Health and Social Care Bill

Earl Howe Excerpts

Wednesday 8th February 2012 Lords Chamber

[Baroness Thornton]

My Lords, I am very pleased to put my name to this amendment and I congratulate the noble Lord, Lord Hennessy, on his tact and diplomacy in getting us to this point, and in getting agreement to have the constitution mentioned in the Bill, and in such a prominent part of it. In preparing a few supportive remarks, I had a look at the constitution because I was working for my noble friend Lord Darzi in a similar role to the one the noble Baroness, Lady Northover, has—as his support and his Whip—when we were working towards the constitution, and when it was discussed and adopted across government and Parliament.

The importance of having it in the Bill is there in various key parts of the constitution, which are worth mentioning on the record here because we need to remember them as we move forward to discuss this Bill in all its glory in the next five or six weeks, or however long it takes us. The constitution says:

“The NHS is founded on a common set of principles and values that bind together the communities and people it serves—patients and public—and the staff who work for it”.

It goes on to say that it,

“establishes the principles and values of the NHS in England. It sets out rights … and pledges which the NHS is committed to achieve”.

It says:

“All NHS bodies and private and third sector providers supplying NHS services are required by law to take account of this Constitution in their decisions and actions”.

That is a very important part of why this needs to be in the Bill.

The final part which I would like to draw to your Lordships’ attention is point 6 of the guiding principles in the constitution, which is a commitment,

“to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. Public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves”.

That is exactly right. It is not the shareholders of companies and not individuals who might seek to make a profit but the people whom the NHS serves, and the taxpayer.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I am very grateful to the noble Lord, Lord Hennessy, for tabling these important amendments and for the eloquent way in which he introduced them. As he said, they seek to require the Secretary of State to have regard to the NHS constitution when exercising his functions in relation to the health service. I say to him in all sincerity that I very much welcome his contribution throughout this debate. I identify myself entirely with the enthusiastic remarks that he addressed towards the constitution itself, which is a most succinct and inspiring document, and I agree with him that we have reached a very workable and satisfactory outcome to the question that he originally posed to me and to the House.

I fully support these amendments. It is right that we continue our commitment to the principles set out in the NHS constitution. I hope that these amendments together provide noble Lords with reassurance of the Government’s continued commitment to the core principles and values to which the noble Lord and the noble Baroness have referred. I commend them to the House.

[Lord Hennessy of Nympsfield]

I am grateful to the noble Baroness, Lady Thornton, and the noble Earl, Lord Howe, for their kind remarks. Earlier, a noble Lord—I forget who—thought we were mired in the treacle of consensus. All I can say is: long may we be stuck in this particular pot of treacle.

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[Lord Northbourne]

My Lords, I intervene briefly to support the noble Baroness, Lady Finlay, because I believe that there will be real problems. The immense complexity of the Bill will lead to tremendous delays and a great deal of misunderstanding among people who feel, rightly or wrongly, that they have failed to get the service or treatment to which they are entitled. I hope the Minister can say something about the possibility of some sort of short-circuit response, whereby people who feel that they have been ill treated can, if necessary, have some kind of help and encouragement to make contact with the right people to resolve their problem.

[Earl Howe]

My Lords, this has been a very useful short debate. As the noble Baroness, Lady Finlay, said, her amendment seeks to provide appropriate recourse for individuals who believe that the commissioning of services for either their condition or their locality is inequitable. It would insert a new paragraph in the Secretary of State’s inequality duties. The noble Baroness spoke with considerable persuasiveness on this amendment but I will suggest to her that it is unnecessary and explain why.

The Bill and existing legislation already provide a number of mechanisms for exactly the kind of recourse that the noble Baroness seeks. She foresaw that I would talk about local healthwatch and I will. Local healthwatch, which will replace local involvement networks from April 2013, will provide local people with the opportunity to have their views on their needs and experiences made known to commissioners and providers of health and social care services and others. One of the roles of local healthwatch will be to make reports and recommendations about how local care services could or ought to be improved. To ensure that these have real clout, the Bill requires the people who receive such reports and recommendations, such as the NHS Commissioning Board, to have regard to them in exercising any function relating to care services.

We then have a further avenue for recourse because HealthWatch England will also provide the NHS Commissioning Board, among others, with the views of people on their needs for, and experiences of, health and social care services and on the views of local healthwatch and others on the standard of provision of services and on whether or how the standard could or should be improved. Where the board is provided with advice, it must inform HealthWatch England of its response, or proposed response, to the advice.

However, if an individual feels that a CCG, or the board, or any other body in the future health service, has neglected their responsibility with regard to tackling inequalities, they can do several things. They may raise the matter directly with the organisation itself, specifically by pursuing a complaint through the NHS complaints procedure. Where not satisfied with the response at a local level, they may refer the matter to the Health Service Ombudsman. As a last resort—I emphasise “last resort” because I do not want noble Lords to feel that this process would be run of the mill—as the NHS constitution makes clear, should an individual feel that local resolution has not been possible, and in the event that the Secretary of State or an NHS body is failing to comply with its legal duties, there would be a right to seek legal redress by means of a claim for judicial review.

There is a central issue here. CCGs will be under a statutory obligation to arrange for provision of care to meet the reasonable requirements of the people for whom they have responsibility. The local authority’s health and well-being board, the membership of which will include the CCG or CCGs, will assess local population needs, and will develop a strategy to meet those needs. Local healthwatch will also be a member of that board and be able to input into the strategy. There will be a duty on the CCG, the local authority and the NHS Commissioning Board to have regard to the relevant assessment and strategy when exercising functions. This would include the function of preparing commissioning plans. The NHS Commissioning Board will have a duty to perform an annual assessment of how well each CCG has fulfilled its duties in the previous financial year. This will include, in particular, an assessment of how well it has taken account of assessments and strategies under Section 116B of the Local Government and Public Involvement in Health Act 2007.

My noble friend Lord Willis rightly said that we should expect that there will be differences between CCGs in their commissioning policies. Of course he is right, because each CCG will be bound to formulate policies for commissioning that reflect the needs of their constituent populations. I do not think that we should shy away from variation that is considered and that genuinely reflects that diversity in population. What we do not want, clearly, is postcode and random variations which have no relationship to the needs and requirements of local patients.

We should not forget either that the Health Service Commissioner has power to investigate complaints that are not resolved locally and to make recommendations as a result of those investigations. It is very rare for those recommendations not to be implemented but, in extremis—and this is not often done—the Health Service Commissioner is able to lay a report before Parliament.

We believe, therefore, that there is already a clear system of recourse where patients are concerned that an equitable service is not being commissioned either for their condition or their locality, and the Bill strengthens the ability of patients to make their views heard. The Bill also introduces, for the first time ever, duties on the Secretary of State and commissioners to have regard to the need to reduce inequalities, and amendments we have tabled would ensure that they would have to report on how they had fulfilled those duties.

With those remarks in the round, I hope that the noble Baroness is perhaps more reassured than she was at the outset of the debate, and that she will be willing to withdraw the amendment.

[Baroness Jolly]

Before the Minister sits down, will he clarify whether the same processes that he has just outlined would apply to people in receipt of specialist services that are commissioned by the NHS Commissioning Board, not by local CCGs?

[Earl Howe]

My Lords, where a service is commissioned by the NHS Commissioning Board—and let us imagine that it is a specialised service—the patient’s recourse should be to the board. However, of course, the board will be represented at a local level rather than only centrally, and we expect that the board will be represented in health and well-being boards and in the discussions that take place there. It would therefore be possible for a patient to address their concerns, in the first instance, to the health and well-being board, which would have the ability and power to communicate directly with the NHS Commissioning Board, if that was felt to be appropriate. However, as I said, the patient would be able to go straight to the board in those circumstances.

[Lord Harris of Haringey]

I appreciate that this is very bad manners, given that I missed most of the debate. The Minister has just said—although perhaps I misinterpreted him—that the NHS Commissioning Board will have a representative on every local health and well-being board. If so, how will those individuals be known or accountable? Is that not the most extraordinary bureaucracy? He seems to have made a most extraordinary statement.

[Earl Howe]

My Lords, we are at Report stage and I hope that the noble Lord will forgive me if I do not reply at length. The point I was seeking to make was not about representation on the board but involvement in the health and well-being board’s wider deliberations. It is entirely open to a health and well-being board to invite a member of the Commissioning Board to be a permanent member, but I am not saying that we are prescribing that.

[Baroness Finlay of Llandaff]

Perhaps I may seek a tiny bit of clarification. The noble Earl spoke about the ombudsman as being almost a final port of call. Will the Minister confirm that the ombudsman would have the ability to investigate any organisation that is providing services to patients if it is in receipt of any NHS money whatever—not only if the care for an individual patient is commissioned from it but if it is receiving a block grant? In particular, I have in mind services such as those provided by hospices that may be receiving a block grant but do not have a specified contract per patient, and it may be that its patients want to question what is going on or that they have a concern that they wish to express and take further. Apart from the local complaints service within the organisation, it is really important that such patients have the same ability as other patients to have oversight through the ombudsman. I know that we have discussed this previously, and I am seeking clarification today on that issue.

[Earl Howe]

The answer to the noble Baroness is that all NHS-funded care would come under the umbrella of the ombudsman. It is not about organisations; it is about whether that person is or is not an NHS patient and about the care that they are receiving as an NHS patient.

[Baroness Finlay of Llandaff]

This is Report; I do not want to and fro. I will assume that that covers part-funding of care by charities as well as where care is fully funded by the NHS, so the same will apply.

I am grateful to the Minister for setting out the processes so clearly. It will be very helpful for patients, patient groups and charities in particular to see that laid out. For clarification, of course there will be local variation, different drug regimes and different ways of doing things. Equipoise is around the evidence base. The problem is where there is no provision or gross differences. That is where patient groups are concerned. I beg leave to withdraw the amendment.

