Health: Local Healthwatch Organisations
Earl Howe Excerpts(13 years, 4 months ago)
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Lord Collins of Highbury
To ask Her Majesty’s Government what progress is being made on establishing local Healthwatch organisations and what steps they will take to ensure that their commissioning and administrative costs are kept to a minimum.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, 75 local Healthwatch pathfinders have generated learning for all local authorities to use. The Local Government Association is working with all local authorities, including holding a series of master classes, and the Government are undertaking targeted engagement on local Healthwatch regulations until mid-June. The Government have made £3.2 million available for start-up costs and information is being made available on commissioning and procurement options.
Lord Collins of Highbury
I thank the Minister for that response. Only one local Healthwatch organisation will be contracted in an individual local authority, but the body itself will be permitted to subcontract most if not all of its activities. What are the department’s estimates for the overall cost of multiple contracts, solicitors’ fees and all the other on-costs of commissioning? Can the Minister also explain how fragmenting local Healthwatch organisations in this way will provide the strong and co-ordinated voice for patients and their carers that we need for real local scrutiny and accountability?
Earl Howe
My Lords, the noble Lord is absolutely right to raise the question of the cost-effective commissioning of Healthwatch and I have no doubt, from the Local Government Association, that both the efficient and effective functioning of Healthwatch is something that is well within its sights. The noble Lord has raised a series of hypotheses which I think are somewhat extreme, of local Healthwatch organisations parcelling out their functions all over the place. Our aim is to have as locally inclusive a body as possible in each local Healthwatch area to enable Healthwatch to perform its functions as much by itself as with the aid of others. Indeed, the pathfinder events to which I have referred have been clear that there is a local appetite to do that.
Lord Kakkar
My Lords, how do Her Majesty’s Government propose to mobilise interest, enthusiasm and participation in local Healthwatch organisations by patients and members of the public?
Earl Howe
We are working with the Local Government Association and the Care Quality Commission to provide support for the implementation of local Healthwatch organisations. As I mentioned, the LGA is running a series of master classes for local authority commissioners. It has published 15 case studies taken from the 75 Healthwatch pathfinders, and a small number of Healthwatch experts will be available to help spread learning. As regards making the public aware, it will be very much for local authorities to decide what is appropriate in their particular areas in order to ensure that patients and the public are engaged in the important work of Healthwatch and understand what the statutory remit of local Healthwatch consists of, because that is the only way in which local Healthwatch will make its voice truly heard.
Baroness Masham of Ilton
My Lords, will local Healthwatch members be able to support members of the public if they go to a tribunal?
Earl Howe
One of the potential functions of local Healthwatch is to act as a support in terms of advocacy for local people and to signpost patients and the public to appropriate services. It is too early to say which local authorities will commission what services from local Healthwatch in an area, but the resources available to local Healthwatch have to be borne in mind in that context.
Baroness Cumberlege
My Lords, does my noble friend agree that in the light of the comparative studies that have been made between different health systems in developing countries, it is very disappointing that the National Health Service comes last out of seven when it comes to patient and public involvement? It does well on other factors but not on this one. Does my noble friend agree that although taxpayers’ money must always be very well spent, really strong patient and public involvement will ensure that healthcare is improved?
Earl Howe
My Lords, I firmly believe that, and that is why the NHS outcomes framework specifically includes a domain relating to patient experience. As we go forward, I think patients will come to realise that their voice really counts. It is about a culture change—I do not wish to wriggle out of that. This is not going to happen overnight, but it is very important that commissioners and providers in the health service are fully engaged with patients, and vice versa, to ensure that the patient’s voice—and indeed the patient’s needs—are right at the centre of commissioning and provision.
Lord Brooke of Alverthorpe
My Lords, on the same theme, if patients are to be at the centre of the new arrangements, and the Government are handing this over, at least for the time being, to local authorities to ensure that they are participating in the new structure, is the Minister content that this arrangement will truly ensure full patient involvement right across the whole country? When will there be a review of the arrangements if they are not working?
