the track. Can the Minister give the House some indication of how many pieces of secondary legislation are still to come, when they might be introduced and what areas they will cover?
Earl Howe
My Lords, I cannot yet give my noble friend a precise number, but before the House breaks up in the summer we hope to lay a number of statutory instruments. Some will come into force this October, others are designed to come into force next April, but we will of course be consulting, where appropriate, on all of those and I shall be happy to give the House further information when I have it.
Baroness Masham of Ilton
My Lords, does the Minister agree that HealthWatch has been left in limbo? Would he agree to a fast-track legislative scrutiny?
Earl Howe
I do not agree that HealthWatch has been left in limbo; in fact, only this morning I was attending a round table of pathfinder local healthwatches and witnessing for myself the tremendous energy and enthusiasm that they were devoting to HealthWatch. So the short answer to the noble Baroness is no, I think the process as regards HealthWatch is very much on track.
Baroness Thornton
My Lords, my question follows on very nicely from that of the noble Baroness, Lady Masham, because “No decision about me without me” was the Government’s mantra when they first introduced the White Paper and the Bill. I would like to know not only how soon that mantra might become a reality but also, in terms of post-legislative scrutiny, how the Minister thinks that post-legislative scrutiny might be carried out to allow independent scrutiny given that the two bodies that will essentially control the funding for the patients’ voice, HealthWatch, are the Care Quality Commission and local government—in other words, government bodies?
Earl Howe
My Lords, we should not forget the capacity of Parliament, particularly the Health Select Committee in another place, to conduct scrutiny whenever it chooses. Indeed, your Lordships' House could if it wished configure itself in a way to conduct scrutiny of any aspect of the Health and Social Care Act.
Health: Pancreatic Cancer
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank the noble Lord, Lord Aberdare, for tabling today’s debate. I am aware that this is a very important issue for him and for countless other people and families across the country. The coalition Government’s cancer outcome strategy was published in January last year. It sets out how we will make sure that people with any form of cancer get care and outcomes as good as anywhere in the world, whoever they are and wherever in the country they live.
Probably the most important factor affecting the survival rates of any cancer is the speed with which it is diagnosed—I think all noble Lords mentioned that issue. We have addressed that in the cancer outcome strategy, and that is why we are supporting the strategy with more than £450 million over four years. This funding is part of more than £750 million of additional funding for cancer over the spending review period to support our ambitions for cancer care. On top of that, or course, a range of support is already available to help GPs assess when it is appropriate to refer patients for investigations for suspected cancer, such as a NICE referral guideline. However, we can do more to support them.
Cancer Research UK and the National Cancer Action Team are working together to develop a new GP engagement programme for the coming years that will allow them to increase awareness and improve training. This will all help diagnose cancer cases earlier. I can say to my noble friend Lord Selborne that Professor Willie Hamilton is currently developing a risk assessment tool to support GPs in the investigation of pancreatic cancer.
The noble Lord, Lord Aberdare, asked if the National Awareness and Early Diagnosis Initiative could do some specific work on pancreatic cancer. Our cancer outcome strategy says that we will work with a number of charities linked with rarer cancers. There have already been meetings with several, including Pancreatic Cancer UK and Pancreatic Cancer Action, to see what more might be done to diagnose these cancers earlier. The Government’s future work on pancreatic cancer will be informed by what we learn from those charities.
I am aware also that Pancreatic Cancer UK is hosting an early diagnosis workshop in June. The National Cancer Director, Professor Sir Mike Richards, my honourable friend the Minister of State for Care Services and officials from NAEDI will be attending. The workshop will be looking at practical steps that can be taken to help GPs and secondary care health professionals diagnose pancreatic cancer at the earliest stage possible. We look forward to receiving the findings of the workshop.