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Moved by

[Earl Howe]

8: Clause 4, page 3, line 5, leave out from “must” to end of line 6 and insert “have regard to the desirability of securing, so far as consistent with the interests of the health service—”

[Earl Howe]

My Lords, I shall speak also to Amendments 9, 34, 53 and 54.

This group of amendments deals with the role of the Secretary of State in the health system. As noble Lords will be aware, our proposals for the NHS involve a fundamental shift in the balance of power away from politicians to patients themselves and to doctors and other professionals. Greater local autonomy is one of the key things that will enable local front-line services to become more responsive and innovative, in turn delivering greater efficiency and quality. The Bill makes clear that Ministers are responsible, not for direct operational management, but for overseeing and holding to account the national bodies in the system—backed by extensive powers of intervention in the event of significant failure.

The amendments we are debating here cover some of the key concerns raised by the Constitution Committee and Peers from across the House, as part of our wider discussions about ministerial accountability. These are the autonomy duties on the Secretary of State and the Commissioning Board and the link between the functions of clinical commissioning groups and the Secretary of State’s duty to promote the comprehensive health service. I will speak to each of the amendments tabled in my name, as well as the amendments tabled by the noble Baroness, Lady Thornton, which seek to remove the duties of autonomy on the NHS Commissioning Board and the Secretary of State.

Amendments 8 to 10 and 52 to 54 concern the autonomy duties placed on the Secretary of State and the board. Government Amendments 8 and 53 re-phrase the duties of autonomy on the Secretary of State and the Commissioning Board as duties to,

“have regard to the desirability of”,

autonomy, rather than duties to,

“act with a view to securing”,

such autonomy. The desirability of autonomy is therefore a factor for the Secretary of State and the board to consider when exercising their functions, rather than an end which they must seek to secure or promote. That should allay the fears of those who felt that the autonomy duties would prevent Ministers and the board intervening when they needed to.

In addition, changing to a duty to have regard necessarily means that the autonomy duties are subsidiary to the primary duties of the Secretary of State in Section 1 of the NHS Act: to promote the health service and to exercise his functions so as to secure the provision of services. To that extent, there is no further need to state that the duties of autonomy are “subject to” his Section 1 duties. However, government Amendments 9 and 54 make a further change to address this point. Rather than simply say that the autonomy duty is “subject to” the duty of promoting the comprehensive health service, they set out an explicit test, which makes clear that promoting the health service and securing the provision of services takes priority over autonomy, if there is ever a conflict between the duties. We think that this more clearly indicates how the Secretary of State and the board should resolve any tension between autonomy and the interests of the health service. I hope that noble Lords will agree that this provides helpful clarity and avoids any possible doubt.

Having said that I would address the amendments of the noble Baroness, Lady Thornton, I think that on reflection it would be discourteous of me to do so before she has introduced them. I shall therefore retain my remarks for later in the debate if she chooses to speak to those amendments. Meanwhile, I beg to move.

[Lord Marks of Henley-on-Thames]

My Lords, perhaps I may explain why I support the Government’s amendments on the autonomy clauses to which I have added my name—that is, Amendments 8, 9, 53 and 54.

The autonomy clauses were at the heart of the Government’s consultation with other noble Lords about the Secretary of State’s duties. During Committee and thereafter, at the very helpful discussions that we have had with my noble friend the Minister and with Peers across the House and, indeed, at the meeting of lawyers in which I took part with my noble and learned friend Lord Mackay, the noble and learned Baroness, Lady Scotland, and the lawyer advising your Lordships’ Constitution Committee, a substantial consensus was reached.

The concerns that we sought to address, which I regarded then and still regard as significant, were twofold. The first was that I believed there would be an inherent conflict between, on the one hand, the Secretary of State’s duties under Clause 1 to promote a comprehensive health service and to exercise his functions so as to secure services and, on the other hand, an unfettered duty to promote the autonomy of others. Secondly, if the Bill went unamended, there would exist a risk that a Secretary of State who was unwilling to intervene when things went wrong would be handed a justification for inaction. Such a hands-off Secretary of State could say, “I will not intervene because I am bound by my duty to promote autonomy”. In my view, with the Bill as it stands it would be very difficult to mount a successful legal challenge to such a failure to intervene.

Those were the two flaws in the Bill that the amendments were required to address. In relation to the board, the unamended Bill was flawed in exactly the same way as it is in relation to the Secretary of State.

The consultations that we held outside the Chamber during Committee led to the formulation of the Government’s amendments. As the Minister has pointed out, the effect of Amendments 8 and 53 is that the duty to act with a view to securing autonomy is reduced to a duty to have regard to the desirability of securing it. That is still subject to the limitation that the duty applies only so far as it is consistent with the interests of the health service. Therefore, what is currently an absolute duty to follow the autonomy line is to be replaced with a more nuanced and, I suggest, a more appropriate obligation to accord to the desirability of autonomy its proper place in the balancing exercise which all discretionary decision-making involves.

However, it is Amendments 9 and 54 that are decisive in addressing the concerns that we identified. Those two amendments provide that in the case of conflict between the Secretary of State’s or the board’s duties in relation to autonomy and their overarching duties under Clause 1 or the board’s overarching duties to secure the provision of services, those overarching duties will prevail. Those four amendments taken together fully address the two flaws of which I spoke and, I suggest, completely resolve the issues that they pose.

I turn now to the two amendments of the noble Baroness, Lady Thornton, directed at deleting the two autonomy clauses. Indeed, at the earlier stages of this process, I believed that the autonomy clauses could and should be deleted from the Bill. However, my view now is that with the problems that they presented having been addressed, we should support the government amendments and retain the two clauses as amended. Promoting autonomy is, in principle, to be welcomed as many who have spoken from all sides of the House both on Second Reading and in Committee have stressed. It is fundamental to the architecture of the Bill, and its great merit that it establishes a clear, decentralised structure for the health service. It is entirely welcome that future commissioning decisions, in particular, will be made locally to meet local needs, locally assessed.

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[Baroness Thornton]

My Lords, when we were having our negotiations on this part—on which I was very happy to take part, even if I was regarded on some issues more as grit in the oyster than as co-operative help—they were about these issues, including autonomy. I have not changed my view. I shall speak to Amendments 10, 36 and 52.

We have no problem with the concept of autonomy. In principle our position is that autonomy has to be earned, and that it should be able to be taken away as well. That formed the principle and the basis on which the foundation trusts were established. However, we part company with the Government on their view of autonomy, and we are not completely convinced by the point made by the noble Lord, Lord Marks of Henley-on-Thames. On first sight of the Bill it seemed that autonomy was to be presumed and that each part of the service would be subject to less interference from the other parts in a way which could be detrimental. There would therefore be less performance management, and giving various bodies more powers with less need to sign off an agreement could mean that there would be less co-operation. Bodies acting in their own interests via a market process will mean that the motivation could be something that does not have the NHS and patients at its heart, and that there is less planning and system management, which sometimes actually is required. That is how you deal with things like postcode lotteries. You have to collect the information, compare it between different parts of the country experiencing different levels of deprivation, and then you have to take decisions which are about planning how to use your resources to ensure that people are not disadvantaged. So there are some very good reasons why planning and systems need to be in place.

The original briefing on the Bill stated that CCGs would not have PCTs or SHAs above them to performance manage them and that the commissioning bodies were not meant to performance manage but only to step in if there was a danger of failure. Again, that was the original briefing. It is not surprising that when we first discussed this in Committee there was general agreement across the House that the Bill would be better off without Clause 4 and what was then Clause 10 but is now Clause 12.

Since then the Constitution Committee has done what I think is really rather a good job. Although I was not deliriously happy about it, I was prepared to live with the draft produced by the committee. However, I do have problems with the draft that the noble Lord, Lord Marks, and the Minister have brought to the House. The provisions are not strong enough and some of the dangers that we originally expressed about problems with the autonomy clauses still exist. Furthermore, I take very much to heart the questions that both of my noble friends have raised. From different points of view they have asked pertinent questions and shown up the problems with the autonomy clauses. That is why, certainly in the process of our negotiations on Clause 4, I reserved my position to come to the House and explore whether what we actually wanted to do was delete it completely at this stage. On Clause 12, for the sake of consistency we feel that it should also be deleted. However, I have to say that because of the amendments that were accepted in the process of our negotiations, we feel less strongly about it.

I am not any more convinced as a result of this debate that our original position is not the right one—that if we cannot have the Constitution Committee’s version of Clause 4, we should delete the whole clause. Obviously I will listen to the Minister’s summing up of the debate, but at the moment I remain convinced that our position is indeed the correct one.

[Earl Howe]

My Lords, the noble Baroness, Lady Thornton, has spoken to Amendments 10 and 52, which, as she has said, would remove altogether the autonomy duties on the Secretary of State and the board. The noble Lord, Lord Harris, asked me what the problem is that the Bill is trying to solve in this regard. The duty is intended to promote a culture of fostering local autonomy rather than to outlaw specific practices; but without a focus on autonomy, it is possible that the mandate from the Secretary of State to the board or the framework document from the board to CCGs could impose disproportionately burdensome requirements on the system. The Government believe that local operational autonomy is essential to enable the health service to improve the outcomes of care for patients, provided that autonomy is within the framework of clear ministerial accountability.

The noble Baroness will be aware, because I have said it before, that we are aiming to free those closest to services to take decisions that are right for patients, free from central micromanagement by either the Department of Health or the NHS Commissioning Board. The amended duties, with the caveat that the interests of the health service take priority, achieve the right balance between autonomy and accountability. Without the clause, a future Secretary of State could choose to ignore one of the fundamental principles of the Bill, which is that those closest to patients are best placed to take clinical decisions. Without the clause, a future Secretary of State would be free to use his extensive powers to micromanage the NHS. The autonomy duty is a necessary part of the Bill, placing a duty on the Secretary of State to consider the expertise of those in the health service while recognising that there will be circumstances—

[Lord Harris of Haringey]

My Lords, the noble Earl seems to be saying that you cannot trust your own Secretary of State not to micromanage unless they are effectively forbidden from doing so. We have all talked of the Secretary of State’s accountability to Parliament. Surely the principle is that an accountable Secretary of State will be under enormous pressure from Parliament not to micromanage. If it is such a central issue of policy, Secretaries of State should simply be told not to do it, rather than requiring an Act of Parliament.