Earl Howe
My Lords, of course we want to see the system working properly. It will be part of the role of Healthwatch England to provide information and best practice advice to local Healthwatch to make sure that local authorities are commissioning both effectively and efficiently. In that sense, there will be national oversight of what happens. Inherently, with the reports that local Healthwatch organisations will have to produce annually on the way that they fulfil their role, there will be transparency on how effective they are being, not just in delivering services but in involving all sections of the community in what they do.
Care Homes
Earl Howe Excerpts(13 years, 5 months ago)
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Baroness Bakewell
To ask Her Majesty’s Government what plans they have for making sure that care home ownership delivers consistent and long-term care.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Care Quality Commission, as regulator of health and adult social care services in England, is responsible for providing assurance that all care home operators, whether in the public or independent sectors, meet regulations that set essential levels of safety and quality.
Baroness Bakewell
I thank the noble Earl for that Answer, but it does not quite meet the background that has arisen since 30 April, when the private equity firm Terra Firma acquired Four Seasons Health Care, which is the largest elderly care provider in the UK. Given that equity firms often favour a short-term business plan model, and in the light of the collapse of Southern Cross, would the Government consider a “fit and proper person” test for care home ownership?
Earl Howe
My Lords, I am aware that this idea is circulating. Recent events have taught us that intelligence about the market and scrutiny of providers should be better. However, we are not convinced that a “fit person” test is necessarily the right approach. Having said that, we will be setting out our proposals shortly and we will consult on those, so there will be an opportunity for the sector to input its views. We should bear in mind that anyone who registers with the CQC as a provider of care must by law be of good character and have the necessary experience. The provider is also required to notify the CQC of any convictions or cautions against them and of any voluntary insolvency arrangements involving them.
Baroness Howarth of Breckland
My Lords, does the Minister agree that one of the greatest inhibitors of long-term, consistent care is funding for individual placements? I speak and declare an interest as the president of Livability, which delivers long-term care for some elderly and a large number of younger disabled people. The great difficulty is ensuring that local authorities will commit to funding in the long term at an appropriate level.
Lord Elton
My Lords, does my noble friend agree that the delivery of a caring and efficient service is dependent not only on training but on character? Is it not true that throughout the health service, and not merely in this area of welfare, there has been a sad departure from reliance on something which was fundamental to the hospital service when it was invented: tender loving care? When will there be an insistence that the right sort of people are admitted to the profession of caring for the elderly and the sick, as well as on proper training?
Earl Howe
My noble friend makes an excellent point. I expect he knows that in the selection process for nurse training, greater emphasis is now placed on the applicant’s suitability as a person to undertake caring duties. As regards healthcare assistants who may not be qualified, it is of course up to the employing organisation to make checks of that kind. We believe that to be a variable practice. We need to focus on that issue more than ever.
Lord Campbell-Savours
My Lords, why does the Minister not reply directly to the question of my noble friend Lady Bakewell? What, in principle, is wrong with a “fit and proper person” test to apply in these cases?
Earl Howe
My Lords, as I made clear earlier, there is already a test for those people who are in charge of a care home. The CQC has procedures to verify the acceptable status of such people. Furthermore, there are very strict rules under the Financial Services Authority regulations, which require company directors to pass a “fit and proper person” test. We are not sure what added value might be conveyed by a further test, as the tests are already there.
Baroness Tyler of Enfield
My Lords, given the very great anxieties experienced by care home residents and their families on this issue, what steps are the Government taking now to prevent another Southern Cross situation arising, in both intelligence gathering and strengthening the regulation and oversight of the sector?
Earl Howe
My Lords, the Government are working with the Association of Directors of Adult Social Services and the Care Quality Commission. We are gathering greater intelligence on the social care market and its major providers, which will be used to give early warning of impending problems. We will continue to meet regularly with the major care providers to discuss their trading performance, their financial situation generally and how they are addressing any issues which put pressure on their ability to continue trading.
Lord Elystan-Morgan
My Lords, perhaps I may raise a technical point in relation to a situation that exists under the Companies Act where a company is threatened with financial difficulties. The noble Earl will be aware that under the Act, to continue trading is a serious offence if there is a danger—not just a certainty—that the company will not be able to meet its financial obligations. Successive departments in successive Governments have properly intervened in the interests of patients. They were probably committing a serious criminal offence. Will the Minister look at the situation so that the law may be relaxed in the interests of patients and of the community in general?
