Health and Social Care Bill
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Wheeler
My Lords, I would have liked to debate this amendment in the light of next week’s debate on the status, powers and functions of HealthWatch England under Clause 180, when we will fully air once again the serious and continuing concerns across the House about the proposed relationship between HealthWatch England and the CQC, and hear from the Minister how the Government intend to address these concerns as they flesh out their proposals for healthwatch, and as the CQC comes under closer scrutiny. However, we support this amendment requiring the Secretary of State to include HealthWatch England in the organisations specified in the Bill that he or she must keep under review. Obviously we do this in the context of the separate independence of HealthWatch and not as a committee of the CQC.
However, it is also important to make it clear that we do not think that the measure in itself, or combined with other government proposals, for example, on the HealthWatch board membership, will be anywhere near enough to provide the independence that HealthWatch England needs if it is to be the robust and trusted patients’ watchdog that is needed—and I emphasise trusted by the public.
The Minister must appreciate that the concerns across the House over the CQC’s relationship are not addressed by referring to the close synergies between the two organisations or to the powers and influence of the CQC rubbing off on HealthWatch. In this context it is difficult not to dwell on the recent developments in the commission and the Department of Health performance and capability review of the commission. I say this as a genuine supporter of the CQC and its work—for example, last year’s excellent special review of stroke services, and the one of residential care—but the department’s major findings that the CQC needs to be more strategic, that accountabilities within the CQC are unclear, as well as the strong concern over the blurring of boundaries between the CQC board and executive team, do not augur well for the future relationship between the CQC and HealthWatch.
Of course, we will come to these matters in detail when we have the full debate on HealthWatch and local healthwatch organisations. I hope that at that stage the Minister will address these ongoing concerns, particularly about the clash of cultures between HealthWatch and the CQC, about public faith and trust in HealthWatch if it is to be formally linked to the CQC, and the lack of confidence in the new arrangements on the part of the overwhelming number of LINks organisations and NALM. As the letter from NALM in the Guardian earlier this week underlined:
“Healthwatch will only be considered the true voice of the public, if it is seen to be independent of those it monitors”.
I look forward to next week’s debate.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Secretary of State has a duty to keep under review the effectiveness of the exercise of health service functions by certain national bodies. These bodies are listed at new Clause 247C, inserted by Clause 51 of the Bill.
As it is currently drafted, the Bill requires the Secretary of State to keep the effectiveness of the Care Quality Commission under review in so far as it is exercising functions in relation to the health service. However, it does not make explicit reference to the HealthWatch England committee. Yet, while HealthWatch England will be established as a committee of the Care Quality Commission, it will have its own statutory functions that it must exercise outside of the CQC’s other functions.
This is, therefore, a helpful and welcome amendment from my noble friends Lady Cumberlege and Lady Jolly. It helpfully clarifies the distinction, in terms of the Secretary of State’s accountability, between the exercise of functions by HealthWatch England and that of the CQC.
The amendment would add HealthWatch England to the list of bodies the Secretary of State must keep under review in respect of how effectively it exercises its functions in relation to the health service in England. Importantly, it would emphasise that HealthWatch England itself is responsible for exercising the statutory functions of HealthWatch England.
I have reflected on this and I will be supporting this amendment. I hope that other noble Lords will join me in doing so.
Baroness Cumberlege
My Lords, I think we are on a roll. I am very excited that we have had another amendment accepted. I very much thank my noble friend.
I appreciate some of the other points that have been made in this debate, but I think we will be debating them next week and perhaps we could hold our fire until then. Indeed, we have debated them previously and noble Lords will know that I am in favour of the present proposal in the Bill that HealthWatch England should be a committee of the CQC, and that is why I have chosen those particular words.
I am very grateful to my noble friend. I think this is the first time ever this has happened to me and I feel very pleased about it. Thank you.
“( ) The report must include the Secretary of State’s assessment of the effectiveness of the discharge of the duties under sections 1A and 1B.”
“( ) after paragraph (e) insert—“(ea) paragraph 11 of Schedule A1,(eb) paragraph 14 of Schedule 1A,”.”
Earl Howe
My Lords, in moving Amendment 145, I shall speak also to the other amendments in this group: Amendments 146, 147, 148, 148A, 151, 153, 154, 155, 156, 159, 160, 222 and 223.
The amendments in this group make a number of changes to some of the Bill’s schedules of consequential amendments. These include, for example, consequential amendments to the Charities Act 2011 and the Health and Safety at Work etc. Act 1974, as well as a number of amendments consequential to the abolition of PCTs, SHAs and NHS trusts.
I am happy to explain any of these amendments, if noble Lords wish, but I hope that noble Lords will take it from me that these are minor, technical or consequential amendments. I beg to move.
Earl Howe
My Lords, with the changes to the Secretary of State’s powers under the Bill, it has recently become clear that it would be better to make express provision for the Secretary of State’s powers to provide the support functions referred to in the amendment rather than rely on Section 2 of the NHS Act 2006 and risk any legal doubt. The amendment would maintain the current position under the Act and enable the Secretary of State to continue to carry out the activities concerned. The context of this is that Section 2 of the Act gives the Secretary of State a general power to,
“do anything else which is calculated to facilitate, or is conducive or incidental to, the discharge of”,
his duties in the Act.
The kinds of thing that come under that heading are support facilities and other assistance to the NHS—for example, the department purchases some medicines centrally for the NHS or provides advice to NHS bodies in carrying out procurement activity. It is also involved in arrangements known as NHS shared business services. It provides accounting, payroll and e-procurement services for all types of NHS organisation. There are benefits to the health service in ensuring that the Secretary of State remains able to co-ordinate activity centrally—for example, in certain cases it is likely to be financially beneficial to purchase services centrally.
Perhaps I may make it clear that Amendment 148A does not allow the Secretary of State to commission or provide health services. As noble Lords will be aware, the Bill requires the Secretary of State to exercise his functions to ensure that services are provided but removes the Secretary of State’s specific powers to provide or commission NHS services directly. This amendment does not change that.
“( ) In subsection (9), for “section 224 or 226” substitute “section 225”.”
(b) before paragraph (a) insert—“(za) section 14A(1),”.”
“Health and Safety at Work etc. Act 1974 (c. 37)(1) Section 60 of the Health and Safety at Work etc. Act 1974 (supplementary provision about the Employment Medical Advisory Service) is amended as follows.
(2) In subsection (1) for “each Primary Care Trust and Local Health Board” substitute “the National Health Service Commissioning Board or each clinical commissioning group (in relation to England) and each Local Health Board (in relation to Wales)”.
(3) In subsection (2)—
(a) omit “for one of their”, and(b) for ““each” to “its”” substitute ““the National” to “arranges””.”
“( ) The amendment made by section 20(6) does not affect—
(a) the validity of any direction made by an instrument in writing which continues to have effect by virtue of sub-paragraph (2),(b) any power to vary such a direction otherwise than for the purpose of directing the Special Health Authority concerned to exercise an additional function, or(c) any power to revoke such a direction.”
Health and Social Care Bill
Earl Howe Excerpts(13 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall now repeat as a Statement the Answer given by my right honourable friend the Secretary of State for Health to an Urgent Question tabled in another place earlier today about the Health and Social Care Bill. The Statement is as follows:
“Mr Speaker, I am glad to have this opportunity again to set out the purposes of the Health and Social Care Bill. It is to give patients more information and choice, so that they share in decision-making about their care. It empowers front-line doctors and nurses to lead the delivery of care for their patients. It cuts out two tiers of bureaucracy, and strengthens the voice of patients and the role of local government in integrating services and strengthening public health.
The values of the Bill are simple: putting patients first, trusting doctors and nurses, focusing on results for patients, and maintaining the founding values of the NHS. We are constantly looking to reinforce those values, strengthening the NHS to meet the challenges it faces. We know change is essential: we will not let the NHS down by blocking change.
Throughout the development and progress of this Bill, we have engaged extensively with NHS staff, the public and parliamentarians. The Health and Social Care Bill is the most scrutinised public Bill in living memory. With over 200 hours of debate between the two Chambers and 35 days in Committee, we have ensured that Members and Peers have had every opportunity to examine, understand and amend the Bill to ensure it does the best possible job for patients.
We have made this legislation better and stronger. We have made significant changes to the Bill, including in response to the NHS Future Forum’s work, and we will be open to any further changes that will improve or clarify the Bill. For example, so far in the Lords, the Government have accepted amendments tabled by a number of Cross-Bench, Liberal Democrat and Labour Peers.
Yesterday, my right honourable friend the Deputy Prime Minister and the noble Baroness, Lady Williams, wrote to their Liberal Democrat colleagues explaining their support for the Bill with those changes and some further amendments they wish to see. They said, for example, how we must,
‘rule out beyond doubt any threat of a US-style market in the NHS’.
I wholeheartedly agree.
The Bill is about quality, not competition on price. It will not permit any NHS organisation to be taken over by the private sector. It will put patients’ interests first. We will not permit any extension of charging. Care will be free and based on need. Where the doctors and nurses on the ground know that competition is in the best interests of their patients and where it is based entirely on the quality of the care and treatment provided and not in any way on the price of that care and treatment, then competition can play an important role in driving up standards throughout the NHS.