[Earl Howe]

I challenge the noble Lord to think of one Secretary of State, with the distinguished exception of my right honourable friend Mr Lansley, who has not succumbed to the temptation of micromanaging the NHS. No Secretary of State has been able to resist that temptation because, frankly, Parliament expects them to do it. That is what the system has expected of the Secretary of State. This is a burden on commissioners and clinicians, and, in the end, it does not well serve the interests of patients. It is all very well for the noble Lord to say, “Well, just stop”, but the system encourages it and the duties on the Secretary of State are there to encourage it.

[Baroness Thornton]

I cannot resist saying that the noble Earl’s right honourable friend Mr Lansley has dabbled and intervened on at least 12 occasions since the Bill started. He is on the record as saying on one of those occasions that certain managers should be sacked. Is the noble Earl saying that that will cease when this Bill is on the statute book?

[Earl Howe]

I am saying that the Secretary of State will not have the ability to micromanage the health service as he does at the moment. Whether the examples cited by the noble Baroness constitute micromanagement, if my right honourable friend is just expressing a view, I rather question.

The autonomy duty is a necessary part of the Bill because it places a duty on the Secretary of State to consider the expertise of those in the health service while recognising that there will be circumstances in which they must be able to step in to protect the interests of health service patients. That is the balance that we are trying to strike.

The noble Baroness, Lady Finlay, asked whether the autonomy duty would allow a clinical commissioning group to justify not commissioning the full range of services. The autonomy duty does not apply to CCGs; it is a requirement on the board and the Secretary of State. If a CCG chooses not to commission services and the board considers that this is not consistent with the interests of the health service, the board can intervene to direct a CCG. If the board fails to intervene when necessary, the Secretary of State has power to intervene. Finally, the Secretary of State can set out services which CCGs must commission, and he can do that in the standing rules if he considers it necessary. The CCG’s key duty is to arrange services as it considers necessary to meet all reasonable requirements of the population that it is responsible for, and the amendments do not change that in the slightest.

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[Baroness Jay of Paddington]

The noble Lord may be surprised to hear me ask this question because, as he kindly said, I have been very determined that the provisions on accountability and parliamentary responsibility et cetera should be strengthened in the Bill. However, I listened to what my noble friend Lord Harris said about what he described as the “increasing tentacles” of these links between the various providers and the Secretary of State. Is the Minister not becoming concerned—as I would in his position—that all this new accountability and these links undermine the basic policy positions of the Bill? That is why, for example, my noble friend Lady Thornton suggested that it would be cleaner—if that is the word—to remove the whole of Clause 4 from the Bill. The complexities that are being set up and strengthened, as the Minister has agreed, make the whole thing so incredibly complicated and bureaucratic that the underlying policy positions are being totally distorted.

[Earl Howe]

I do not share that view at all. I do not think that the autonomy and accountability arrangements are as complex as the noble Baroness seems to suggest. Autonomy and accountability are two sides of the same coin; one confers autonomy in exchange for accountability. That is the model that we have adopted and the one that I would hope that Parliament would wish us to adopt, given that substantial sums of public money will be at the disposal of commissioners throughout the NHS. I therefore do not see that the metaphor of tentacles employed by the noble Lord, Lord Harris, is actually very appropriate. It implies that there is an organisation holding those in the health service in a grip. That will not be the case. The role of the board is to support local commissioners; it is to be there as a resource to promote guidance, supported by the quality standards that we were debating earlier. It is not—I repeat not—a replica of the kind of line management that the NHS has seen to date.

Amendment 8 agreed.

Moved by

[Earl Howe]

9: Clause 4, page 3, line 11, at end insert—
“( ) If, in the case of any exercise of functions, the Secretary of State considers that there is a conflict between the matters mentioned in subsection (1) and the discharge by the Secretary of State of the duties under section 1, the Secretary of State must give priority to the duties under that section.””

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Moved by

[Earl Howe]

11: Clause 5, page 3, line 16, leave out “have regard to the need to”

[Earl Howe]

My Lords, we come to an issue that exercised us on more than one occasion in Committee—the issue of health-related research and the use of research evidence in the health service. My noble friend Lord Willis and others urged me to look again at the Bill’s drafting, having expressed a concern that there was a need to strengthen the duties on the Secretary of State, the NHS Commissioning Board and CCGs to promote research, and the use in the health service of evidence obtained from research when exercising their functions.

Government Amendments 11, 60 and 103 are a response to that concern, and I hope that they will be welcome. The Government are absolutely committed to promoting research throughout the health service. By tightening the wording around the duties, we believe that the amendments send a powerful signal of that commitment. I beg to move.

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[Lord Hunt of Kings Heath]

My Lords, from the opposition Benches we too welcome the amendments, which very much reflect the debate that we had in Committee on the importance of research. The Chief Medical Officer has paid a visit to Birmingham over the past two days; he gave a lecture at Birmingham University and visited my own trust to discuss research and the role of the NHS in it. My noble friend Lord Warner has put his finger on it: the question to the Minister is how we make sure that the NHS makes a sufficient contribution in future to the development and support of research. The Minister will know that the Chief Medical Officer is a passionate advocate of research and excellence in the NHS, and that is to be warmly welcomed.

There are some issues that need to be tackled. We have already heard about the issue of getting approval for clinical trials. We still have the problem, which has been with us for many years now, of local committees taking far too long and repeating work by other committees. I understand that there are some issues around the fact that, because foundation trusts are separate legal entities, they have to go through the process themselves, but if they join a clinical academic network some of that work can be reduced. I know that there is to be an announcement at, I think, the end of March about how these clinical networks are to be developed in the future. That is a very important way of enhancing research.

There is no question that the more we do in research, the better the outcomes not only for patients but for the UK’s reputation and economic well-being. Healthcare research is surely an area to which we need to give great priority. The noble Earl, Lord Howe, is of course responsible and we are very glad that he is leading this work. However, there is no doubt that, welcome though these amendments are, we should be given some assurance that the Government will now take them forward into the new situation with enthusiasm.

[Earl Howe]

My Lords, I begin by saying how much I agree with the remarks of the noble Lord, Lord Hunt. There are two very good reasons why research needs to be promoted in the NHS. The first is that it is for the good of patients. The other is that it is potentially for the good of UK plc. If we can attract investment in translational and clinical research to this country, it will be a major advance. The sad truth is that in recent years the UK has been slipping back in the international league table as a location for clinical research. The Government are determined to reverse that trend, as were the previous Government. We are trying our best to build on the foundations that the previous Government set.

Noble Lords have asked me to explain how the Secretary of State’s duty to promote research will work in practice. I shall try to do so in a few words. The Secretary of State will use the mandate to set priorities for the health service, based on his legal duties. One of those duties is to promote research within the health service, which is shared by the board and CCGs. What are the tools at the Secretary of State’s disposal? The National Institute for Health Research—the NIHR—which is headed by Professor Dame Sally Davies, provides transparent, competitive funding to support clinical and applied health research, the training and development of health researchers, systems to support research and the NHS infrastructure for research. The NIHR will continue to be part of the Department of Health. Its budget of £1 billion is held centrally by the department. The Chief Medical Officer will remain responsible for the NIHR and its budget.

The second main route that the Secretary of State uses, and will continue to use, to support research, is through the NHS. Since the NHS was established, its patient care budget has funded the patient care costs of patients who are taking part in research in the NHS, as set out in existing guidance. In the future, the NHS Commissioning Board and clinical commissioning groups will ensure that these costs continue to be met through these arrangements. The research costs of these studies are paid by the Government and charity research funders such as the Medical Research Council, the NIHR, Cancer Research UK and the Wellcome Trust. The NHS benefits greatly from the evidence provided by this research.

Let us not forget, too, that the Secretary of State will be held to account for what he does. He must report annually to Parliament on the performance of the health service. There is an expectation that he will report on how he has fulfilled his statutory duties.

That brings us to the duties placed on the board. In the document we published, Developing Clinical Commissioning Groups: Towards Authorisation, we set out the early thinking on the authorisation process. The document highlights that as part of the process CCGs will need to demonstrate how they will exercise important functions, such as the duty to promote research, and the NHS Commissioning Board will seek consistency in the way in which CCGs exercise these duties. Furthermore, a CCG’s commissioning plan, and its annual report, as well as the board’s annual assessment of the group’s performance, will cover the exercise of all the CCG’s functions, including the duty to promote research.

I hope that that has given noble Lords a clear outline of how this is all going to work. We regard these duties as extremely important. These amendments are extremely important, as my noble friend said. I am in no doubt that both the health service and its patients will be better off as a result of them.

Amendment 11 agreed.

Health: Children and Young People

Earl Howe Excerpts

Monday 6th February 2012 Lords Chamber

[Baroness Hughes of Stretford]

To ask Her Majesty’s Government what assessment they have made of the NHS Confederation report Children and Young People’s Health—Where Next? on the impact of the Health and Social Care Bill on children’s health.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, last month my right honourable friend Andrew Lansley launched the development of a health outcomes strategy for children and young people. An independent children and young people’s health outcomes forum will inform the development of this strategy and will consider the findings of this report alongside the wider views of children, young people, their families and the professionals who support them. It will report back to government by the summer.

[Baroness Hughes of Stretford]

I thank the Minister for his Answer. However, as this report makes clear, under government proposals up to six different commissioning bodies will have responsibility for commissioning child health or child public health services. Will the Minister tell the House how the Government will prevent the fragmentation of those services to ensure that children do not fall through the gaps, and whether the Government will therefore now consider placing a specific duty on all those commissioning bodies to improve outcomes and reduce inequalities in children’s and young people’s health?