My noble friend Lord Sharkey and the noble Baroness, Lady Warwick, talked about the possibility of awareness campaigns. Decisions on campaign work in this financial year will be based on the evidence from the pilots that we have run regionally in 2011-12. To further address the need to improve awareness of rarer cancers such as pancreatic cancer, consideration is being given to piloting a symptom-based awareness campaign based on covering multiple cancers. We are talking with stakeholders, including rarer cancer charities, about that work.
Once pancreatic cancer is diagnosed, patients need to have access to appropriate and consistent treatment, delivered to a high standard, across the board. I am aware that there are variations in survival rates across the country and across cancer networks. Pancreatic Cancer UK’s Study for Survival 2011 confirmed that. Quite simply, it is not good enough and it must change. That is why we are providing data to help the National Health Service tackle regional variations. For example, the National Cancer Intelligence Network has made available data collections on survival rates and surgical resection rates across a range of cancers, including pancreatic cancer. These data will allow providers and commissioners to benchmark their services and outcomes against one another and to identify where improvements need to be made. They will then be able to channel resources into improving services in the areas that need to be brought up to an acceptable standard.
The noble Lord asked whether we would develop an audit of pancreatic service and care. The National Advisory Group on Clinical Audit and Enquiries recently considered a proposal for an audit of pancreatic cancer as part of the National Clinical Audit and Patient Outcomes Programme. I understand that the proposal was not recommended for inclusion in the national programme. However, the advisory group suggested that elements of the proposal could be taken forward as part of the existing bowel cancer audit when this is retendered in 2012. I will ensure that this option is considered when the department reviews the existing arrangements for the bowel cancer audit later this year.
In Improving Outcomes: A Strategy for Cancer—First Annual Report, published in December last year, we said that continuing to provide the NHS with benchmarked data,
“as a lever for improvements”,
is a priority for 2012.
Of course, a hugely important element in all this is the patient experience, to which the noble Baroness, Lady Warwick, referred. In December 2010, we published the report of the 2010 cancer patient experience survey, which recorded the views of more than 67,000 cancer patients across 158 trusts. The survey showed that 90 per cent of patients with an upper gastrointestinal cancer, which includes pancreatic cancer, reported having a clinical nurse specialist. The survey also showed that cancer patients who had support from a clinical nurse specialist had a better overall experience of care. We expect the National Health Service to consider this in developing its policies to improve patient experience. A 2011 survey is now in progress. We will be looking closely at the results of the survey to see where improvements have been made and where more needs to be done.
Research featured large in this debate, including in the speeches of the noble Lord, Lord Aberdare, my noble friends Lord St John of Bletso and Lord Sharkey, the noble Lord, Lord Kakkar, the noble Baroness, Lady Thornton, and others. The National Institute for Health Research is making a significant contribution to the search for scientific breakthroughs in pancreatic cancer. The institute’s clinical research network is currently hosting 17 studies of pancreatic cancer and is recruiting patients as we speak. In August 2011, the Government announced £6.5 million of funding for the Liverpool biomedical research unit for gastrointestinal disease. About half this investment will support pancreatic cancer research. The NIHR clinical research network, as mentioned by the noble Lord, Lord Kakkar, is currently hosting 17 trials and other well designed studies in pancreatic cancer that are recruiting patients. In 2010-11, a total of 687 patients were recruited to pancreatic cancer studies hosted by the CRN. The National Cancer Research Institute’s upper-gastrointestinal clinical studies group is dedicated to developing a portfolio of research studies in pancreatic cancer, and has a pancreatic cancer subgroup, which has developed a number of internationally run trials. That is a cause for some encouragement.
The noble Baroness, Lady Thornton, referred to the research involving processed meat. She is right; Swedish research published in the British Journal of Cancer in January 2012 said that two rashers of bacon or one sausage a day increases the risk of pancreatic cancer by 20 per cent. There is also a link with bowel cancer. The department urges everybody to have a balanced diet. As with other forms of cancer, higher consumption of fruit and vegetables seems to be protective, but I will write to the noble Baroness if I have any further information on that subject.