We will not see a market free-for-all or a US-style insurance system in this country. I believe in the NHS. I am a passionate supporter of our NHS. That is why I understand the passionate debate it arouses. But it is also why I resent those on the Benches opposite who seek to misrepresent the NHS, its current achievements and future needs.
We are using the debates in the Lords further to reassure all those who care about the NHS. I am grateful for the chance to reassure all my honourable friends in the House of the positive and beneficial effects of debate in the House of Lords, and of the work we are doing to secure a positive future for the NHS”.
My Lords, that concludes the Statement.
Baroness Thornton
My Lords, I thank the Minister for that Statement. We are in a slightly odd situation here. We have a letter from the Deputy Prime Minister and a distinguished Member of your Lordships’ House to MPs and Peers in their party concerning a matter of public policy involving a major piece of legislation currently before this House. I thought that we could not be further surprised by the parliamentary twists and turns of this Bill, but it is really a case of “Whatever next?”. Is it the first time that a serving Deputy Prime Minister has decided to send a letter suggesting amendments to his own Government’s legislation? This letter seems largely to concern Mr Clegg saying that he wants more amendments to the Bill and expects this House to deliver them so that Liberal Democrat MPs can support the said amendments in the Commons. It is not clear to me whether the Minister in the Commons, or even Conservative MPs, will do so as well. Remarkable!
I appreciate that it may be difficult for the Minister to answer this question, but I am going to ask it anyway. How exactly does he think that the Liberal Democrats propose to achieve this target set by Mr Clegg in this House when they are part of a coalition wedded to this Bill in all its glory—and Part 3, too—and the Lib Dems command 70 to 80 votes in the House on a good day? Who will deliver Mr Clegg’s amendments to Part 3 of the Bill, I wonder? Will it be done by consent with the Government or will it be by Division?
I would like to ease Mr Clegg’s dilemma in this matter and make a very generous offer. The Liberal Democrats can have our amendments to Part 3 of this Bill. We have a great set of amendments to Part 3 which would serve to deliver what Mr Clegg and the noble Baroness, Lady Williams, say that they seek on competition and, indeed, more. So I look forward to the Minister’s response to my offer.
However odd the mode of delivery, it is important to ask whether this is a major announcement of a change in government policy and, indeed, was the text of the letter discussed with and agreed by No. 10 and Mr Andrew Lansley. This development has added to the considerable confusion about what government policy around the Bill is exactly, and I think that Ministers need urgently to clarify what precise changes are being proposed, what discussions have been held with the Deputy Prime Minister and whether these policy changes now represent government policy. I ask this because we know that Mr Clegg has to manage the challenge of the Lib Dem spring conference—and a challenge it is certainly shaping up to be. According to today’s media, the Liberal Democrat health activists are planning to put an emergency motion to the party’s spring conference urging their leadership to reject the provisions of the NHS reform Bill despite, presumably, the final changes advanced by Mr Clegg and the noble Baroness, Lady Williams, in this joint letter. Certainly this letter and that conference, combined with the growing tumult against the Bill—another royal college might bite the bullet and say that it wants the Bill to be withdrawn again; I think that there are only about two more to go—put the discussions that we will have on Part 3 in your Lordships' House next week in an interesting light.
This is an odd way to develop and announce policy—or is it shift in policy? Yesterday morning, the Minister, Simon Burns, was insisting the whole Government backed the Bill “as amended now”. At the same time sources close to Mr Clegg, whoever they may be, were insisting the changes that he is demanding are,
“significant and not simply reassurances”.
However, at the same time the PM’s spokesperson said,
“we do not see any need for further significant changes to the Bill”.
We need to know which of these is correct. I hope that the noble Earl will be able to enlighten the House.
This letter states that,
“we want to rule out beyond doubt any threat of a US-style market in the NHS. That is why we want to see changes made to this bill that have been put forward by our Liberal Democrat team in the House of Lords to make sure that the NHS can never be treated like the gas, electricity, or water industry”.
That is exactly what I have been saying all the way through this Bill. The letter proposes four broad changes. The first is that we should remove the reviews by the Competition Commission from the Bill. In fact, amendments to that effect where tabled by the Labour Party. Imitation being the greatest form of flattery, I am very happy that the Liberal Democrats are tabling them again. Secondly, the letter suggests that we keep the independent regulator for foundation trusts, Monitor,
“to make sure hospitals always serve NHS patients first and foremost.”.
Well, hurrah! We have an amendment down that does exactly that. Thirdly, the letter proposes to,
“introduce measures to protect the NHS from … threat of takeover from US-style healthcare providers by insulating the NHS from the full force of competition”.
Mr Clegg might just have noticed the threat that competition posed when he signed this Bill a year ago. Finally, it proposes,
“additional safeguards to the private income cap to make sure that foundation trusts cannot focus on private profits before patients”.
Well, the amendments that the Liberal Democrats have promoted so far on this certainly need some thought and some change. We would agree with them and we shall see. This is all familiar to us on the Labour side, because those proposals were part of the substance of our amendments in Committee which were so soundly and roundly rejected by the Minister. Is he about to resile from his earlier position and embrace the Labour amendments? I would appreciate some notice if that is what he intends to do.
I have a few questions. The document issued at the Conservative away day last Friday said:
“If we changed or altered the bill now, we would end up in a no man's land, and chaos”.
Can the Minister confirm that this is still the Government's position? Can he clarify whether the changes outlined in the Deputy Prime Minister's letter now represent government policy? His letter promises,
“additional safeguards to the private income cap”.
Can the Minister explain what these additional safeguards are, and why the Deputy Prime Minister feels that they are necessary? Why does the Secretary of State seem to have no regard for the views of health professionals and the public when it comes to making changes to this health Bill but is quite happy to make concessions to accommodate the Liberal Democrats before their spring conference? Will the Minister clarify whether these amendments to the Health and Social Care Bill are “significant”, as stated by the Deputy Prime Minister, or a “reassurance”, as stated by the Prime Minister's official spokesperson?
In 2009, the Prime Minister said:
“There will be no more of those pointless re-organisations that aim for change but instead bring chaos”.
It seems to me that the Secretary of State has seen a clear example of unmitigated chaos in the latest incarnation of his Health and Social Care Bill. Really, this is a most unloved and unwanted piece of legislation and the Bill should be dropped. In conclusion, the Minister has my deepest sympathy in dealing with this Statement, because it seems that it puts him between the rock of Andrew Lansley and the hard place of the noble Baronesses, Lady Jolly and Lady Williams, and their colleagues—probably not a comfortable place to be. Actually, this is not the way to treat Parliament and its consideration of this Bill. It is not the way to treat the people who work so hard for the NHS and, indeed, it is not the way to treat our NHS.
Earl Howe
My Lords, the noble Baroness said that she was surprised by the letter in question. I can tell her that nothing in the letter was in any way a surprise to me, for the simple reason that it reflects the very constructive discussions that I have had with my Liberal Democrat colleagues, which are a natural part of good government. I can only conclude that she does not recognise that such discussions are a part of good government, but it certainly is the case with the coalition. As far as I am concerned, Mr Clegg needs no permission to bring members of his party up to date with progress on the Bill or to make it clear, as he does, that he is fully behind it.
The noble Baroness asked about the changes that Mr Clegg and my noble friend Lady Williams have outlined in the letter that they would like to see. I simply direct the noble Baroness’s attention to the Marshalled List for the Bill; there are a number of amendments already tabled and discussions continue on a number of other issues. Are the changes that have been made significant? I say to her that any amendments we accept are significant, and the amendments made to the Bill are largely about reassurance to those noble Lords who are unclear, uncertain or worried about the Bill and what it says. They are about delivering greater clarity and making sure that the Bill delivers on its intentions. I have been very happy to accommodate the concerns of Peers of all parties who have come to speak to me—not simply my Liberal Democrat colleagues—because the function of this House is to make Bills better, and we are certainly doing that with the Health and Social Care Bill. A prime example of that, surely, was the fruitful discussion that we had across the party divide on the Secretary of State’s powers and duties, and I believe that the resolution of that matter was very satisfactory.
With regard to the issues themselves, it would not be appropriate for me to give a running commentary. The place for debate on each issue is surely our debates on Report. We are in the middle of the Bill; we should not attempt to engage in substantive discussion on matters of policy now when we still have four more days of Report ahead of us. We are open to constructive discussions with Peers of any party to make the Bill better, just as we listened, contrary to the assertion of the noble Baroness, to members of the public and members of the medical profession in their thousands during the listening exercise last year. We listened, paused, reflected and amended the Bill extensively. I am sure that the noble Baroness knows that nothing has changed in that respect, and my door is open to her as it is to anyone else.
Baroness Jolly
My Lords, I thank the Minister for his ever-open door and his willingness to listen. Will he further explain to the House how he believes that the NHS will be stronger for the scrutiny from all sides of the House? How does he believe that the objections of the Royal Colleges, such as the Royal College of Nursing, the BMA and other professional bodies have been met as a result of this cross-party scrutiny?