Earl Howe
The noble Lord made a very good point. As he will know, there are existing oversight and regulatory frameworks, with the CQC regulating the quality of care and support services and local authorities overseeing local providers. The point made by the noble Lord is a major part of why the Government are engaging with the sector, as I described just now to my noble friend. The main point to stress is that under the existing system no one will be left homeless should a provider fail. In an emergency, local authorities have a duty to provide accommodation to anyone, whether they are publicly funded or self-funded, who has an urgent need for it.
Baroness Wheeler
My Lords, this summer the Care Quality Commission is conducting thematic inspections of dignity and nutrition in 500 care homes with nursing provision. Does the Minister agree that these will be vital in providing evidence and guidance to ensure improved standards of care? Will he assure the House that these inspections will go ahead despite the commission’s increased responsibilities and workload resulting from implementation of the Health and Social Care Act and other government policy initiatives?
Earl Howe
My Lords, the noble Baroness is right; this is very important work. I am led to understand by the CQC that the programme is due to proceed as planned. We will place a great deal of reliance on its findings. In the light of recent distressing and unfortunate stories about the absence of dignity in certain care settings and the shortcomings in care quality, it will be important to learn lessons from the CQC’s programme.
NHS: Health Tourism
Earl Howe Excerpts(13 years, 5 months ago)
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Baroness Gardner of Parkes
To ask Her Majesty’s Government what is the cost to the National Health Service of international health tourism, and whether the Home Office has consulted the Department of Health on appropriate assessments of likely health needs or conditions before issuing visas to visitors to the United Kingdom.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, estimated written-off debt for NHS treatment provided to chargeable overseas visitors in 2010-11 was £14 million. However, this will include debts for visitors requiring unexpected treatment as well as those actively seeking NHS treatment to which they are not entitled. On 21 May, the Home Office announced the introduction of pre-entry screening for tuberculosis for long-term migrants from countries with high TB incidence. The department and the Health Protection Agency worked with the Home Office to review current arrangements.
Baroness Gardner of Parkes
That is a considerable increase. In his Written Answer last year, the noble Earl gave the figure for the previous year as under £7 million, so the amount has doubled. I do not know whether the £14 million includes the previous £7 million, but obviously the amount is growing. In the same Written Answer, he said that the Home Office was now consulting. On screening—for TB, for example—does the visa application ask applicants to declare any pre-existing medical condition, as is the case in many overseas countries?
Earl Howe
My Lords, the Home Office, with our agreement, drew up a list of high-risk countries where TB was prevalent. In those countries, if someone seeks a visa to come to this country for six months or more, they will have to undergo TB testing. Questions on other medical conditions are not relevant in this context. We do not screen for other things. TB is an exceptional case because it is an airborne disease and poses a public health risk.
Lord Kakkar
My Lords, what assessment have Her Majesty’s Government made of potential future health tourism from eurozone countries facing imposed austerity measures and cuts to their own local healthcare provision?
Earl Howe
The best answer I can give the noble Lord is that this entire area of health tourism is one which we in the department are looking at extremely closely. A review has been carried out by officials and Ministers are considering the recommendations flowing from that. It is a complex set of issues but clearly the context to which the noble Lord rightly refers will need to come under the spotlight.
Lord Roberts of Llandudno
My Lords, if this is devolved to Scotland, Northern Ireland and Wales, how are the Government relating this particular problem to the Assemblies and the Parliament?
Baroness Boothroyd
My Lords, when I travel abroad on holiday, which I am happy to say I do quite often these days, I have to carry health insurance and it is quite expensive. Because of my age and various other problems I have to take it out each time I go on holiday. I will not tell you how many times a year that is. What happens in reverse when people come here on holiday? Is it required of them to carry health insurance in case they have any problems here?
Earl Howe
The rules are complex, depending on whether the person is from the European Union, where certain rules apply, or from other parts of the world. There is no mandatory requirement for people to carry health insurance unless there is a transparent medical need when they enter the country. For example, a heavily pregnant woman might be asked to produce proof that she could pay for treatment if giving birth was likely. There are clear rules for NHS trusts where a patient who is chargeable presents. The trust must seek either to secure payment before treatment or to bill the person immediately afterwards.