[Earl Howe]

My Lords, the outcomes framework that I have just referred to should assist in the latter regard. I think the noble Baroness would agree that the system we have at the moment is not sufficiently joined-up, and in that sense does not adequately serve the needs of children. The approach we have taken to the proposed NHS reforms is to promote the importance of the integration of care and service provision for everyone, including children. We believe that strong partnerships at a local level, supported by professionals and local leaders, are the way forward, not top-down direction. The health and well-being board provides the forum for repositioning the joint strategic needs assessment into a truly joined-up strategy for local people.

[Baroness Walmsley]

I welcome what my noble friend the Minister has said about getting the views of children, but does he think that giving the commissioning of the excellent Healthy Child programme to local authorities is going to bring about the universal dissemination and delivery of that programme?

[Earl Howe]

The role of local authorities will be pivotal in this because it is at local-authority level that public health, social care, and indeed the discussions that will go on in the health and well-being board context will bring together policy in a way that informs NHS commissioning. I think that the approach we have taken has been widely welcomed, and we are absolutely determined that all sectors of society, including children, are included in these processes.

[The Lord Bishop of Blackburn]

My Lords, my northern diocese of Blackburn scores heavily on the deprivation indices for children’s health outcomes. Does the Minister share my concern that if phase 3 children’s centres become self-financing—as I understand they are to—and a children’s centre is deemed not viable, surely the health impact on the community and of course on the health services will be immense?

[Earl Howe]

The right reverend Prelate is right to draw attention to this issue. I simply say to him that the process that I have described at health and well-being board level is specifically designed to enable local people to determine the priorities that they see as most important for their area. It is right that these decisions are taken locally. I do not argue in the slightest with his analysis of the importance of these centres; I think they do a tremendous amount of good. I am sorry to hear that there may be some threat to the one that he mentioned, but I hope he will also tell me that discussions are going on at a local level to try to find a way forward that will suit the needs of local children.

[Baroness Finlay of Llandaff]

My Lords, given the emphasis on local-level decision-making, will the Minister explain how the Government intend to monitor fairness of access for children with less common conditions who at a local level may not appear to have a great need because there is a lack of awareness of the complex nature of their needs but whose outcomes can be greatly improved with highly specialised care?

[Earl Howe]

The noble Baroness raises an important point. She is right that it is all too easy for children or indeed any patient with a less common condition not to have their voices heard. That is why we are absolutely clear that local healthwatch should be configured in a way that reaches out to hard-to-reach groups. We are looking in particular at patients with specialised conditions to ensure that there is a mechanism for them to have their voices heard at the local level.

[Baroness Massey of Darwen]

My Lords, first I will say how much I welcome the new outcomes framework for children. Will the Minister say which proposed structures in the Health and Social Care Bill will benefit children, and who will have overall responsibility for child health?

[Earl Howe]

My Lords, the Secretary of State will retain ultimate accountability for children's health services. Under the Bill, as the noble Baroness knows, the functions will be conferred directly by Parliament on specific organisations. That will strengthen accountability. In answer to the first part of her question, the reform of the health system offers a real opportunity to address some of the well documented challenges that the current system presents. We are moving, through the Bill and through our reforms, to a system that will focus on promoting good health, which we see as important as delivering good care. Informed and expert knowledge will underpin the commissioning of integrated services, where we will measure success on improvements in the outcomes that are achieved. Treatment will be evidence-based and children will be involved in decisions about their care. All these things are embodied in the Bill.

[The Countess of Mar]

My Lords, recent research at Bristol indicated that as many as one in 100 children who are absent from school long-term suffers from CFS/ME. There is a dearth of centres for the treatment and diagnosis of children with CFS/ME. Does the Minister envisage this improving under the new proposals?

[Earl Howe]

My Lords, it is yet to be decided finally which services will be commissioned at a national level. I cannot give the noble Countess a definitive answer on where services for CFS/ME will be commissioned. However, we are sure that the arrangements will provide much better, more locally responsive ways of commissioning services generally. Whether clinical commissioning groups join together in commissioning services, whether lead commissioners do that or whether commissioning takes place at a higher level, we are clear that in all services this needs to improve.

[Baroness Gardner of Parkes]

Will the Minister tell me what the position is with accident and emergency services? We have all read in the papers that we should not get sick at weekends and how desperately people are treated in some hospitals. Are children’s services as adversely affected as those of adults, or are no figures kept on the difference? What does the Minister propose to do to increase cover, because misdiagnosis is a major worry in some cases?

[Earl Howe]

My Lords, accident and emergency services will be commissioned at a local level. I am afraid that I do not have in front of me detailed information on the split between adult and children's services in an emergency context. If I can get the information, I will be happy to write to my noble friend.

[Baroness Thornton]

My Lords, given that responsibility for commissioning for 0 to five year-olds will be at a national level, and commissioning for six to 19 year-olds will be the responsibility of local arrangements, as the noble Earl described, what are the risks for the continuing responsibility for safeguarding the health of the most vulnerable children in our society?

[Earl Howe]

My Lords, the two main outcomes frameworks relevant to this are the NHS and the public health outcomes frameworks, which we are trying to align as far as possible. They set a clear direction for the health and healthcare of children and young people, but there is more to do. As our data improve, we need to ensure that the outcomes measured are the ones that matter most to children and young people. That is why we are developing a health outcomes strategy for children. This will be the first example of an outcomes strategy as part of the health reforms model.

[Baroness Tonge]

My Lords, would the Minister remind us—in fact, more than that, would he make it absolutely clear—who will treat children whose families are not registered with a general practice?

[Earl Howe]

My Lords, as my noble friend knows, it will be the legal responsibility of clinical commissioning groups to commission care on behalf of all patients living in their geographic area, whether or not they are registered with a GP. That means that arrangements have to be made to ensure that those patients are treated when needed.

Tobacco

Earl Howe Excerpts

Monday 6th February 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the Government take very seriously their obligations as a party to the Framework Convention on Tobacco Control. The convention encourages parties to take a comprehensive approach to tobacco control to improve public health. The United Kingdom is a recognised leader for tobacco control internationally. The Government’s tobacco control plan sets out a government-wide approach to tobacco control, as well as what will be done to support local authorities to reduce rates of tobacco use.

[Lord Faulkner of Worcester]

My Lords, the Minister will be aware that the reason that the United Kingdom Government and 173 other Governments have become parties to the WHO’s Framework Convention on Tobacco control is because the tobacco industry has had a uniquely malign influence on health policy in all countries where tobacco is sold. Does he agree that its record in the United Kingdom since the 1950s has consisted of first denying the link between tobacco smoking and ill health, then suppressing the results of its own research on the addictive properties of nicotine, then denying the harmful effects of second-hand smoke and now funding front organisations to oppose tobacco control legislation such as the point-of-sale restrictions, which I am delighted that the Government have embraced? Are not all these powerful reasons for sticking to the framework convention and ensuring that the tobacco industry has no influence whatever over the formulation of health policy relating to tobacco?

[Earl Howe]

My Lords, yes, the vested interests of the tobacco companies are well recognised. The Department of Health is careful to ensure that the Government’s obligations under the framework convention are met, including the treaty obligation to protect public health policies from the vested interests that he referred to. For example, I hasten to reassure him that the tobacco industry was not involved in the development of the Government’s tobacco control plan, which was published last year.

[Lord Ribeiro]

Can my noble friend outline what steps the Government are taking to reduce the promotional impact of tobacco packaging, particularly that which is targeted at vulnerable young girls?

[Earl Howe]

My Lords, we shall shortly be announcing a consultation on the subject of plain packaging for tobacco. We wish to hear views from all interested parties on that subject.

[Baroness Thornton]

My Lords, it was as a direct result of the evidence of the underhand tactics of the tobacco industry that the UK very wisely adopted Article 5(3) of the Framework Convention on Tobacco Control. In 2008-09, the noble Earl’s noble friend Lady Northover successfully asked the then Secretary of State Alan Johnson to write to all his ministerial colleagues drawing attention to and outlining the importance of Article 5(3) and asking for their assurance that they were abiding by the article in their dealings with the tobacco industry. I invite the Minister to agree to ask his right honourable friend the Secretary of State to do the same with this Government.

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[Earl Howe]

My Lords, I can reassure the noble Baroness that my right honourable friend the Secretary of State, and indeed all Ministers in the department, have had no direct dealings—or indeed indirect dealings—with the tobacco industry since coming to office. However, I am sure that the noble Baroness’s message will be very warmly received by my colleagues.

[Baroness Hussein-Ece]

Is my noble friend aware that almost 50 per cent of loose tobacco sold in the UK comes from illicit and illegal traders on the streets, which makes it more affordable for children and young people? What progress is being made in cracking down on the illicit tobacco trade? As my noble friend will know, it is an industry controlled and funded by an international network of organised crime gangs.

[Earl Howe]

My Lords, Her Majesty’s Revenue and Customs and the UK Border Agency published a renewed strategy in April last year to tackle the illicit trade in tobacco products. Our tobacco control plan complemented that strategy by stressing the importance of cracking down on illicit tobacco sales, which will in turn reduce tobacco consumption and organised crime, and support legitimate retailers. In fact, the latest figures show that fewer and fewer people are using illicit tobacco. The market for illicit cigarettes was down to 10 per cent in 2010 from 21 per cent in 2000.

[The Countess of Mar]

My Lords, some years ago I was given a statutory instrument, the Sheep Scab Order, which was dated about 1914 and had an excellent recipe for sheep dip made from tobacco. I wonder whether the current tobacco problem could be relieved by diverting tobacco from smoking to sheep dip.

[Earl Howe]

My Lords, I wonder too.