The noble Lord, Lord Aberdare, referred to new cancer drugs. Our priority is to ensure that cancer patients get the drugs that their doctors believe are best for them. We have delivered on our promise in the coalition agreement for a cancer drugs fund, with £650 million, all told, devoted to it. This funding has so far helped more than 12,500 cancer patients in England to access the cancer drugs that their clinicians recommend. We have listened to feedback on the first year of the fund’s operation, and today are publishing new guidance on the cancer drugs fund, which will further speed up access for patients. The new guidance makes it clear that patients will not normally need to go through the primary care trust funding processes prior to applying to the fund. In most cases, it will mean that patients are able to access drugs within a matter of days of an application being made to the fund. In the longer term, our intention is to introduce a system of value-based pricing for new drugs, with the aim of enabling patients to have greater access to effective and innovative new medicines. The whole premise of value-based pricing is to ensure that the price of a drug will be linked much more closely to its assessed value. It will bring the price that the NHS pays more into line with the value that a new medicine delivers.
My noble friend Lady Jolly asked about that. She also asked about mechanisms in the Health and Social Care Act that might assist cancer patients. The main mechanism is the outcomes framework, which will of course pervade everything that the NHS Commissioning Board does in the way of commissioning guidance, and will inform the way that the commissioning outcomes framework is developed. She also asked about engagement with the royal colleges. Ministers are currently meeting representatives from the royal colleges on education and training—I do not think on pancreatic cancer specifically but certainly on the training of doctors.
The noble Baroness, Lady Morgan, asked me a number of questions. The NHS outcomes framework— I pay tribute to the work of the All-Party Group on Cancer over a number of years—will be updated annually to ensure that the most appropriate measures are used for comprehensiveness, while recognising that we need to keep a broad continuity of indicators year on year. The refreshed NHS outcomes framework 2013-14 will be published alongside the mandate in the autumn. To support the ongoing development of the framework, we are in the process of establishing an independent technical advisory group that will provide advice to the department and the board about current indicators and proposals for new ones.
The noble Baroness asked about the national cancer patient experience survey. With the leave of the Committee, as there is a small amount of time left I propose to utilise it, unless there are any objections. In the first NHS outcomes framework we explained that the approach to Domain 4, which is patient experience, was evolutionary and the initial set of improvement areas for this domain was drawn from existing nationally co-ordinated surveys or from surveys that would be available in 2011-12. Collectively, the improvement areas aim to achieve wide coverage of the interactions that people have with the NHS and focus on different features of patient-centred care. Future work will involve refining surveys and developing new questions and measures to allow existing indicators to be replaced over time as necessary.
With regard to cancer networks, we have already made clear that there is a role for clinical networks such as cancer networks in the reformed NHS, as a place where clinicians from different sectors come together to improve the quality of care across integrated pathways, and the cancer networks are a clear example of how that way of working delivers better quality. That is why the Secretary of State announced last May that we would continue to fund cancer networks this year and that, subject to legislation, the Commissioning Board will support strengthened cancer networks.
The noble Lord, Lord St John of Bletso, asked about quality standards. There is no intention to produce a quality standard for pancreatic cancer as such, but in future there will continue to be flexibility in the library of quality standards to take account of new and emerging priorities, should such need arise.
Our ultimate goal is to improve survival rates and the quality of life for those living with all cancers, including pancreatic cancer. There are many challenges to be overcome but they are not insurmountable. Because of the Health and Social Act, clinical commissioning groups will be free to pursue innovative ways of delivering care that bring better results for all patients, including those with pancreatic cancer, and NHS provider organisations will have the operational independence to determine how best to meet the needs of commissioners.
We have set five ambitious but measureable goals: to prevent people from dying prematurely from cancer; to improve the quality of life for people with cancer; to help people recover from episodes of ill health; to improve the experience of care; and to ensure that all patients are treated and cared for in a safe environment. We will continue to deliver on those goals.