Earl Howe
My Lords, I completely agree with my noble friend. I feel that the debate and discussions that we have had in your Lordships’ House have made this a better Bill, as I said a moment ago. Again, a prime example of that is the clauses relating to ministerial accountability. With regard to the Royal Colleges, we have made all sorts of improvements, such as those in response to concerns about the integration of services, education and training, research, health inequalities, ensuring that competition is never an end in itself and a number of other important issues. I am glad that these changes were all welcomed by a wide range of Royal Colleges.
Lord Campbell-Savours
My Lords, in the light of what the Minister has just said, if I came to him over the next couple of days and handed him a document about the problems that it is felt will be experienced in specialist services, would he then deal with it before the completion of Report and let me have an answer?
Lord Crisp
My Lords, like, I suspect, every other Member of your Lordships’ House, I very much respect the way in which the Minister has handled the Bill and his willingness to engage in debate. I sit here as a Cross-Bencher listening to what seems to be the healing of a rift between the coalition parties, if I may put it like that, but I also see—my postbag is full of this, as I am sure everyone else’s is—a rift with the medical profession, the nursing profession, midwives and others. Even though this approach may deal with some of the issues that they have wished to raise, I do not see that it will deal with the much more fundamental issue of the loss of trust and unity that seems to have been created as part of the passage of the Bill. Can the Minister say something about how he believes that that will be handled? These issues go far beyond your Lordships’ House, as we all understand.
Earl Howe
The noble Lord is right. The stance taken by a number of medical bodies and members of the medical profession is of course a matter of great regret to me and my ministerial colleagues. I say to them and to the noble Lord that once the Bill has been approved by Parliament, as I sincerely hope it will be, that will be the time to re-engage with the medial profession and work with it to ensure that the Bill delivers on the promise that we have held out for it and that we still believe in. The principles that the Bill embodies, which the medical profession has always said that it supports, can then be given substance in the form of the improvements that we would like to see delivered to patients. From all the comments that I have heard from doctors and others who are in doubt about the Bill, most of their concerns revolve around its implementation and what it will mean in practice, rather than the principles that it enshrines. We need to look forward collectively and work together to make the NHS work better.
Baroness Meacher
My Lords, I, too, applaud the noble Earl for the way that he handles this very difficult Bill in very difficult circumstances. I am sure he is aware that there is a lot of concern about the Bill in the field of mental health, particularly as private provision gathers pace. Can he give any assurance to mental health professionals and services up and down the country about what in the Bill might protect mental health services in the future?
Earl Howe
Several things in the Bill are new. One is the duty to reduce health inequalities, which is very important in mental health. Another is the duty to promote integration of services. Again, we have had many debates on that and there are mechanisms that we propose to use to support greater integration of services.
I also believe that the worries about competition are misplaced. Competition is a tool that commissioners can use, or decide not to use, in the interests of patients. It is no more than that. The Bill does not change competition law or increase the scope for competition to be used in the NHS. It leaves the decision-making to commissioners on whether competition does or does not serve the interests of patients. There is a lot of misapprehension about what the Bill does, not just among those in the mental health world but more widely. I hope that that reassurance is helpful.
Baroness Williams of Crosby
I apologise to the Minister for being the cause of another late night for him. I apologise because, obviously, the Statement relates to some extent to the letter that I co-signed with the Deputy Prime Minister. I simply say, as have many in the House, that the Minister has shown amazing patience. Indeed, his door is always open; a number of us stumble our way through it and we are extremely grateful.
I shall say just two more things about the point raised by the noble Lord, Lord Crisp. First, a great deal of the concern that has been expressed in public was expressed before some of the very recent changes, which are not widely realised or well understood among the public or the media.
Secondly, it is probably fair to say that Chapter 3 has been the centre of much of the concern about the Bill. There are other things in it that many people will widely recognise and accept, not least the work on education, training and research. This is not yet widely known, even within the medical profession. It may be that there is a great deal to be said for making a further attempt to get across exactly what changes have been made to the Bill. I think that would carry with it a rather different attitude among the public and the media from what has existed in the past few weeks.
Earl Howe
I am very grateful to my noble friend and agree with everything that she said. Many of the changes that the Government have made to the Bill—not just those made in your Lordships’ House but those that were made last year—have not been fully appreciated, or appreciated at all in some quarters. The changes that we have made are not sufficiently understood even by those who recognise that amendments have been made to the Bill. Without naming names, I have spoken to very senior members of the medical profession who have had no idea at all about some of the amendments that we have made to bring greater clarity to the Bill and change it substantively. As my noble friend knows, we did that in particular with Part 3 of the Bill. There is no doubt that there is a job of work to do to put over the correct messages to the medical profession and to reassure its members that this Bill does not represent a threat to them or to the NHS—quite the reverse.
Lord Patel
My Lords, although many of the comments that have been made relate to amendments that have yet to be presented to the House, particularly to Part 3 of the Bill relating to competition, does the Minister agree that there are other amendments relating to other parts of the Bill that are of broad concern to people outside the House: namely, those relating to public health issues and how public health will be delivered, and that we also need to address those amendments?
Earl Howe
Of course, I acknowledge the point made by the noble Lord. It is a matter of regret to me that the commentary on the Bill hardly ever focuses on the proposals it makes for public health, which have generally commanded widespread approval. However, I recognise that there are concerns around the detail of those proposals. That is why we are here as a Chamber to address those concerns. I am sure that when we come to the amendments referred to by the noble Lord, this House will not be found wanting in the way that it explores those issues and resolves them.
Lord Martin of Springburn
The noble Earl has repeated a Statement made in the other House by a Cabinet Minister responsible for health. We have also heard mention of the Deputy Prime Minister supporting the noble Baroness’s amendments. The Deputy Prime Minister is clearly a Cabinet Minister. Therefore, we have two Cabinet Ministers in the picture. If everyone is so enthusiastic about the Liberal Democrat amendments —the noble Baroness, Lady Thornton, was kind enough to tell us that those follow her proposals, and imitation is the best form of flattery—does it mean that everybody is happy? However, the only piece of the jigsaw that I am concerned about is whether that means that the Conservative Party will support the relevant amendments. If that is the case, they will all go through on the nod and everybody will be happy. Perhaps the noble Earl can tell me whether I am wrong and I have missed something.
Earl Howe
Far be it from me to say that the noble Lord, Lord Martin, would ever miss anything; he is too wise a head for that. I see nothing strange or amiss in a party leader wishing to address his parliamentary colleagues on the eve of a party conference to bring them up to date on a major Bill and its progress in the House and to set out some of the remaining concerns that he has that we need to settle. These concerns came as no news to me as I have been talking about them regularly not only with Liberal Democrat colleagues but with other Members of your Lordships' House and members of the medical profession. I see nothing amiss in the letter spelling out those concerns. How we arrive at a resolution of those issues is yet to be seen. As I have said, amendments have already been tabled which we shall debate. It is possible that more will be tabled over the days ahead—I do not rule that out at all. However, the noble Lord should not forget that there are non-legislative ways of reaching the destination that some of my noble friends would like to get to. There are many ways of achieving some of these objectives. It is entirely possible that we shall agree amendments to do that but that is not by any means the only course open to us.
Lord Greaves
My Lords, I am a little confused about all this, and I wonder if my noble friend the Minister can help me. I received the letter yesterday. At the top it stated, “Keep this completely secret and do not tell anybody”. I switched on the television and there it was. I am confused because I watched and listened to the exchanges in the House of Commons this afternoon, which, I have to say, were a great deal more vigorous and bad-tempered in many ways than the exchanges here; and I congratulate the noble Baroness on the Labour Front Bench who did a much better job of responding on this matter than her colleagues in the House of Commons.
However, here we have the Labour Party, which in government made major strides towards introducing competition, privatisation and commercialisation of the health service, and now has been very strong indeed in opposing those matters when it comes to the Bill. I do not understand that. The other thing that I do not understand is that if what the noble Baroness says is correct—that many of the things she and her colleagues have been putting forward at Committee stage and have been saying outside this House are now being put forward by Liberal Democrats in the amendments that we were told about in the letter from my noble friend and my party leader—why is she not standing up and offering her help, with some enthusiasm, instead of being so grumpy about it all and the way in which this has been done? There seems to be huge confusion on the Opposition Front Bench and in the opposition party, and I wonder if my noble friend can suggest any gentle therapy that it might take up to help it with this problem.
Earl Howe
I am very happy to pick up that challenge from my noble friend; in fact, I have been using all my charms and skills on the Benches opposite without any effect at all. I feel that I may have arrived at an impasse. My noble friend is absolutely right because the situation that we inherited from the previous Government was in many ways one that we embraced—it was they who opened up choice in the NHS and indeed put a right of choice into the NHS constitution. However, they did not roll out competition and choice in the way that was appropriate and right, because it cannot be right to impose competition on the NHS whether it wants it or not. It cannot be right for there to be preferential prices for the private sector, with the NHS being disadvantaged. It cannot be right to have an explicit target of increasing private sector provision in the NHS, which is what the previous Government had. It cannot be right for private providers to cherry-pick the easy cases and leave the NHS with the hard cases. We do not approve of fragmenting care pathways.