[Lord Naseby]

My Lords, the Minister says that the control of illegal importation of tobacco is showing progress. Is it not the reality that the vast majority of illegally imported tobacco and cigarettes is being consumed by young people, and that while the official statistics may show one thing, all the evidence, when I inquired of the tobacco industry on this particular aspect, is that this is still the major problem in terms of young people taking up smoking?

[Earl Howe]

My noble friend is absolutely right that that is where the problem principally lies: 320,000 young people experiment with smoking or take it up every year. That is a very serious rate of incidence and it must be tackled at every possible level. The tobacco control plan sets out a concerted programme of action to try to do just that.

[Lord Rea]

My Lords, on 11 July this year the noble Earl said to the House,

“we will make sure that we publish details of policy-related meetings between the tobacco industry and government departments and we are currently exploring the most effective and appropriate mechanism for doing that”.—[Official Report, 11/7/11; col. 560.]

Could the noble Earl please say what that mechanism is, and whether it is now being implemented?

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[Earl Howe]

My Lords, since 2010 the Government have published details of hospitality and gifts received by Ministers and special advisers, ministerial meetings with external organisations, and all overseas trips by Ministers across government. These details are published on each department’s website. The information is published quarterly to promote transparency and to provide the public with up-to-date information.

Alcohol

Earl Howe Excerpts

Thursday 2nd February 2012 Lords Chamber

[Baroness Finlay of Llandaff]

To ask Her Majesty’s Government how they plan to reduce alcohol harm.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, we will set out the Government’s approach to tackling alcohol-related harm in the forthcoming alcohol strategy. It will address the full range of harm from alcohol, both health and social impacts, and will describe the respective future roles of central and local government, the third sector, other agencies and people.

[Baroness Finlay of Llandaff]

Today’s British Liver Trust report shows that 28 per cent of deaths in 16 to 24 year-olds and almost 9,000 deaths a year in this country are alcohol-related. Do the Government recognise that there is now a need for social strategies that look at issues such as minimum pricing and licensing controls of home delivery services that provide night-time party top-ups when parties have run out of alcohol and people are already drunk, as well as criminal justice controls so that breathalysers can be used compulsorily, given that 45 per cent of violent crime and 37 per cent of domestic violence are alcohol-related?

[Earl Howe]

My Lords, the Government fully recognise the adverse effects on society of alcohol misuse and the devastating consequences that it can bring to individuals. That is why we feel it is so important to issue the alcohol strategy that I mentioned in my initial Answer. I understand that there are no plans in government to widen the use of breathalysers, but we are clear that irresponsible sales of alcohol need to be controlled, and that area will be covered in the strategy. On the noble Baroness’s particular question on pricing, we recognise that the irresponsible sale of alcohol at a loss to gain wider trade can lead to binge drinking. That is clearly undesirable for all sorts of reasons. We are committed to ending the sale of heavily discounted alcohol, and that will send a message to retailers and, indeed, the public that we take the issue very seriously.

[Baroness Trumpington]

My Lords, may I ask the Minister whether the answers he has been giving fit in with the order that my noble friend Lord Strathclyde has on the Order Paper for later today?

[Earl Howe]

My Lords, my noble friend is ahead of me, and I will have to write to her.

[Baroness Hayter of Kentish Town]

My Lords, has the Minister seen the letter today from the churches and charities to the Prime Minister asking that there should be a minimum price on alcohol? Will he agree with that recommendation and do that rather than rely on the industry in this case?

[Earl Howe]

My Lords, as I have already said, we recognise that the irresponsible sale of alcohol at a loss or heavy discount is undesirable. We know that price is important in this equation but we also know that it is not the only factor that affects demand for alcohol. We need to find ways to change people’s relationship and behaviours with alcohol. We do not believe that the only way to do this is by more rules and regulations but the issue of price will be addressed in the forthcoming alcohol strategy.

[Lord Taverne]

My Lords—

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[Lord Taverne]

My Lords, the Sheffield University report to NICE in 2010 pointed out the extreme importance of price rises. It came to the conclusion that a 10 per cent price rise would, among other things, reduce hospital admissions by something like 50,000 a year, crimes by something like 96,000 and absenteeism from work by something like 500,000 per annum. Very similar huge social benefits would also come from introducing a minimum price. Does the Minister agree that price rises are probably the most important single weapon in dealing with this social matter?

[Earl Howe]

My noble friend makes a very good point, which is why the Government have taken action on tax. We will be raising alcohol duty by 2 per cent above inflation every year to 2014-15. We introduced a new additional duty on high-strength beers to address the consumption of cheap super-strength lagers and a reduced rate of duty on low-strength beers to encourage consumers to switch to those brands.

[Lord Imbert]

My Lords—

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[Lord Imbert]

In the light of the 60,000 alcohol-related calls answered by the London Ambulance Service alone and the 18,500 alcohol-related crimes of violence in London alone in one year, does that not mean that we should introduce a compulsory alcohol sobriety testing scheme which magistrates can use to sentence in order to reduce this awful number of offences?

[Earl Howe]

The noble Lord is right to point that out. Proposals of the kind he suggests should be considered. As I am sure he will recognise, there is no single solution to the complex challenge of alcohol misuse. We need to look at licensing, pricing, health promotion, the criminal justice system, the role of local authorities, early engagement by the NHS and labelling, and the list goes on. But I am very happy to feed in the noble Lord’s ideas to my department in the work that it is doing.

[Baroness Massey of Darwen]

My Lords, what impact does the Minister think rising unemployment may have on alcohol consumption? He has not mentioned unemployment, which is an important issue. I declare an interest as the chairman of the National Treatment Agency for Substance Misuse.

[Earl Howe]

My Lords, the evidence is that the population’s overall consumption of alcohol tends to fall if incomes are depressed. Particular groups in the population, including some who are unemployed, may consume more alcohol as a result of being unemployed but the evidence does not enable us to quantify this effect. This is one aspect of health inequalities which we are determined to reduce, as we stated in Healthy Lives, Healthy People, a document we published last year.

Health: Diabetes

Earl Howe Excerpts

Wednesday 1st February 2012 Lords Chamber

[Lord Collins of Highbury]

To ask Her Majesty’s Government what plans they have to act on the National Diabetes Audit Mortality Analysis 2007–08, published by the NHS Information Centre, which estimated that up to 24,000 deaths from diabetes per year could be avoided by the condition being better managed.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, we are working with the National Diabetes Information Service and National Health Service organisations to ensure that local services have the audit data for their own areas to show how they compare with others and where improvements can be made. NHS Diabetes has a suite of tools that can be used to help drive improvements and reduce avoidable deaths.

[Lord Collins of Highbury]

I thank the Minister for his response. Diabetes UK estimates that about 26 per cent of the 450,000 residents in nursing and care homes in England have diabetes. Care home residents are a highly vulnerable group of people and, without regular screening for diabetes, they are at an increased risk of complications such as heart disease, stroke, kidney failure, blindness and amputation. What are the Government doing to ensure that residents in care homes receive the appropriate screening that they need for diabetes?

[Earl Howe]

My Lords, much will depend on the way in which primary care engages with those in social care to ensure that the residents of care homes, who need diabetes care management, receive it properly. We very much want to see that joined-up commissioning arise from the reforms that we are currently in the process of debating in your Lordships' House. The noble Lord makes a very good point. We have many tools at our disposal. There is no shortage of guidelines in this area. Much will depend on the training of care home staff and a lot of work is going on under the aegis of the National Clinical Director for Diabetes in this area.

[Lord Rennard]

My Lords, does the Minister agree with the 15 checks or services promoted by Diabetes UK that every person with diabetes should receive or have access to? In particular, does he agree that they should have access to high-quality, structured education, firmly embedded in the NHS, based on a programme such as that for type 1 diabetics, promoting dose adjustment for normal eating?

[Earl Howe]

My Lords, the answer to my noble friend is yes. Those checks and services are firmly supported by NICE, by the National Service Framework and by the NICE quality standard. I also agree with him that structured education is fundamental if we are to ensure that patients can self-manage. A number of tools are available for that. He mentioned one for type 1 diabetics that has the acronym DAFNE—dose adjustment for normal eating—and for type 2 diabetics there is DESMOND—diabetes education and self-management for ongoing and newly diagnosed.

[Baroness Finlay of Llandaff]

Can the Minister please tell the House what levers the Government will have in the new NHS to ensure an increase in the use of insulin pumps for the control of diabetes in children, given that the pump appears at face value to be expensive, but as a long-term investment it is very cost-effective because it results in far better control of diabetes and a lower incidence of hypoglycaemic attacks, which is important for children at school?

[Earl Howe]

My Lords, we know that insulin pump therapy can make a huge difference to glycaemic control and the quality of life in some people. It is not appropriate for everyone, as the noble Baroness will, I am sure, recognise. We know that much more has to be done to improve the uptake of insulin pumps in line with NICE recommendations. The NHS operating framework for this year highlights the need to do more to make these devices available. The NHS Technology Adoption Centre has published guidance to support NHS organisations in the adoption of these devices and I know that the National Clinical Director for Diabetes, Dr Rowan Hillson, chairs a working group focusing on the uptake of insulin pumps.

[The Earl of Courtown]

Does my noble friend agree that one of the greatest problems for those suffering from diabetes—particularly type 2 diabetes—and for those looking after them, is that they are not actually taking up the education that is available so that they can learn how to live their lives to get a better result from their illness?

[Earl Howe]

I agree with my noble friend. We are firmly of the view that education is a major action area for primary care clinicians, and for those in secondary care too, if we are to avoid unplanned admissions to hospital, which are unpleasant for patients and very costly for the NHS.

[Lord Brooke of Alverthorpe]

Does the Minister agree—I am sure that he does—that the recommendation that there should be more comprehensive and effective preventive care is an important part of the report, and that it is important to highlight the link between obesity and this illness? Does he agree that it is now high time for the Government to introduce calorific labelling of alcohol products so that people know the number of calories they take in when they drink, and to stop citing the European Union as the reason why they are not doing it?