Lord Patel
I am not sure if it is in order for me to do this, but I know that whatever the Minister says is taken as gospel, and he quoted a study from Sweden about the association of eating meat with pancreatic cancer. I do not know about the quality of that study, but it sounds surprising that that amount of meat-eating increases the risk of pancreatic cancer by 20 per cent. I presume that he was talking about relative risk, not absolute risk.
The Deputy Chairman of Committees (Lord Geddes)
The Grand Committee stands adjourned until 4.30 pm, or indeed there may be a Division during that time, in which case it will be 10 minutes from the time when the Division is called.
Autism Act 2009
Earl Howe Excerpts(12 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank my noble friend for tabling this Question and pay tribute to the way in which she has championed the cause of those with autism in its various forms over many years. This debate has done full justice to the key issues facing us at the moment. It has also generated a great many questions and I shall do my best to answer as many as I can but I shall inevitably need to write to noble Lords on some of them.
The Autism Act was a landmark piece of legislation. As my noble friend said, it was the first ever disability-specific law. It led to the development of the adult autism strategy and statutory guidance for local authorities and the NHS. The strategy made it clear that to be a success, it would require long-term cultural change. We need to remember that this is not going to be an overnight process. It also requires action right across the public sector.
Since then, we have had some real successes; for example, the North East Autism Consortium regularly brings together local authority and NHS lead commissioners for autism to share their experiences and to drive forward their priorities, all the while involving people with autism in the process. Personal budgets have begun to make a real difference to people’s lives. They have a degree of flexibility that enables people to be creative about how they spend their money. People can make every penny count and get real value for money.
A central tenet of the autism strategy is that adults with autism should be able to access the same services as everyone else. If someone with autism is being assessed for social care, their autism should be taken into account, regardless of their IQ, and I will turn to that point again in a moment. If they are looking for work, Jobcentre Plus should find suitable positions that are sensitive to their needs. To reap the full potential of the Act, local authorities and the local NHS need to work together and co-operate on planning and training, on the identification, diagnosis and assessment of autism, and on the transition from childhood to adulthood. I will come on to some of those themes in a moment.
While the lead must come from local communities, more still can be done to help at the national level. We recently announced a new children and young people’s health outcomes strategy, which is aimed specifically at developing the life chances of young people. To support this, we have established a children and young people’s forum, under the leadership of Christine Lenehan, chief executive of the Council for Disabled Children and Ian Lewis, medical director at the Alder Hey Children’s NHS Foundation Trust. Last April, we published new tools for local authorities and NHS bodies to support communities with the implementation and monitoring of the strategy and the statutory guidance.
The learning disability public health observatory has been finding out from local authorities just how they are delivering the strategy. The results will be published at the end of the month, enabling people to lobby locally and to challenge where necessary. So far, about nine out of 10 areas say that they have a commissioning plan for services for adults with autism either in place or in development. More than half the local authorities in England have established autism partnership boards to ensure that the views and wishes of people with autism and their carers inform the design, development and commissioning of services at a local level.
While central government can set the framework and work to remove barriers and increase awareness, the real work—the delivery of lasting change—is for professionals, providers, voluntary organisations, service users and carers working together in collaboration. The autism strategy has never advocated a top-down process. It is not about setting targets and milestones. It has always been about empowering local communities to come together and to get things done. It is also about integrating care across the NHS, social care and other local authority services, and putting people with autism at the centre of any plans to improve their own lives and, as much as possible, to put them in control. The new health and well-being boards will be crucial to integration. They will bring together all those with an interest in local health and social care. They will draw up the local needs assessment. Crucially, they will also write the local strategy to meet those needs and be responsible for fulfilling it.
A huge amount of work has taken place over the past couple of years. Consistent pathways for diagnosis are being delivered through the NICE clinical guidance for the diagnosis and management of autism. Newly diagnosed patients are being given appropriate advice and information. Lead professionals have been appointed in most local areas to develop diagnostic services. We now have NICE guidelines covering the diagnosis, referral and management of autism among children and young people. Similar guidelines for adults are out for consultation and are due this summer. The proposed adult autism quality standard has now been referred to NICE and an announcement on further referrals following this engagement exercise will be made shortly.