We do not think that the previous Government thought nearly hard enough about how this was all to be regulated, which is why we want a sector-specific health regulator. That is the reason for having Monitor and is why we think the provisions of Part 3 make sense because they are in the interests of patients and the NHS. I still hope that in our debates I can engender some movement on the Benches opposite to recognise that we are actually trying to improve the situation that we inherited for the benefit of everyone.
Organ Transplantation
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Gardner of Parkes
To ask Her Majesty’s Government how they intend to reduce any waste of organs for transplantation arising from inadequate co-ordination of the process and the extent of out-of-hours and weekend services.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the National Organ Retrieval Service—NORS—provides continuous 24/7 cover. I understand there have been two exceptional occasions when a NORS team could not be provided. Contingency arrangements enable other teams to stand in when needed or for local kidney transplant centres to be reimbursed for retrieving from kidney-only donors. NHS Blood and Transplant is also considering a tariff to fund National Organ Retrieval Service teams willing to provide additional cover.
Baroness Gardner of Parkes
Can the Minister confirm for me a statement that was made when I was chairman of one of the London teaching hospitals—that when you die your body is no longer your own? That is a highly significant point in the case of people who carry donor cards but whose relatives reject them. Can he also assure me that they will do something to ensure that when potential donors come to accident and emergency at weekends due to accidents, the retrieval team is alerted to the possibility that such organs—each of which is very precious to the recipient—may be available?
Earl Howe
My Lords, it is a well established principle of law that there is no property in a corpse. This means that, as a general rule, the law does not regard a corpse as property protected by rights. In other words, there can be no ownership of a dead body. However, the law does prescribe what may lawfully be done with the body of a deceased person. For example, a person can say while they are alive what they would like to happen to their body after death, such as donation of organs. My noble friend raises an extremely important point about A&E. The number of donors from A&E units is improving but it is generally recognised that it had to because performance was not good. Since 2007-08 there has been a 388 per cent increase in donations from emergency medicine, which is good news, but there is much more that could be done. The transitional steering group that we have set up under the chairmanship of Chris Rudge is looking at that area as a priority.
Baroness Howarth of Breckland
My Lords, it is widely recognised that the Government and the previous Government have made huge strides in this area but from a fairly low position. Many countries in Europe—particularly Spain—do much better than we do. What are we doing to ensure that we are learning from others and making the improvement even faster? Every day is someone else’s life.
Earl Howe
The noble Baroness is absolutely right. The record in Spain is particularly interesting because the rate of donation is about twice what it is in this country. It is interesting to observe that Dr Matesanz, who is head of the transplantation effort in Spain, observed that this was not, in his opinion, due to the opt-out system which Spain employed in 1979. It is much more to do with the organisation of the service which came in about 10 years later. That is what we are trying to replicate in this country.
Lord Hughes of Woodside
My Lords, is it not the case that despite the great advances that have been made there is still a problem, whereby if someone carries a donor card the relatives still have to be consulted, and very often they say no? Can we do something to speed that up, if we cannot go for the proper opt-out system?
Earl Howe
The noble Lord makes a good point. It is generally the practice that the relatives are consulted even where someone has expressed a wish to donate an organ after death. Doctors will normally respect the wishes of the relatives; however, it is equally true that that person’s wishes will be emphasised to the relatives. There is a delicate balance to be struck here. The moment that action by medical teams is seen to be high-handed, it risks damaging the credibility of the transplant service.
Baroness Barker
My Lords, what is the Government’s response to the recent BMA report on increasing donation, particularly regarding the obligation introduced last year on individuals who apply or reapply for documents such as driving licences and passports to answer a question about donation of organs?
Earl Howe
My Lords, the report from the BMA was very useful and we are looking at it extremely carefully. It made some useful suggestions about how we might expand the number of donor organs. A number of initiatives have already been taken: for example, there is a prompt when you apply for a driving licence online as to whether you wish to donate an organ. In general, public awareness is being raised in a number of useful ways, which has led to the increase in the number of people donating organs.
The Lord Bishop of Liverpool
My Lords, I very much welcome the increase in the number of donors. I have been pastorally involved with the Alder Hey families and seen the devastating effect of the taking of organs without consent, and I have been involved in the burial of 10,000 bodies and body parts. Can the Minister assure the House that in the work towards a more efficient and effective system of harvesting organs, the principle of requiring the consent of next of kin will not be compromised?
Earl Howe
The right reverend Prelate is absolutely correct. In England, Wales and Northern Ireland, the Human Tissue Act 2004 requires that appropriate consent be given for the removal, storage and use of material from a deceased person for a range of purposes, including transplantation. Appropriate consent means the deceased person’s consent or that of his or her nominated representative, or of a person who stands in a qualifying relationship to the dead person. There are no plans to change that principle.
Lord Patel of Bradford
My Lords, while we have seen an improvement over the years in the number of donors from minority and ethnic groups, particularly the south Asian community, for a whole host of reasons, including religious and cultural matters, the number of donors needed to come through the system remains very short of what is required. What are the Government doing to improve the situation?
Earl Howe
The noble Lord is quite right: 75 per cent of people from a BME background refuse to donate organs when asked to, compared with an average figure of 40 per cent across the population. We are completely committed to increasing organ donor rates among the BME population, and there has been funding to support specific projects to work with local faith leaders and explore issues around organ donation. We held a workshop on 7 February with national and local groups to identify the barriers that exist in the BME and mixed-race communities, and plans are being developed to take forward that work. We have public awareness campaigns on local radio stations and through organisations such as the African-Caribbean Leukaemia Trust.
Lord Cormack
My Lords, if a donor expressed his or her wish in a will, would that not be legally binding?
Lord Davies of Coity
My Lords, the question that I was going to ask earlier has been answered. However, the question I am going to put now is this: are the same people who will not participate in the donation of organs also reluctant to receive organs from donors?
Baroness Walmsley
Will the Minister accept that it can be very difficult for doctors to approach a bereaved family to ask about organ donation? I know this from personal experience, because doctors did not approach me when I lost my late husband; I had to raise the matter myself. It is understandable that they do not want to upset the family. However, can it not be even more upsetting for a bereaved family who have not been asked about donation to realise some time later that they have missed the opportunity for their loved one to give life to other people?
Earl Howe
My noble friend raises an extremely important set of issues. This was one issue identified by Chris Rudge when he took up the post as National Clinical Director. A great deal of work has been done in the NHS to increase the number of organs available to patients and to have the kinds of conversations with families that are necessary but very delicate. There has been an increase in the number of specialist nurses for organ donation who are of course highly trained in that area, and appointments of clinical leads for organ donation have also helped.
Health: Neurological Conditions
Earl Howe Excerpts(13 years, 4 months ago)
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Lord Walton of Detchant
My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In so doing, I declare an interest as a former neurologist holding honorary positions with many neurological charities.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we will be providing a detailed written response to the National Audit Office report Services for People with Neurological Conditions in due course. While some progress has been made, we acknowledge that there is more to do to improve care for people with neurological conditions. Work is under way to develop a new outcome strategy for long-term conditions and to introduce more personalised care, including piloting of personal health budgets.
Lord Walton of Detchant
My Lords, I thank the noble Earl for that reply. This report was extremely critical in demonstrating serious inequalities in the standards of care for patients with various neurological conditions, not least Parkinson’s disease, multiple sclerosis, neuromuscular disease and many more, in different parts of the UK. That is highlighted by two major inquiries conducted by all-party groups demonstrating serious deficiencies in the care of patients with parkinsonism and neuromuscular disease. Is it not time that the Government appointed a neurological tsar to oversee the situation and to recommend improvements?
Earl Howe
My Lords, I pay tribute to the noble Lord’s extensive work in Parliament on behalf of those with neurological conditions. We have taken the view that the appointment of a tsar or a clinical specialist in this area should be one for the NHS Commissioning Board. It is satisfied with that position and we must await its determination on that.
Baroness Hussein-Ece
My Lords, the report also highlighted important indicators that the quality of care for people with neurological conditions in some instances had worsened. For example, the number of people admitted to hospital as an emergency had increased significantly and, indeed, emergency readmissions after spending a night in hospital have increased for patients with Parkinson’s disease, multiple sclerosis and motor neurone disease, to give three examples. What are the Government doing to address this?
Earl Howe
My noble friend is quite right. We know that people with long-term neurological conditions are high users of NHS services and, as the NAO report identifies, they often have high levels of unplanned admissions to hospital. To help to provide personalised care and to support better-planned care, there is quite a deal of evidence—of the generic kind, but nevertheless very useful—out there for neurological patients. It focuses on the individual, on planning, on supported self-care and on how patients themselves can improve their own outcomes. We are building a strategy on that model to set out how local authorities, the voluntary sector and government agencies can work together to prevent the kind of emergency admissions to which my noble friend refers.
Baroness Masham of Ilton
My Lords, does the Minister agree that specialised nurses working on these very complicated neurological conditions are very important? Would he see to it that their services are not cut but increased?