[Earl Howe]

The noble Lord is to be congratulated on bringing me back to the very important subject of the labelling of alcoholic drinks. I hope that the House will feel that he was a little unfair in blaming the Government for the line that they have taken on this. As the noble Lord knows, labelling is an area that is very largely a matter of EU competence. However, he is right that type 2 diabetes is closely linked to obesity and insufficient physical activity. We would like to see businesses use a more consistent front-of-pack nutrition labelling approach than has been achieved in the past, particularly with food.

[Lord Harrison]

Will the noble Earl recognise another acronym, the DAFNE programme, and give greater government support to rolling out such a programme, as illustrated by the noble Lord, Lord Rennard? Will be also reply to the Danish Government, who have made diabetes a priority under their presidency for the coming six months? What is being done with our Danish colleagues to promote a better understanding of diabetes and its treatment?

[Earl Howe]

The noble Lord is right to emphasise the role of DAFNE. The 2011-12 NHS operating framework signals the need to commission patient-structured education for people newly diagnosed with diabetes, and at appropriate points in their life as their condition progresses. I do not have a briefing on the dialogue with our Danish colleagues on their programme of action, but I will write to the noble Lord on that.

Health: Stroke Care

Earl Howe Excerpts

Monday 30th January 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I am delighted that the noble Baroness, Lady Wheeler, has been successful in securing a debate on stroke care, and I thank her for introducing the subject so ably. As demonstrated today by the number and quality of contributions made by noble Lords, it is an area of great interest and one that it is vital to keep in the public eye. I shall do my best to cover as many issues that have been raised as I can, but I shall write to those noble Lords whose questions I have not been able to cover.

Stroke care has witnessed huge improvements over the past few years and many thousands of people have benefited. Stroke patients are getting treatment that is faster and better than ever before and data suggest that improvements are continuing. I pay tribute to the work of Sir Roger Boyle during his time as national clinical director. The latest data show that over 80 per cent of stroke patients are spending the majority of their hospital stay on a stroke unit, and the management of high risk transient ischaemic attack patients has also improved by 20 per cent since 2009. Access to immediate brain scanning has improved considerably and more patients are receiving thrombolysis giving them a better chance of regaining their independence following a stroke. There has been the very successful campaign to raise awareness of stroke—the Act FAST campaign.

We want the progress underway to continue but we also know, as was pointed out by the noble Baroness, Lady Pitkeathley, that we need to do more to improve support for people after stroke. As we acknowledged when the Care Quality Commission published its report last year, there is still more to do in ironing out the variations in stroke care, particularly in the support provided to patients when they leave hospital.

The noble Baroness, Lady Wheeler, asked about monitoring of outcomes with the benefit of robust information. At a national level, our focus on outcomes through the NHS, public health and adult social care outcomes frameworks sets out the areas we want to improve. Stroke specifically features in two parts of the NHS outcomes framework in terms of reducing premature mortality and in recovery from major illness.

Noble Lords will be interested to hear that the stroke indicator on recovery has been developed in collaboration with several organisations, including clinicians, academics and the NHS. The indicator, based on the modified Rankin scale, will assess the patient’s recovery from stroke after six months. It will provide an incentive for the NHS and social services to work together, getting the right services in place so that when patients leave hospital they have the support they need to make the best possible recovery. I hope that that reassures those noble Lords who are afraid that care will be fragmented. This outcomes framework will drive services in the opposite direction.

The social care outcomes framework is helping to gauge the progress made by local services and drive up standards across the country. One of the areas this framework covers is reducing the need for care and support and delaying dependency. This will help people to live healthy independent lives and properly manage any health needs. Local authorities will be able to compare their services with those of other authorities around the country and make improvements based on what has been proven to work elsewhere, integrating care and working together to provide care that suits individual patients. For stroke survivors, this means providing access to the kind of support that they need to enjoy the best possible quality of life after their stroke.

Building on the national stroke strategy, the NICE quality standard for stroke, which has been mentioned by a number of noble Lords, has been developed with patients, commissioners and leading doctors. This provides an authoritative definition of what high quality care for stroke actually means. They are the measures of quality that matter most to patients and the NICE quality standard for stroke recognises the key role that rehabilitation plays in making sure people can live their lives as fully as possible after their stroke.

My noble friend Lady Browning suggested that there is perhaps inadequate understanding of what patients need in care settings. The NHS, through the stroke improvement programme and the 28 stroke networks in England, is working to make sure that stroke care improves at all stages of the patient pathway. The stroke networks connect different organisations and teams that have roles to play when someone has a stroke so that patients can be sure of co-ordinated management from the moment they are first in touch with a doctor or nurse and throughout their lives as a stroke survivor. This whole approach takes the needs and wishes of stroke survivors and their carers into account when delivering these services. I should like to reassure the noble Baroness, Lady Wheeler, about funding of the networks. Funding is in place for 2012-13. The future of the networks is being actively considered as part of the development of the NHS Commissioning Board.

The stroke improvement programme and the stroke networks have made good progress in getting the stroke strategy up and running, and they have done the same with the NICE quality standard. Patients now see better acute care as a result of both. Attention is now being focused on improving care for patients who have left hospital. The accelerating stroke improvement programme was developed specifically to improve care in areas where progress needs to be made faster and is looking at improving post-hospital and long-term care. The stroke improvement programme, working with the stroke networks, is delivering this.

Accelerating stroke improvement is concentrating on four key areas of post hospital care: that is, providing early supported discharge; making sure patients and carers have a joint care plan on discharge from hospital, which was mentioned by my noble friend Lady Browning; making sure stroke survivors have a review six months after leaving hospital; and making sure psychological support is provided for those who have mood, behaviour or cognitive disturbance.

One example of where a stroke network has been working well with commissioners to improve access to stroke community services is south London. Through the ASI programme, the network has developed a service specification for early supported discharge and community services, and has helped commissioners to make the case for change. What is more, analysing data from the CQC review, the stroke network was able to identify areas that needed to do more in the provision of post-hospital services. This has resulted in one of the care trusts commissioning a stroke community rehabilitation service, which is an excellent example of how the CQC review has actually driven improvements in services.

A number of questions were put to me. The noble Baroness, Lady Wheeler, asked about clinical leadership in this area, a point also raised by the noble Baroness, Lady Thornton. The replacement of the National Clinical Director for Heart Disease and Stroke is being considered as part of the development of the NHS Commissioning Board, but I would just say generally that improving stroke services is a priority for the Government, and there should be no doubt about that. It is a priority against which we shall hold the NHS Commissioning Board to account. Tackling premature mortality from stroke is an area for improvement in both the NHS outcomes framework and the public health outcomes framework.

The noble Baroness, Lady Wheeler, mentioned the Stroke Association, and again I pay tribute to its work. My officials meet its representatives on a very regular basis. The local stroke networks are working with clinical commissioning groups and PCT clusters to ensure that improvements are made in stroke services, including those recommended by the CQC. I was asked how improvements in quality will be monitored. There are two audits running this year. The Sentinel Stroke Audit and SINAP will both publish their results, which will help commissioners and providers of stroke care to monitor and improve their services, helped by the local stroke networks. The noble Baronesses, Lady Wall and Lady Thornton, asked whether we agree with the hyper-acute model that has been adopted in London. We certainly acknowledge that the reconfiguration of stroke services in London has produced very good results. The Stroke Improvement Programme works through local stroke networks, which are responsible for disseminating good practice across the country. They have done so with the London example very much in mind and, indeed, other examples where reconfiguration has delivered better stroke care.

The noble Baronesses, Lady Masham, Lady Gould and Lady Rendell, my noble friend Lord Rodgers and the noble Lord, Lord Clinton-Davis, all spoke of aphasia services and speech and language therapy. Stroke survivors should receive care and support from staff with the skills and competence to meet their needs, ensuring that those with communication difficulties such as aphasia have opportunities to return to a full life back in their communities. A good example of working with those who have aphasia is the Access to Life project in Cornwall, run by Connect. Twenty people with aphasia have been trained to provide one-to-one support to others with aphasia at home or in hospital, which helps those with aphasia grow in confidence in the way they communicate, and so reduces their risk of social isolation, a point well made by my noble friend Lord Rodgers.

The noble Baroness, Lady Rendell, spoke about entitlement to reviews and reassessments. Patients should have reviews at six weeks and six months. The NHS outcomes framework will include an indicator in the recovery domain to ensure that patients are reviewed at six months, as I have mentioned. The noble Baroness, Lady Pitkeathley, referred to the needs of carers. Carers play a critical role in ensuring that stroke survivors enjoy the best possible quality of life. Local authorities, working with PCTs, should together make sure that appropriate services are available to support both stroke survivors and their carers. Health and well-being boards will in the future have responsibility for ensuring that these local needs are met. The noble Baroness, Lady Gould, asked about support for third sector organisations. It is for local commissioners to decide how to use the third sector in providing stroke services, but many local authorities and PCTs commission such services from organisations such as the Stroke Association.

We want our stroke services right across the pathway to match the very best in the world. As I have said, huge improvements have been made to that end, but significant improvements still need to be made. I have given a couple of examples of what is being done to address this, and there are many more examples from around the country of services continuing to improve. But we are not stopping here. Identifying how we can deliver better outcomes in cardiovascular disease, including stroke, is a key task. This is one of our biggest killers and causes of adult disability. That is why my right honourable friend the Secretary of State for Health recently announced the development of an outcomes strategy for cardiovascular disease, building on existing strategies and the national service framework. I hope that the noble Baroness, Lady Wheeler, will see this as good news.

The aim of the strategy is to create a joined-up approach across the NHS, public health and social care to improve outcomes for patients with CVD, which includes stroke survivors. This will mean even more stroke survivors living active and fulfilling lives.