The noble Lord, Lord Collins, paid tribute to the work of the voluntary sector and, in particular, the National Autistic Society, and I would like to echo what he said. The society is now in its 50th year, and there is no doubt that its lobbying, research, advice, support and services do a huge amount to set the standard for autism services and to drive system reform. I would like to thank it and many other organisations that work to improve the lives of people with autism. Alongside them, we have to thank the parents, carers, teachers and friends of those with autism.
My noble friend Lady Browning asked me specifically about the question of someone’s IQ. The strategy and guidance make it clear that people with autism or Asperger’s syndrome can no longer be refused an assessment or access to support because their IQ is too high and they do not have a learning disability. She is aware of that.
We expect more low-level and preventive services to be developed in response to the autism strategy and statutory guidance as commissioning plans are developed locally and a better understanding of local needs is developed. Given the right support, many more people with autism, particularly those with high-functioning autism or Asperger’s syndrome, will be able to live more independently in the community. Some areas, such as Liverpool and Bristol, have developed multidisciplinary teams that help with diagnosis and post-diagnosis support and their expertise can greatly increase awareness of autism among other services. The NICE guidelines, which will be published this year, will look at the use of these teams in more detail.
A number of noble Lords, including my noble friend, the right reverend Prelate, and the noble Lords, Lord Addington and Lord Collins, spoke about the need to raise awareness and expertise at a local level among front-line professionals. The Department of Health has funded a series of online training resources and booklets to increase awareness and understanding of autism across all public services, costing half a million pounds in total. Working with the Royal Colleges of Nursing, GPs and Psychiatrists, the Social Care Institute for Excellence, the British Psychological Society, Skills for Health and Skills for Care, the NAS and others, a range of quality materials to enable front-line staff to better recognise and respond more effectively to the needs of adults with autism have been produced. We are planning further work with our partner organisations to ensure dissemination and uptake of this material. It is, however, important to emphasise that it is for local health and social care organisations to ensure that professionals involved in providing services have the necessary qualifications, expertise and training for the purposes that are required.
My noble friend referred to local governance structures. Those structures are in place, including the partnership boards. Local JSNAs and autism self-assessments should also provide information for local service users and representative groups to benchmark provision within their localities and identify where there are gaps. A key issue is to explore whether local health and care commissioners and providers are taking forward services in line with Implementing Fulfilling and Rewarding Lives, the statutory guidance which was published in December 2010, and to challenge locally where that is not happening.
The right reverend Prelate referred to self-assessment. He is right that we have asked the learning disabilities public health observatory to collect and collate data from the reports that are coming out of self-assessment. Those will be online by the end of this month. I am confident that this is a step in the right direction. Almost 90 per cent of local authorities have submitted a report, which is encouraging.
Clinical commissioning groups were referred to by the noble Lords, Lord Collins and Lord Touhig, among others. The NHS Commissioning Board will be issuing guidance to the CCGs. That may be for a variety of purposes, including to support improvement of outcomes in the NHS outcomes framework, within which are indicators on long-term conditions and mental illness. However, I am careful not to refer to autism as a mental illness. Health and well-being boards and CCGs will be expected to ensure that they comply with all relevant legislation included in the Autism Act.
I am receiving signals that my time is almost up. I apologise to noble Lords as I have a great deal more material here that I would gladly have used. I just highlight two essential priorities for us. We need to benchmark the services and outcomes for people with autism. We have made a start with this through the self-assessment tool. We need better information to plan and commission services, robust local prevalence data on autism and up-to-date joint strategic needs assessments so that services can be commissioned appropriately. By being clear and transparent at every stage we can hold local authorities, the local NHS and others to account for the quality of the services that they are delivering. As we devolve power down, place far more focus on local leadership and personal control and work to drive up outcomes, it will not be only the statistics that start to look better but also the lives of people with autism.