Earl Howe
The noble Baroness is quite right that specialist nurses provide an important source of support and advice to patients with a range of neurological conditions. They enable patients to manage their own condition effectively, as I mentioned just now. Guidance issued by NICE is clear on the important role that specialist nurses can play in the provision of effective services for those living with a range of neurological conditions.
Baroness Gardner of Parkes
Has the Minister seen the reports in the newspaper today about the worry that people have about the shortage of medication for those with Parkinson’s disease, for example? Is it a worry more in the press than in reality? How can the Government ensure adequate supplies of necessary medication for these cases?
Earl Howe
There have been shortages of certain medicines over the past two or three years for a number of reasons; there is not a single reason. The Department of Health is working with the medicines supply chain established under the previous Government, and is doing very effective work. It is liaising with manufacturers, wholesalers and the pharmacy trade to ensure that medicines are available when needed. I have not seen the article to which my noble friend refers, but we are not of the view that there is any need for undue concern. However, we are keeping the position under review.
Baroness Thornton
My Lords, it has been suggested that the UK currently does not have enough neurologists—that there should be one neurologist per 40,000 people, and at the moment we have one neurologist per 125,000 people. How will the Government increase the number of neurologists; and how will they do that under the current proposals for the reform of the NHS? Who will drive that increase?
Earl Howe
As the noble Baroness may remember, the National Service Framework for Long-term Neurological Conditions set out as a principal requirement the need for an appropriately skilled workforce to manage the care of people with long-term neurological conditions. At the moment that is the responsibility of primary care trusts. The good news is that full-time equivalent numbers of consultants have been rising steadily. According to the Information Centre census, there were 523 in 2010, an increase from 517 the previous year and from 449 in 2004. To answer the latter part of the noble Baroness’s question, I can say that the Centre for Workforce Intelligence will feed into Health Education England, which will in turn inform the local partnerships that we intend to establish under the reforms, so that there is both a national and a local input on workforce numbers and the numbers we need to train to deliver the service that patients require.
Lord Brooke of Sutton Mandeville
My Lords, in the context of the all-party report to which the noble Lord, Lord Walton of Detchant, referred, is my noble friend aware that, of the time invested in the production of that report, some 97 per cent was provided by Members of your Lordships’ House? Does he think that that has any relevance in the context of discussion about the future of the House of Lords?
Earl Howe
I am sure that my noble friend will introduce that and other considerations when we come to debate House of Lords reform. I will observe that, when I was on the opposition Benches and used to attend all-party group meetings on neurological conditions, practically the only people there were Members of your Lordships’ House.
Health and Social Care Bill
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Wheeler
My Lords, we had a long debate on this very important issue of the duty of candour before the Recess, and I do not intend to take up very much of the House’s time on this amendment by responding to the issues that we covered then, or by repeating our views on why we are concerned that the Government’s current proposal for a contractual duty will not address the need for the huge cultural change in the NHS that has to take place in order to ensure openness and honesty when things go wrong in the care and treatment of patients.
Nevertheless, I hope that the Minister will accept the case for regulations on including the duty of candour in commissioning contracts. We on these Benches emphasise our commitment to trying to help to make the contractual duty work. I therefore place it on record that we welcome the Minister’s reassurance during the previous debate that he will come back to the House on the outcome and actions resulting from the current government consultation on the contractual duty. I also hope that he will be magnanimous in the victory that he had before the Recess in the vote rejecting statutory requirement by standing by his assurances on a future review of the effectiveness of the contractual duty, after an appropriate period, and whether its effectiveness is being held back by the lack of statutory provision. My third hope is that the NHS Commissioning Board will issue clear and strong guidance to assist CCGs in this matter, and I look forward to the Minister’s response.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been another very good debate on the duty of candour. As we have discussed previously, the Government’s position is that the NHS contracts are the most appropriate mechanism through which to implement a further requirement for openness. Amendment 38A proposes that the contractual duty of candour should be given a specific reference in primary legislation. I hope that I can satisfy the House on this and that the undertakings I am about to give the noble Baroness from this Dispatch Box will reassure her sufficiently to enable her to withdraw the amendment.
I give an assurance to the House that the Government propose to use the provisions in Clause 19 relating to the standing rules to specify that the contractual duty of candour must be included in the NHS standard contract, developed by the NHS Commissioning Board. If that assurance is accepted, as I hope it will be, a specific reference is not required to ensure that a contractual duty of candour is imposed. The question, therefore, is whether, despite my assurance, it is necessary or appropriate to include a provision in Clause 19. I have given this proposal substantial thought, and I admit that it is one which on the surface has some appeal. I have spent a good deal of time discussing the matter with noble Lords as well as with Professor Sir Bruce Keogh, the NHS Medical Director.
Let me explain where my deliberations have taken me. At present there is a very wide range of issues that we incorporate into the standard contract. These include issues of paramount importance to the quality and safety of healthcare. For example, the contract is used as one of the mechanisms that we are using to drive improvements in prevention of venous thromboembolism, or VTE. It has been estimated that every year 25,000 people in England die from VTE that they have contracted in hospital. We also use the standard contract for driving improvements in cancer treatments and referrals in healthcare-associated infections in issues such as consent and many other areas.
As the Bill stands, it does not contain a list of the requirements which are to be included in the standard contracts, and for good reason. The Bill should not contain unnecessary detail. On top of that—and I think that this is perhaps a more important point—there should be sufficient flexibility for the Secretary of State and the board to consider and draft appropriate terms and conditions and adapt them to changing circumstances.
The question I pose to myself is this: if, through a reference to the duty of candour, we are to start down the road of specifying particular quality and safety contractual requirements in the Bill, then where do we stop? Just including the few issues that I have briefly mentioned, without any others, means that we will almost certainly land up with a cumbersome and unwieldy list. There are many other areas besides those which some might see as having a similarly valid claim to be mentioned. We should not use primary legislation to cherry-pick priorities to the detriment of other equally important areas.
We have further concerns about precisely what the amendment would require the Secretary of State to provide in the standing rules. We are still looking at what the appropriate contractual term should be in the light of the recent consultation that was mentioned. Imposing a duty in the Bill to adopt a specific formulation, as the amendment would have us do, constrains our ability to take proper account of the consultation and the engagement that we have had with stakeholders—it risks forcing us to implement an inappropriate requirement—and from easily improving it in the future, if the evidence supports that.
I was struck by the very powerful speech of my noble friend Lord Faulks during our last debate on this topic, and indeed by his words today, when he challenged the House to consider the difficulties involved in drafting a duty which adequately encapsulates these obligations. The noble Lord, Lord Winston, was very wise in what he said. For example, how would we specify the types of incidents to which any contractual requirement would apply? The contractual duty and provision in the regulations must be neither too wide nor too narrow in order to be effective and proportionate. We need the flexibility to consider this in more detail.
The noble Baroness’s amendment would have us require particular steps to be taken in particular defined circumstances and adopt a particular definition of the incidents to be covered by the duty of candour. I am extremely uncomfortable with that. Apart from anything else, we specifically asked this question in the public consultation, so we would be undermining that process if we were not properly to consider the responses we received. I really think, therefore, that it would be better to let that consultation guide us as to the precise way in which the duty should be framed. It is for those reasons that, after considerable thought, I can tell the noble Baroness that I do not think it would be wise for us to accept Amendment 38A.
The noble Lord, Lord Walton, asked about the duty placed on individual doctors within a trust. Doctors are expected to follow the code of practice laid down by the GMC, as he will know, and failure to do so may lead to action against a doctor by the regulator in the exercise of its statutory powers. I can confirm to the noble Lord that the code is not just words; it is backed up by real regulatory force. Indeed, I have the wording of the code in front of me:
“If a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects”.
There are similar provisions in the Nursing and Midwifery Council code as well.
Earl Howe
My Lords, this has been a very good debate indeed and I thank noble Lords for the careful consideration that they have given to how CCGs should best manage conflicts of interest. I have listened carefully to the various points raised and it is clear that this is an area of key concern. I hope that the House will therefore forgive me if I start by setting out the position on this issue before I turn to the detail of the amendments before us.
At the heart of the Bill is an intention to balance autonomy with accountability. We are giving freedom to those best placed to take decisions in the interests of patients to do so, but we will also hold them to account, not only for the outcomes they achieve but also for their managing this responsibility effectively, transparently and with integrity.
CCGs will be the guardians of significant amounts of taxpayers’ money, as the noble Lord, Lord Hunt, rightly pointed out, so it is only right that there are strict requirements in terms of governance, probity and transparency of decision-making. We must balance the benefits of the clinical autonomy of doctors with a robust management of potential or actual conflicts of interest. It is essential to get this right, and that means a proportionate and reasonable approach.
I reinforce the point that the Bill already provides very real safeguards in relation to conflicts of interest. The CCG must make arrangements in its constitution for managing conflicts and ensuring the transparency of its decision-making process. The CCG must have appropriate governance arrangements, including a governing body with lay members and other health professionals. These arrangements will be scrutinised by the NHS Commissioning Board as part of the process of ensuring that a CCG is fit to be established as a commissioner.