Health and Social Care Bill

Earl Howe Excerpts

Thursday 19th January 2012 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government what were the estimated costs of implementing the Health and Social Care Bill when it was originally introduced to the House of Commons one year ago, and whether they have changed.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, in January 2011, we estimated the costs of implementing the Health and Social Care Bill at £1.4 billion. When we published the revised impact assessment in September, we estimated the costs of implementing the Bill to be between £1.2 billion and £1.3 billion. This will reduce administrative costs across the system by one-third by the end of this Parliament, saving £1.5 billion per year from 2014-15 onwards.

[Baroness Thornton]

My Lords, I thank the Minister for that Answer. Many people in the medical world believe that the cost is mounting and that the cost which the Minister cites is not accurate. It is safe to say that this upheaval is costly both in money and in the risk to patient care. As well as the cost, at a time when the NHS has to find £20 billion of efficiencies, today the nurses and midwives have asked for the Bill to be dropped, arguing that their concerns have not been answered. Can the Minister give the nation and the NHS a first birthday present by listening to what is said and advising his right honourable friends Mr Lansley and the Prime Minister that it is time to pull back—

--- Later in debate ---

[Baroness Thornton]

I am asking a question; I am in the middle of asking it. You may not care about the NHS but, on these Benches, we do. When the medical professions and nurses say that the Government should think again, it would be wise for the Government to do so. My question is whether the noble Earl will ask his colleagues to do so, and whether we can then move together, with consensus, as my right honourable friend Andy Burnham has now twice asked the Secretary of State to do.

[Earl Howe]

My Lords, I understand that the noble Baroness is asking me to deliver a certain message to my right honourable friend. I am not quite sure what that message was, but if it is to do with the Health and Social Care Bill, I have to say that we need that Bill. We believe that reform of the NHS is essential if it is to be sustainable in the future. Every penny saved from this reform will be reinvested in front-line patient care. The previous Government had, as we do, an ambition to save £20 billion—the so-called Nicholson challenge—over the next three or four years. This reorganisation will enable us to contribute to that total. The modernisation will also move the NHS to a much more patient-centred system where good providers are rewarded for high-quality services. We are spending money on redundancy now to gain in the future.

[Lord Touhig]

My Lords, will the Minister tell us whether the report in this morning’s Guardian that the NHS regulator is proposing that a hospital should be credit-rated is correct? If it is correct, why are the Government pursuing this commercialisation of our hospitals? They are not supermarkets; they are places of care.

[Earl Howe]

My Lords, I have not seen that report, but clearly there is concern, following Southern Cross, as to whether difficulties such as those should be predictable in some way. I am sure that a lot of thought is being devoted to trying to avert such crises in the future. I will look at that report and write to the noble Lord with any comments.

[Baroness Greengross]

The Bill is called the Health and Social Care Bill. If the recommendations of the Dilnot commission for social care are implemented speedily with cross-party support there will be a huge saving to the NHS, where many frail and vulnerable people are inappropriately treated because the impending crisis in social care has not been addressed. Does the noble Earl agree that that is the case?

[Earl Howe]

I strongly agree. The noble Baroness will know that running right the way through the Bill are duties around the integration of services between health and social care and indeed between different aspects of healthcare. By giving clinicians greater autonomy to decide what good care looks like for their patients in an area, I am confident that we will see fewer unplanned admissions to hospital, which cost a great deal of money, and much better preventive care for patients delivered by healthcare and social care professionals.

[Lord Tebbit]

My Lords, has my noble friend noticed that this upsurge in criticism of his proposed reforms in the health service has coincided with an upsurge in the demands for more pay by some of the people who are making the criticisms? Perhaps if they were a little more modest in their demands, there might be a little more money for patients.

[Earl Howe]

My noble friend makes a good point. Of course we wish to see professionals properly rewarded, but it behoves everyone in the public services to bear in mind the difficult economic circumstances in which we currently live. Many public servants, I am pleased to say, are responding to that call.

[Lord Tomlinson]

Is the Minister aware that his message about the imperatives of health service reform does not appear to have reached the Royal College of Nursing and the Royal College of Midwives, based on statements that they made yesterday? Does he share the view of his right honourable friend the Secretary of State in another place, who has stated that these are not disputes about the health service but politically motivated strikes?

[Earl Howe]

I do think that the objections that the Royal College of Nursing has raised have very little to do with the Health and Social Care Bill. They are much more about what may or may not be happening in certain hospital trusts, which are matters that, in general, the Bill does not affect.

[Lord Harris of Haringey]

My Lords—

--- Later in debate ---

[Baroness Jolly]

My Lords, health reforms rarely come at low cost. Can the Minister tell the House how much the previous Government’s health reforms cost between 1997 and 2010?

[Earl Howe]

My noble friend is right to remind the House of the repeated reforms of the health service made under the previous Administration. I do not have a figure for how much they cumulatively cost the taxpayer, but it was clearly a great deal and I recall that one of the reforms took place over the course of the summer without any reporting to Parliament at all. The contrast between those reforms and this one is marked. We are doing this to get better care for patients. The previous Government were really only doing it to rearrange the deckchairs.

[Baroness Wall of New Barnet]

Does the noble Earl agree that, contrary to my noble friend’s comments, there is a real regret in the health service that our excellence awards—as you know my trust in Chase Farm has received one—have been done away with by the Government with the CQC. I do not know what the Guardian article said and I do not know what it means by “credit”, but getting credit for good services and proper care is something that everyone in the health service would welcome. The focus for us in the health service is indeed to join social care and healthcare. Can any emphasis that can be given by the noble Earl or the Department of Health come as quickly as possible please?

[Earl Howe]

The noble Baroness was absolutely right in what she said in the last part of her question. I apologise to the House if I misunderstood the previous question about credit ratings, which I took to mean something to do with finance rather than gold stars, which I think the noble Baroness was talking about. I will try to clarify that in a letter.

NHS: Transition Risk Register

Earl Howe Excerpts

Wednesday 18th January 2012 Lords Chamber

[Baroness Pitkeathley]

To ask Her Majesty’s Government whether their risk assessment of their proposed National Health Service reforms will be published before the Report stage of the Health and Social Care Bill commences.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the Government are appealing the Information Commissioner’s decision that the transition and strategic risk registers should be released, for the reasons explained in my recent statements to the House. The tribunal has initially fixed the oral hearing for 2 and 3 April, but my department is urgently discussing with the tribunal how the case may be expedited further. Regrettably, however, it is not possible for this to take place before Report commences.

[Baroness Pitkeathley]

My Lords, the Minister’s reply will be disappointing to many Members of this House, who believe with the Information Commissioner that,

“there is a very strong public interest in disclosure of the information, given the significant change to the structure of the health service the government's policies on the modernisation will bring”.

Moreover, the noble Earl himself is, I know, on record as saying that he is anxious to get the matter decided as speedily as possible. Are the Government considering a delay in the timing of Report, so that the House can have before it all the information that it needs to ensure that this important Bill is subject to detailed scrutiny, which is such a significant function of your Lordships' House?

[Earl Howe]

My Lords, I understand the noble Baroness’s disappointment. As I have said, my department has made strenuous representations to ensure that this process is concluded as speedily as may be possible, consistent with the need for both parties to assemble the necessary evidence and present their cases properly. In answer to her second question, of course we have considered the timetable for Report in the context of this process, but we have concluded that if the Bill is to go through its full passage by the anticipated time of the end of the Session we need to start Report at the beginning of February. So, regrettably, our conclusion is that the start of Report cannot be delayed.

[Baroness Meacher]

I understand the Government’s reluctance to publish risk registers. Governments do not tend to be keen to publish documents that are going to be deeply embarrassing to them. However, will the Minister invite the Information Commissioner to identify key sections of the risk registers that really should be before the House of Lords before it undertakes its work on Report, and will the Government and the Minister comply with the Information Commissioner’s recommendations?

[Earl Howe]

My Lords, this issue turns on a disagreement between ourselves and the Information Commissioner about where the balance of public interest lies. Our view is that the balance of public interest does not lie in disclosure, and his view is the opposite. It would be likely, if we gave the Information Commissioner a second opportunity to look at this, that he would come to the same conclusion as before, so we have to let due process occur.

[Baroness Thornton]

My Lords, the strategic health body in London was perfectly content to make the register of risks on the health Bill available, so the House needs to know, first, what the difference is—except in terms of size—in the national Department of Health making its risk register available. Secondly, I realise that in appealing the Information Commissioner’s decision the Government have said, in effect, that this decision has cross-government implications. Does the Minister accept that it also has wider implications for Parliament? In this House, our ability to scrutinise legislation effectively must be in doubt if any Government withhold important information from us, so what course of action does the Minister suggest that noble Lords in this House should take under these circumstances?

[Earl Howe]

My Lords, to answer the second part of the question first, a substantial number of the risks pertaining to the Bill are already in the public domain and we are considering whether there is scope to draw these sources of information together in a single place, so that noble Lords can look at them more easily. To answer the first part of the noble Baroness’s question, I made inquiries about NHS London. Its situation is very interesting and quite different from that of the Department of Health. NHS London developed its risk management strategy with a view to it being visible to stakeholders and the public, as its document says. It is therefore a reasonable assumption that officials will have worded their risks for inclusion in the register in the knowledge that that wording would be likely to form part of a document placed in the public domain, so there is a very real difference between the two situations.

[Baroness Jolly]

My Lords, as has been suggested, there are wider issues here. Could my noble friend the Minister tell the House to what extent he believes the use of risk registers might be compromised if their authors feel they cannot be entirely candid?

[Earl Howe]

My Lords, risk needs to be thought about and assessed thoroughly and often in worst case terms in order to inform policy development and implementation. Risk registers are therefore a basic policy management tool and, for robust risk management to take place, officials have to be free to record all potential risks fully and frankly, with absolute candour, in confidence that anything they say will not be disclosed. If officials knew or believed that what they wished to say was going to be disclosed, that would inhibit them in expressing views fully and frankly. That, in turn, would erode confidence in policy-making and impede good government.