Lord Foulkes of Cumnock
My Lords, in answer to the question asked by the noble Lord, Lord Roberts of Llandudno, the Minister rightly described the situation as it currently is. Is the Department of Health doing any study into the disaster that would happen in terms of healthcare between Scotland and England if Scotland were to separate from the rest of the United Kingdom? If it is not doing a study, why not?
Earl Howe
My Lords, were that situation to occur, the issues arising from it would be little different from the issues today in that health is already devolved. However, I cannot speculate on whether there would be a different policy on immigration in Scotland compared to south of the border as we are really not in that territory yet.
Lord Swinfen
What checks are actually carried out to ensure that patients are entitled to free National Health Service care?
Earl Howe
My Lords, it is incumbent on NHS trusts when a patient presents directly to them to ensure that the person in front of them is entitled to NHS care, and they have various means of doing that. However, primary care in this country—care delivered by GPs—is not subject to any checks of that order.
Baroness Farrington of Ribbleton
My Lords, would somebody from anywhere in the world who had a British passport be entitled to NHS treatment were they to be in this country at the time of need?
Greater London Authority Act 1999 (Amendment) Order 2012
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National Health Service Trust Development Authority (Establishment and Constitution) Order 2012
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Baroness Thornton
My Lords, much of what I would like to say has been said by my two noble friends, but I would like to add my tuppenceworth because this is the beginning of some of the very important statutory instruments we are going to consider that will bring the Act into being. I have a few questions for the Minister. The first one has been alluded to by my noble friend Lord Warner: I refer to the creation of a new arm’s-length body, which I thought the Government did not really want to do. I wonder why it was felt necessary to create another arm’s-length body when many of the useful arm’s-length bodies, which some of us thought should not have been abolished, have been abolished, particularly the NHS Appointments Commission, which I will come back to in a moment.
Under point 7.1 in the Explanatory Notes, liabilities and assets are referred to. There is the recurring notion that this new body will take responsibility for those. My noble friend Lord Warner questioned the liabilities, but I am interested in the assets. For example, if an NHS trust is not viable as a foundation trust but a private sector organisation offers to purchase it, merge with it or whatever, what happens to the ownership of its assets—the land, the buildings and the kit? Where do they go? Who do they reside with? Is it the new provider body, whatever that is? I would like some explanation.
Appointments are important. Once the NHS Appointments Commission has been abolished, I cannot see from the Explanatory Notes that there is a guarantee of independence and transparency in appointments to the new bodies or when people in NHS trusts retire and have to be replaced. I am not clear what happens in those circumstances and who makes those appointments. If it is the new authority, which is my understanding, what guarantees do we have of independence, accountability and transparency in those appointments? The reason why I think that is important was alluded to and described much more adequately than I can by my noble friend Lord Warner and is in point 8 of the evidence base, which states:
“To date, 50 per cent of NHS trusts whose applications for FT status are rejected by Monitor fail because they do not have sufficiently robust governance. It is proposed that SHAs will be abolished in 2013, so new support arrangements will be required to support the FT pipeline”.
Do the Government think that, because NHS trusts fail because of their lack of robust governance, by taking control of this issue they will be able to appoint more robust trustees or do whatever it is to ensure that they meet the foundation trust requirement? I have exactly the same question as my noble friend: what is the magic that will increase the success rate from 50% to 100% with the new authority? We need to be concerned on several counts: the accountability, viability and credibility of the new body proposed in these statutory instruments. I am not convinced that what is being proposed meets those requirements.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am grateful to the noble Lord, Lord Hunt, and the two other noble Lords who have spoken because their questions give me an opportunity to clarify what these statutory instruments are designed to do and to say why we believe that they are appropriate.
The NHS Trust Development Authority will play a vital part in laying the foundations for the new health and social care system. From April 2013 it will provide essential governance and oversight of NHS trusts that are not yet foundation trusts to support them in delivering the vision of an NHS consisting entirely of fully autonomous healthcare providers.