Let me be clear that this is not just about declaring conflicts of interests, which of course is vital, but also about putting in effective and appropriate arrangements to manage these conflicts where they arise. There is not, and cannot be, a one-size-fits-all approach to managing conflict, as it depends on the interest itself and where it may become a conflict. However, likely methods may include absenting the person from decisions in that area, or bringing in others—for example, the independent lay members—to oversee the process for decision-making in a particular area. The key factor here is that they cannot avoid the need to manage the conflict and to be clear about how they are going to do so.
The provisions around conflict of interest apply to all aspects of a CCG’s commissioning activity, which means that they would apply to how it worked with a commissioning support organisation. I appreciate that there is apprehension and, in some cases, misunderstanding about the role of commissioning support organisations, so I shall set out the facts about this issue for the benefit of noble Lords today, in particular my noble friend Lady Barker, to whom I was grateful for referencing the brief on this issue provided by Professor Allyson Pollock.
Commissioning support organisations are not intended to act on behalf of a CCG in making decisions. They provide support, which might take the form of analysis of performance or finance data, supporting procurement or the management of a contract, and back-office functions. Let me be clear: at no point can they take decisions for the CCG or assume responsibility for a CCG’s statutory duties. It would be unlawful for a CCG to sub-delegate its commissioning responsibility to another organisation.
I am, however, conscious of the concerns, particularly those raised by my noble friend Lady Barker, about whether members of commissioning support organisations could sit on a CCG governing body. I give noble Lords a commitment today that we will prohibit any representative of a commissioning support organisation sitting on a CCG governing body through our secondary legislation-making powers under new Section 14N.
I should also like to explain some of the other safeguards in the Bill relating to management of conflicts of interest. Under Clause 73, the Secretary of State may make regulations which we intend will impose specific requirements in relation to the management of conflicts of interest. They will also confer on Monitor various powers to investigate the actions of a CCG and take remedial action. Monitor will be required to issue guidance on these regulations.
The NHS Commissioning Board may also provide guidance on conflicts of interest. This renders unnecessary any additional amendment requiring the Secretary of State to issue guidance on conflicts of interest, as Amendments 86 and 93 would do, or to issue a specific code of conduct or financial interest rules, as Amendment 38B requires. I shall return to that point in a moment.
The Bill is also clear on the transparency and accountability of the decision-making process. Schedule 2 provides that the CCG constitution must specify arrangements for securing transparency about the decisions of the CCG and governing body. The NHS Commissioning Board will be able to issue guidance on the publication of minutes and will ensure that the constitution meets these requirements. This meets the intention behind Amendment 92. We cannot accept the amendment because it might not always be appropriate to publish details of all decisions made by a governing body.
Transparency and accountability must not be achieved at the expense of the effectiveness of the commissioner. PCTs are not required to discuss all matters in public now and we should ensure that CCGs are not subject to more onerous requirements. Amendment 91 may well prevent CCG governing bodies discussing potentially commercially sensitive issues relating to contract values or performance without the public being present, which could pose difficulties.
I can fully understand the intention behind Amendment 102, tabled by the noble Baroness, Lady Finlay, to ensure that local knowledge informs the work of the CCG. However, we have always maintained that the presence of health professionals on a CCG governing body is not intended to be a means for the CCG to obtain advice to inform its commissioning decisions. The non-GP members of the governing body are there to provide an independent perspective, informed by their expertise and experience, in the body responsible for ensuring that the CCG adheres to the principles of good governance. They must have no conflict of interest in relation to the clinical commissioning group’s responsibilities. Amendment 102 would mean that a CCG could have only local professionals in the governing body. This would obviously limit the CCG in its choice of governing body members and risks a conflict of interests. I urge the House not to accept that amendment.
GPs in CCGs have to meet the ethical standards set by the General Medical Council in good medical practice. That includes provision to avoid conflicts of interest. Anyone may raise a concern that a doctor has failed to meet the conditions of their registration with the regulator. However, a failure to meet the conditions which Amendment 93 would impose would not necessarily mean that a GP had been in breach of their conditions of registration, and the duty which Amendment 110 would place on the board would be disproportionate. I know that there is a real concern among some noble Lords and that it is felt that this is a necessary sanction, but it is far better to ensure the robustness of the approach that CCGs take and that it is appropriately overseen. It is more appropriate for an independent monitor to police the transactional behaviour of CCGs and to be able to take effective remedial action where it discovers evidence that a CCG has not followed regulations in relation to procurement and the management of conflicts of interest, which is the approach taken in the Bill.
I similarly urge that we do not place in legislation an indiscriminate requirement, as Amendments 38B, 93 and 116 would do, that people with an interest withdraw from the relevant decision-making process of the CCG. Clearly, that is often going to be the most appropriate means to manage a conflict of interest, and that is made clear by the NHS Commissioning Board Authority’s guidance, Towards Establishment, which was published recently. However, it should not lead us to impose on CCGs a blanket ban on individuals being involved in a decision-making process or sitting on the governing body in all circumstances in which they have an interest. It ignores the fine line that can be drawn between situations in which withdrawal is absolutely necessary and those in which it would be more effective for the CCG’s exercise of its commissioning function for the conflict to be managed, carefully and with external oversight, in a different way that maintains the integrity of the CCG.
I listened with great care in particular to the speeches of the noble Lords, Lord Warner and Lord Walton, on this theme. The best example of the second category that I mentioned is where a CCG is commissioning for local community-based alternatives to hospital services and it determines that the most effective and appropriate way to secure these is from all local GP providers within its geographic area. There are already inherent safeguards in the legislation to help manage conflicts in this scenario. The CCG would have to declare its commissioning intentions as part of its annual commissioning plan, on which it would consult the public, and it would engage with health and well-being boards in developing; and that makes the proposal transparent. It enables the health and well-being board and others to challenge the proposals. CCGs could similarly secure additional involvement in the decision-making process—for instance, by involving members of the health and well-being board or, indeed, other CCGs or members of the CCG’s audit committee. There is a choice. We have not identified one single right way of doing this. We think it is important to allow best practice to evolve rather than trying to pin it down in legislation. If all GP members of the CCG had to withdraw from the decision-making, it would be extremely hard for the CCG to actually make a valid decision, as it could not be delegated to the non-GP members of the governing body or a similar arrangement. It is only in certain circumstances that we would expect individuals with a conflict not to withdraw absolutely, but we have to keep this option open in legislation.
For the same reasons, I cannot support the proposals of the noble Lord, Lord Hunt, and the noble Baroness, Lady Thornton, in Amendment 38B, which would either require a CCG not to contract with a provider in which any member of the CCG had an interest, or require them to secure an exemption from this rule from the NHS Commissioning Board. The conflict and financial interests rules, which this amendment references, already require an individual to withdraw from any part of the decision-making process with a provider in which they have an interest. It is hard to see why it would be necessary also to prevent the CCG from contracting with such a provider or undergo a cumbersome—I have to say cumbersome—exemption process. That approach would make the board have to scrutinise individual procurements and generally police the transactional behaviour of CCGs. It would not allow for alternative local arrangements for quality-assuring the openness and transparency of a CCG’s approach. It should not have to be the board only that can ensure the probity of the commissioning decision. As I have suggested, the health and well-being board might provide a suitable external view, as might another CCG.
Lord Hunt of Kings Heath
I am grateful to the noble Earl for giving way so freely. I understand what he is saying about the bureaucratic process. However, will he not accept that the reason for that is that the corporate governance processes around the clinical commissioning group are so weak? For instance, why is there not to be a majority of independently appointed non-execs, as there would be on any other public board?
Earl Howe
I will come to that point in a moment. I do not agree with the noble Lord that the governance arrangements are weak. As I have said, one of the things that the board will have to do when authorising CCGs is to assure itself that there are fit and proper governance procedures in place.
I turn to the question of sanctions, which has been raised by a number of noble Lords. It is essential that patients and clinicians remain confident that members of clinical commissioning groups will always put their duty to patients before any personal financial interest. It is important that CCGs take all possible steps to avoid conflicts of interest. We foresee that the guidance that Amendment 79A requires the board to produce would set out the need for CCGs to make clear in their conflict of interest policy that any member of a CCG found to have failed to declare an interest may face a number of possible sanctions and individuals may also be referred to their professional body, which is a serious matter. The noble Lord, Lord Walton, was quite right in all that he said. I am very drawn to the provision of Amendment 79A, and I will come on to that more fully in a moment.