[Lord Wills]

My Lords, apart from the specifics of this case, there is clearly an issue of constitutional significance when this House is being asked to scrutinise legislation without having available to it all the centrally relevant information. That is clearly the case here. Which committee of which House would the Minister recommend looks at this particular constitutional issue?

[Earl Howe]

My Lords, with respect to the noble Lord, I do not think that is a matter for me. Obviously, if there is a committee that feels able and willing to look at this matter, we shall of course co-operate and comply with that committee to the fullest extent.

[Lord Owen]

My Lords, there is a Motion on this very subject before the House in my name, and I hope that there will be an opportunity well before we reach Report for it to be debated. Since public companies are under strict obligations to publish their risk assessments—they have to weigh very carefully what they say because they could be sued by shareholders in their companies—why is it so different for Her Majesty’s Government in the circumstances in which the Information Commissioner has expressed the view that this is a legitimate case that ought to be made available?

[Earl Howe]

The Freedom of Information Act was framed specifically in a way that would protect the process of policy-making within departments. Our view is that the risk register forms an integral part of policy-making and implementation; the Information Commissioner came to a different view. It is about the balance of public interest here: we wish to see this process adjudicated further.

Health: End-of-life Care

Earl Howe Excerpts

Monday 16th January 2012 Lords Chamber

[Baroness Greengross]

To ask Her Majesty’s Government what measures are in place to inform people of the steps they need to take to ensure their wishes regarding medical treatment at the end of life are respected if they lose capacity.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the Department of Health makes annual resources available to the NHS and local authorities to implement the Mental Capacity Act. These resources are for them to inform and support people who may have lost or be about to lose capacity about their wishes regarding treatment and care. The department’s end-of-life care strategy provides further guidance in this area.

[Baroness Greengross]

I thank the Minister for that helpful reply. Advance directives are now well established in this country, and it is accepted that patients’ wishes in this respect should be followed wherever possible. What systems does the NHS use to record the existence of advance directives and to ensure that they are accessible to doctors as well as available to them so that patients’ wishes can be respected? Where patients have made an advance decision in this regard, what evidence does the Department of Health have on the degree of adherence to their end-of-life medical preferences?

[Earl Howe]

My Lords, the department does not hold information about the degree of adherence to advance decisions, but I can tell the noble Baroness that there are a number of systems available in the NHS that enable patients to record their preferences for care at the end of life and the choices that they would like to make, including saying where, if possible, they want to be when they die. We know that there is widespread use in the NHS of the Preferred Priorities for Care tool that supports decisions about preferences.

We have also supported the piloting of electronic palliative care co-ordination systems to ensure that a person’s wishes and preferences for care are taken into account and to improve communication between the professions and organisations. The Information Standards Board is currently considering a proposed standard setting out a core data set to support the implementation of those systems.

[Lord Walton of Detchant]

My Lords, what evidence do the Government have regarding the number of elderly people in the population who have taken advantage, as I have, of signing an advance directive and lodging it with my general practitioner to specify what forms of treatment I would and would not wish to have if I became incompetent? What is the present position of the legal right of an individual to specify while competent a proxy who could fulfil a similar role if the individual in turn became incompetent?

[Earl Howe]

Unfortunately, my Lords, we do not hold information about how many advance decisions have been made out or pursued; those statistics are not collected centrally. However, I am aware that lasting powers of attorney, which the noble Lord will know came in under the Mental Capacity Act, are growing in popularity and number. The numbers are rising, although I do not have those statistics in my brief. We are encouraged by the fact that people are now aware that they can delegate to a loved one—a family friend or whoever—to take decisions in their best interests should they lose capacity later on.

[Baroness Bakewell]

Given that people on the whole now know that they have a right to decide when treatment can be withdrawn, and to ask for that to happen, what advice is in place for medical staff who, faced with such a decision, still hesitate to carry out the wishes for fear of prosecution?

[Earl Howe]

My Lords, the end-of-life care strategy that we are pursuing, published by the previous Government, highlighted the need for a cultural shift in attitude and behaviour related to end-of-life care within the health and social care workforce. The noble Baroness is quite right that this is an issue. In partnership with the national end-of-life care programme, we have taken forward a number of initiatives to develop the workforce’s understanding. We have commissioned the development of an e-learning package, which is turning out to be popular, that includes advance care planning and communication skills. Core competences and principles for end-of-life care have been developed, and a number of pilots have been taken forward in that area. A document called Talking About End of Life Care: Right Conversations, Right People, Right Time has been published and was completed early last year. There are a number of initiatives in this area.

[Lord Carlile of Berriew]

Does my noble friend agree that the new NHS commissioning arrangements are such that they give an opportunity for advance directives to be collected and collated in a coherent way by general practitioners? Will he also confirm that, whatever advance directives are given, the need to provide comfort to patients remains a duty on clinicians?

[Earl Howe]

I agree with my noble friend on both counts.

[Lord Singh of Wimbledon]

My Lords, in considering better enhanced provision for end-of-life care for those who have lost capacity, will the Minister note that our opinions and attitudes change with the perspective of time? A young boy may consider that upon reaching the age of 60 or 70, life would not be worth living. I think that a 60 year-old—and most of us here—would differ from that opinion. It is very important that advance directives—living wills—should be considered and should be important. However, they should be tempered with proper questioning and proper care.

[Earl Howe]

I agree fully with the noble Lord. Advance care planning is not a one-time issue, it is an ongoing process. It requires regular reviews of a patient’s wishes and assessments of their needs. Support, training and education for staff in understanding that, and taking forward care planning, are being made available through the end-of-life care strategy. People’s wishes and needs change throughout life, and that is to be expected.

Health: Pathfinders

Earl Howe Excerpts

Thursday 12th January 2012 Lords Chamber

[Baroness Jolly]

To ask Her Majesty’s Government what support and guidance is being offered to pathfinder clinical commissioning groups in commissioning integrated health and social care services.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, pathfinders are receiving national and local development support. With their SHA and PCT cluster, pathfinders are exploring approaches to clinical commissioning, including integration of health and social care. Key to this will be engagement with local authorities and secondary care. Our national learning network allows pathfinders to share learning and best practice. Pathfinders will be authorised to take on their full commissioning functions only when the NHS Commissioning Board is certain that they are ready.

[Baroness Jolly]

I thank the Minister for his reply. He outlined the fact that local authorities will play a key role in this new world. We hope that they will commission for patients and not for the condition. For the health and well-being boards to operate effectively, they, too, need support. What support are the Government able to offer, and what support are they offering pathfinder health and well-being boards within local government at present?

[Earl Howe]

My noble friend is right. We were very pleased to see the NHS Future Forum says that running right through the Health and Social Care Bill is the desire and aim to integrate services. That is certainly right. We recognise that there is a balance to be struck between allowing local ideas to spring up and people to progress their own ideas and having the necessary support from the centre to do that. We have established a national learning network for pathfinders to complement the support given to them by strategic health authorities and PCTs. Those learning networks will ensure that best practice is spread and, specifically, that pathfinders support other local groups which are less developed.

[Baroness Thornton]

My Lords, perhaps I may ask a question concerning clinical commissioning groups and the legal advice and support they might be receiving. Has the Minister taken advice on the impact of EU procurement law as regards the tension in commissioning and delivering integrated services and the legal requirements concerning procurement of services which are integral to the Health and Social Care Bill that is before the House? Will the Minister make any such advice available to us?

[Earl Howe]

My Lords, my understanding is that procurement law, which already applies in the NHS, is certainly part of the learning sets that clinical commissioning groups have been provided with. I would be delighted to supply the noble Baroness with further information but I do not have it in front of me.

[Lord Carlile of Berriew]

Can my noble friend confirm that the NHS will take fully into account the success of pilot pathfinder projects in places as diverse as Newcastle, Swindon and Bedfordshire so that the NHS itself encourages the development of pathfinder projects? Will he also take into account the fact that GP co-operatives were very successful as long as they lasted, but the discouragement they were given by the previous Government brought a disastrous end to some very good schemes?

[Earl Howe]

I am grateful to my noble friend. I think everybody agrees that integrating services, however one defines that—although the common denominator is surely from the point of view of the patient—is a good thing. We do not wish to lose sight of the lessons that have been learnt so effectively in the places mentioned by my noble friend. It is true that other areas have yet to catch up. We recognise that, and the focus over the next 12 months will be very much on sharing the lessons that have been learnt by the pathfinders that we know are working well.

[Lord Laming]

Does the Minister agree that the success of this scheme depends a great deal on the facilities within the health service becoming much more community orientated and much more available to people in the community? It is not either social services or the health service. Both have to play their part. What are the Government doing to achieve that?

[Earl Howe]

I do recognise that. It gave rise to the fairly famous quote by Sir David Nicholson, the chief executive of the NHS, who went down to Torbay to see the work being done there. He came away saying:

“I have seen the future and the future is Torbay”.

There was good reason for him to say that because Torbay has established close relationships between social workers, district nurses, therapists and allied health professionals through a single point of contact so that intermediate care services are delivered effectively, thus avoiding the need for patients to be admitted to hospital.

[The Lord Bishop of Bath and Wells]

My Lords—

[Baroness Gardner of Parkes]

Can the Minister tell me—sorry, I would have given way to the right reverend Prelate. I had better press on. Does the Minister believe that the new legislation will change the problem that has always existed—that social care always felt that health should pay and health always felt that social care should pay? There may be good will and a wish to integrate, but can he assure me that the new financial systems in the health service will cover this point and prevent that problem continuing?

[Earl Howe]

My noble friend is right. This has been a perennial problem. We are addressing it in a number of ways. There are measures in the Bill which lay out duties on bodies. We are constructing the outcomes framework in a way that encourages integration of services with the right metrics. We are trying to align the outcomes framework in the NHS with that for social care and public health as well so that everybody is working to the same agenda.