Foundation trusts are sustainable, autonomous providers with far greater freedom to innovate, design and deliver services to local communities, and there I believe that the noble Lord, Lord Hunt, and I are in full agreement. Helping every NHS trust to attain foundation trust status is key to creating an environment in which adaptable, sustainable organisations deliver high-quality care and collaborate with NHS and other partners to provide integrated care designed around the needs of individual patients.
The Government’s vision of care delivered in an all-FT landscape means that NHS trusts must either become authorised as foundation trusts in their own right, merge with an existing FT, or move forward in another organisational form. There is a strong expectation that the majority of NHS trusts will achieve FT status by 2014 and that only by exceptional agreement, made after close scrutiny of financial and clinical feasibility, will they be allowed to continue in their present form beyond this date. Supporting the progress of NHS Trusts through the process of applying for FT status is often referred to as “managing the FT pipeline”.
Of course, FT status is not an end in itself but a crucial step in the process by which we can drive up the quality of care and make sure that the services we offer patients are robust, sustainable and of the highest quality. The benefits that achieving FT status can bring patients and communities cannot be underestimated. In doing so, NHS trusts examine their leadership, financial sustainability, quality of service and plans for continuous improvement. It is a mechanism designed to bring all provider services in all parts of the country up to a level of excellence.
An important part of this transition is the establishment of a new special health authority, the NTDA. The orders before noble Lords now provide the legal underpinning. The NTDA will be a short-lived, enabling organisation in the reform programme. The authority is important because once the current system of strategic health authorities comes to an end in 2013, the infrastructure to support NHS trusts on their way to becoming foundation trusts, or indeed to support them if they become unsustainable and can no longer function as a foundation trust, will no longer be in place.
The legislative framework set out in the Health and Social Care Act 2012 introduces a new and comprehensive regulatory system, including measures for dealing with providers at risk of becoming unsustainable. The new system will concentrate on protecting essential local services for NHS patients, not on maintaining failed organisations at great and unnecessary cost to the taxpayer. The NTDA will work closely with the whole of the new NHS to ensure innovation and that the very best of clinical practice is brought to bear on the most complex problems. It will work with local communities and their representatives to make the case for change when service reconfiguration is needed to deliver sustainable services.
The NTDA, on behalf of the Secretary of State, will also appoint chairs and non-executive directors to NHS trusts while they continue to exist, and appoint certain trustees such as special trustees and trustees to hold trust property for some NHS bodies. The organisations that the NTDA will take responsibility for cover a wide spectrum of services, including acute hospitals, ambulance services, mental health services and community services. Some are on the cusp of achieving foundation trust status while others face some of the most significant challenges in the NHS, with long-standing financial and operational difficulties to contend with.
It will not be an easy task. That is why the Secretary of State has appointed David Flory, currently deputy chief executive of the NHS and director of finance, performance and operations, as its chief executive-designate, and Sir Peter Carr, former chair of NHS North East SHA and vice-chair of the NHS north cluster of SHAs, as its chair. We are establishing the authority now to give it time to design its operating model, recruit staff and engage in the planning round for NHS trusts for the financial year 2013-14 before it takes up its full operational functions in April 2013.
Lord Hunt of Kings Heath
My Lords, like other noble Lords, I thank the noble Earl, Lord Howe, for his response. I prayed against this statutory instrument in a genuine spirit of seeking information. I agree with the Minister about the importance of foundation trust status. I have no problem at all with the Government wishing to see NHS trusts becoming foundation trusts as soon as possible; that is absolutely right. Equally, I have no problem about the establishment of the new authority, and I commend the Government on the appointment of David Flory as the chief executive and Sir Peter Carr as chairman. Sir Peter has been a long-standing chairman in various guises in the health service going back more than 20 years. I suspect that he may well be chairman of this authority for a little longer than the department thinks at this moment.
There is genuine puzzlement about how these trusts—more than 100 of them—are to become foundation trusts by 2014. The fact is that many of them are facing great problems, mainly financial. They may have a PFI scheme that is expensive and which the local system is unable to afford without consequences on the rest of the system or, as my noble friend Lord Warner said, it may be tied up with very difficult reconfiguration issues.
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(13 years, 5 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(13 years, 5 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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