Lord Hunt of Kings Heath
My Lords, I think that that is a very disappointing response. The noble Earl, Lord Howe, said that clinical commissioning groups will balance autonomy with accountability, and he acknowledged that they will be guardians of billions of pounds of taxpayer’s money. He went on to say that there were three safeguards: the constitution, transparency and the governing bodies. However, he still fails to respond to the fundamental gap, which is the lack of proper corporate governance around clinical commissioning groups. Looking at other public sector bodies—NHS trusts, for instance; not foundation trusts, but NHS trusts—how would we feel if the Government came forward with proposals stating that the board of an NHS trust would consist of executive directors and one or two lay members? It is just possible—but it is not certain—that one of those lay members will be the chairman of the trust, or they could, indeed, be the chief executive. That, in essence, is what the Government are proposing for the governance of clinical commissioning groups. A group of GPs will sit round the table. They will have a couple of lay members who presumably will be appointed by the clinical commissioning group, because the Government consistently fail to say whether there will be an independent appointments process. The noble Earl never responds to me on this point. They will be deciding how billions of pounds should be spent. The noble Earl refuses to acknowledge that these GPs are business people who run businesses which depend mainly on contracts—
Earl Howe
My Lords, I realise that I did not answer the noble Lord and I apologise to him. It may be helpful for him to know that we intend to work with patient and professional groups and with emerging clinical commissioning groups to determine the best arrangements for appointing members of governing bodies. We will be issuing regulations in due course setting out in more detail the requirements for appointing clinical—that is to say, non-GP—members to the governing body.
The report that we had from the NHS Future Forum stated that it would be unhelpful for clinical commissioning groups’ governing bodies to be representative of every group under the sun. We agreed with that. Requiring a bigger group of professionals on the governing body itself, or expanding it in any way at all, would not really mean that a broader range of interests are involved in designing patient services. It would just lead to governing bodies that are too large and slow to do their job well. However, we think that it is important for clinical commissioning groups to be led clinically. That is the point.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl. However, that ultimately means that a majority of the people on the board of a clinical commissioning group will potentially be able to take advantage of the commissioning decisions of that group. That is why the corporate governance is so concerning. I accept that my amendment might be regarded as rather lengthy. However, I am pushing this forward because I am trying to replace the lack of effective corporate governance.
The noble Earl says that sanctions will be contained in guidance, but I do not think that that is sufficient. The potential for conflicts of interest are so great and the amount of public money involved so considerable that we should have in the Bill a clear commitment to sanctions. I do not agree with the noble Earl that this is something that can be left to professional bodies. My noble friend Lord Warner was absolutely right to mention that case. It shows some of the risks of what essentially was, in that person’s case, a managerial issue being pursued by a regulatory body. I do not think that that is the right way of dealing with GPs who, it was alleged, had pursued actions in breach of whatever guidance was issued.
Lord Hunt of Kings Heath
My Lords, I am sure that Monitor will play an extremely useful role, but surely it would be much better to give further and clear guarantees that these matters will be dealt with effectively. I believe that we need more provision in the Bill specifically on sanctions. I should like to test the opinion of the House.
Baroness Thornton
My Lords, I am not going to attempt to answer the noble Baroness’s question. I shall leave that for my noble friend Lord Warner or the noble Lord, Lord Patel. The noble Lord, Lord Patel, and my noble friends Lord Warner, Lady Pitkeathley and Lord Turnberg made a very good job of introducing these amendments, stressing the importance of joint commissioning, the work of the Health Select Committee in the Commons and its recommendations, and indeed the vital nature of tariff reform. This is a modest but very important amendment that strengthens the Bill.
Every time we meet on Report on this Bill we are in a different world. The world we are in today is not the same one we were in 10 days ago. As we speak, the Royal College of Physicians has decided by a majority of 80 per cent to ballot its members about how they feel about the Health and Social Care Bill. By my counting that leaves only two royal colleges which have not consulted their membership so far. We all know what the results of the consultations have been, but still we plough on with this Bill.
The remarks of the noble Lords, Lord Mawhinney and Lord Newton, and the noble Baroness, Lady Jolly, together underline the defects of this Bill. Why are we having a debate about integration at this point in the passage of this Bill? It occurred to me that perhaps those debates should have been had before we had the Bill. However, because you cannot achieve everything does not mean that you should not try to achieve something. That is what these amendments do and that is why we on these Benches are very keen to support them. It seems to me that through all the many definitions of integration that we have discussed in this House, the one that is going to have the most effect on budget and finance is in these amendments here before us today. I hope the Minister will accept these amendments because they will improve this Bill.
Earl Howe
My Lords, integration has been a consistent theme throughout our debates on the Bill and the noble Lord, Lord Warner has made a number of highly informed speeches on this topic, as indeed have many in your Lordships’ House. The noble Lord, Lord Warner, made a powerful case for taking action for further integration. There is no disagreement between us on this. It is why the Government have already taken a number of steps to do precisely what he is asking and I name a selection only. We have put duties on commissioners to promote integration. We are creating health and well-being boards, bringing together health and social care commissioners and their representatives—one of the main manifestations of joined-up thinking in this Bill. We are strengthening the duties in relation to pooled budgets. We are placing specific duties on Monitor to support integration and tabling an amendment prior to Report giving Monitor express power to do that. We are working with the Future Forum, the King’s Fund and the Nuffield Trust in a whole range of non-legislative measures. This is not as the noble Baroness, Lady Howarth, put it, something the Government have put into the “too difficult” box. We are determined that we need to tackle this. I hope no one in your Lordships’ House is left in any doubt about our commitment in this area.
There are numerous examples of the non-legislative things we are already doing. We agreed with the Future Forum’s recommendations that the board should produce commissioning guidance for CCGs that focuses on how to meet the needs of different groups of people who may have multiple problems such as the frail elderly. By April 2012 the department will put in place new metrics that bring together existing data on patients’ experiences at the interface between services. We are working with the NHS Institute for Innovation and Improvement to identify and spread examples of good practice in local measurement and improvement of pathways of care. Through the NHS operating framework for 2012-13 we are asking all PCTs to work with their local authority partners to look at how integration can be better achieved. I have a whole string of other examples.
As I have said, the commitment of the Government in this area should not be doubted. I was very pleased to see the King’s Fund and the Nuffield Trust in their report to the Future Forum recognising that,
“integrated care lies at the heart of”
this Bill,
“to put patients first, improve health outcomes and empower health professionals”.
That is exactly right. While there is clearly work to be done to make this a reality, the Bill will, for the first time, create duties for NHS bodies to promote and encourage the commissioning and provision of integrated services. It is a difficult concept to define. While the noble Lord, Lord Warner, is to be congratulated on the attempt he has made in his amendment, my fear is that the amendment will not actually take us very far. The precise term “integration” is used only in headings in the Bill and the concept of integration is applied in a number of different contexts so a fixed definition of this kind may not be appropriate in every case. It may be too narrow in some cases—some noble Lords have alluded to that point. It is also a somewhat circular definition, referring as it does to integration meaning the delivery of integrated care. That serves to illustrate the real difficulties with this approach.
I am not convinced that it is necessary to try to describe what integration means. Integration is a broad concept. It could encompass a range of measures. As the recent King’s Fund and Nuffield Trust report noted,
“integrated care means different things to different people. At its heart, it can be defined as an approach that seeks to improve the quality of care for individual patients, service users and carers by ensuring that services are well co-ordinated around their needs”.
Yes that is right and the duty on the board in new Section 13M is absolutely consistent with that approach.
We were very grateful to the Future Forum for its recent work on integrated care. We welcome its recommendation that the entire health and social care system should share a clear and common understanding of the value of integration as a means of putting patients at the centre of their care. However, it was also clear that rather than being an end in itself, integration is,
“a means to achieving better outcomes for people”.
That is surely right. There must be the scope for integration to be adaptable to the needs of local communities and individual patients. The noble Lord’s definition holds,
“improving the delivery of integrated care and treatment to individual patients”
as the objective in itself when improving outcomes and reducing inequalities should be the ultimate objectives.
Very recently, I was advised of a paper produced by the World Health Organization in 2008, Integrated Health Services - What and Why? It starts off by stating that integrated health services mean different things to different people. It lists a whole variety of interpretations of what integrated healthcare means and says that it is in essence very difficult to boil these things down to a definition that is going to please everybody. It also casts doubt—I do not want to make too much of it—on the empirical base for claiming that integration is the answer in every set of circumstances. In making that point, I do not want to imply that the Government are anything other than fully committed to integration, because we certainly are, but the paper’s conclusion is:
“‘Integration’ is used by different people to mean different things. Combined with the fact that this is an issue which arouses strong feelings, there is clearly much scope for misunderstanding and fruitless polarization”.
For the World Health Organization to come to that conclusion tells a story. In drafting the various duties and powers in relation to integration, we have consciously avoided a fixed definition to allow for a measure of flexibility and innovative thinking. We have focused on the purpose—the “why” rather than the “how”.
I recently met front-line staff when I visited the NHS on the Isle of Wight to look at how they were delivering an efficient, integrated, urgent care service. I made a point of asking them whether they thought that a definition of integration in the Bill would be helpful. I received a resounding no in response. They felt that something like that would stifle their ability to apply fresh thinking and to come up with inventive solutions of their own as to how best to provide integrated care. We are clear that we should not put clinicians, who know the needs of their patients best, in a straitjacket by defining integration in the Bill.
Clearly, it will be important that the board and CCGs are held to account for delivering against these duties. They are already required to set out in their annual reports how they have exercised their functions, including how they have met the various duties placed on them.
Amendment 38C also makes particular reference to the board and Monitor developing tariffs that will support integration. On that point, I reassure the noble Lord that the duties on the board and Monitor to promote integration would apply in relation to their functions in relation to the tariff. The clauses on the tariff allow a high degree of flexibility for the board to adopt different approaches to tariffs, including “bundles” of services or pathways, and we are committed to extending these. They also allow scope for local flexibility in how the rules are applied where necessary. The noble Baroness, Lady Wall, provided considerable insight into what is needed here. Perhaps it would be helpful if I gave an example of a pathway tariff.
In 2012-13, we are introducing a “year of care” tariff for funding cystic fibrosis services, developed with the support of the Cystic Fibrosis Trust. This includes all the care for cystic fibrosis patients for a whole year. The price is broken down into different “bands”, depending on the complexity of the patient. The tariff will cover the care undertaken by specialist centres and local hospitals, but it will be paid only to the specialist centre thereby promoting better joint working between specialist centres and local hospitals. We are confident that the board, with support from Monitor, will continue to develop and increase the scope of bundled service tariffs where it is clear that tariff design of that kind is appropriate and will deliver benefits to the patient.
Lord Winston
I am sure that the Minister will want to answer my question because it is not aggressive or political; it is really to find out how this Bill will work. When somebody goes to casualty after a month with a broken nose and complains, “Look, my main problem is the pain in my sinuses which I have had for a long time”, and is told by the doctor when they had already waited six hours, “I’m afraid the sinuses are a different department. You’ll have to make another appointment”, that is a problem with integration. How does the Minister think we might accomplish better integration with this Bill?
Earl Howe
It is a very interesting question from the noble Lord. When I visited Oldham a few weeks ago, I saw for myself how they were getting around that problem in the context of musculoskeletal services. Instead of patients being shunted from pillar to post, they had a system whereby the patient could move seamlessly and immediately from one specialist to another. They did not have to be referred; they could ring up the centre and ask to see a particular person. That is the kind of integrated model that we need to see rolled out more generally in other services. I recognise the issue that the noble Lord raises, but it is one that we are seeing inventive solutions arising to address. I hope that the work being done will do that.
Lord Warner
My Lords, there have been some extremely powerful speeches of support for this amendment for which I am extremely grateful. I am grateful in particular to my co-signatories and I noted the powerful speeches of the noble Lords, Lord Owen and Lord Sutherland, and the noble Baroness, Lady Young. They have made the case for an amendment of this kind to the Bill.
I was disappointed by the Minister’s response. That was not just because I got only a B- for my definition—I expected to have my homework marked by officials in the Department of Health and was not expecting to get a high score—but because I think that the definition meets the needs that we have. I find it very difficult to see how the Minister can stand up and say, “Well, we’re going hold people to account; we’re going to monitor their performance”, if we do not have a definition against which we are going to monitor their performance.
The definition proposed by the amendment moves us away from a preoccupation with integration as organisation and process change to delivery of services to the individual. I do not see how the Minister can say, “We’re concerned about outcomes for individuals”, if we do not integrate delivery. You are highly unlikely, I would say as a jobbing ex-public sector manager, to get good outcomes if you have not orchestrated the delivery of the services to the individual that meets their needs.
Earl Howe
I would not want the noble Lord to believe that I was dismissive of the point that he has just made. I recognise that it is important that we somehow give the meaning of integration a clearer explanation, whether that is through the guidance issued by the board or, indeed, the Explanatory Notes to the Bill. I am just wary of putting something in the Bill. That is all.
Lord Warner
I guess I am more of a risk taker than the noble Earl and I believe that we could put a definition of this kind in the Bill. It would cause no confusion—indeed, it would remove it—in the minds of many people working day in, day out in the NHS. As to those who have asked, “What is the purpose of some of the other changes?”, the noble Lord, Lord Owen, powerfully made the point that we need to give strong signals to these new players in the game. We want them to start off knowing that they will be held to account in their annual reports for monitoring their progress on integration. We want that: it is deliberate. We want them to know that Parliament put that in the Bill for a purpose. I am not satisfied with the Government’s response and I beg leave to test the opinion of the House.
“( ) Subsection (1) does not apply to any function of the Secretary of State of making an order or regulations.”
Baroness Thornton
My Lords, I support these amendments, and I do so because I agree with the noble Lord, Lord Patel, that there was a grave omission from the Bill that would allow strategic reconfigurations to take place that are not based on failing institutions. It was certainly not clear to us—and I rest on the authority of my noble friend Lord Warner on this—how, with the abolition of the SHAs from April 2013, strategic reconfiguration of specialist services would take place. Ministers have said, “Oh no—it’s all going to be okay”, but they have not explained how you would reconfigure the stroke services in London, as the noble Lord, Lord Patel, said, after the abolition of the strategic health authority. We support the amendments and hope that the Minister will do so as well.
Earl Howe
My Lords, we have had several lively debates on the importance of redesigning services if the NHS is to become more personalised and productive, and the noble Lord, Lord Warner, speaks with great insight and passion on this issue. He has tabled further amendments on this topic, which we will have an opportunity to debate in detail at a later stage.
The Government are clear that, as a basic principle, the reconfiguration of services is a matter for the local NHS and that decisions about service change should be driven by local assessment of need. The reconfiguration of services works best when there is a partnership approach between the NHS, local government and the public. What matters is that strategic decisions are taken at the right level. We believe that our reforms will enable commissioners to make the changes that will deliver real improvements in outcomes for patients and the public. The Bill places clear duties on the Commissioning Board and clinical commissioning groups, which will underpin a locally driven approach to service redesign, clinically based and framed around the needs of patients. That includes duties to promote the NHS constitution and the involvement of patients as well as duties to secure continuous improvement in the quality of services and to reduce inequalities. These duties set important guiding principles against which the commissioning system will develop and oversee service redesign and reconfiguration. In addition, the NHS will continue to assure reconfiguration proposals against the four clear tests set by the Secretary of State, which are that proposals should have support from clinical commissioners; should be based on robust patient and public engagement; should be underpinned by a clear evidence base; and should be consistent with current and prospective plans for patient choice. The Bill and the four tests will ensure that any proposals for service change are based on a thorough assessment of local need, underpinned by clinical insight and developed through dialogue between commissioners, providers, local authorities, patients and the public. Of course, the board will have an important role in providing support and assurance to local commissioners, but we will not be replicating layers of top-down management.
With the clear legal duties set out in the Bill, the four tests and the support and assurance that will be available, there should be no need for the Secretary of State to prescribe through the mandate how the commissioning system should prioritise and determine the design of services. To do so would cut right across the clinically led local commissioning, which is at the heart of the Bill. Nevertheless, I recognise the importance of getting these arrangements right, and between now and Third Reading I commit to working with the noble Lord with a view to finding a formula designed to address the concerns that he has articulated. We are looking at a range of options. I hope to be able to say more about this when we reach his later amendment on the subject. I hope that for now he will find this rather broad assurance sufficiently strong to enable him to withdraw that part of the amendment.
I hope that the noble Lord will be able to withdraw the rest of Amendment 42 as well, because it also raises another issue. It is vital, especially in the current economic climate, for the NHS to provide financial support for adult social services where possible in relation to those services at the interface between health and social care. Here, I pay tribute to the noble Lord, Lord Warner, who has been a tireless advocate of social care at numerous stages of our proceedings, to ensure that this element of the equation—and that part of the Bill’s title—is not overlooked.
The noble Baroness, Lady Murphy, has tabled Amendment 148B with a similar aim in mind. We are all, I think, aware of the impact that such services can have in helping people to live independently in their own homes and in reducing unnecessary hospital admissions—which is, of course, better for the individuals involved and relieves pressures on the NHS. The last spending review included a commitment to provide £648 million in 2011-12, rising to £700 million by 2014-15, for these purposes. Early indications are that this funding has helped to promote integrated working between social care and health commissioners. We want this to continue. I can reassure the noble Lord and the noble Baroness that by virtue of paragraph 130 of Schedule 4 to the Bill the NHS Commissioning Board and CCGs will inherit the powers that primary care trusts currently have under existing legislation to make payments to local authorities towards expenditure on community services.
Generally speaking, our approach in this Bill has been to give NHS commissioners maximum autonomy in how the NHS budget is used. However, I have sympathy for the argument that it is legitimate that the Secretary of State should be able to determine the proportion of NHS funding that is to be transferred to local authority community services in order to secure closer working between the NHS and social services. I am not sure that the mandate is the right vehicle for this. However, I can see very considerable merit in the approach that the noble Baroness has taken with Amendment 148B. This amendment would give the Secretary of State additional powers to direct the board on the minimum amount that it should transfer to local authorities in a given financial year. The Secretary of State would be able to specify in the directions the bodies to which those payments should be made, the amount that should be paid to each body and the functions in respect of which the payments must be made, and to amend these instructions if necessary. It would essentially enable the current arrangements to continue.
The noble Lord, Lord Warner, asked whether the amendment was wide enough to cover adult social care; whether it was within vires; and whether the Treasury is content. The answer to all those questions is yes. Indeed, I am advised that the amendment would enable funding to be transferred to other community services, such as housing, if necessary.
The approach taken is in line with current practice, which is approved by and agreed with the Treasury. Importantly, this would represent only a minimum. The board would retain the power to make additional payments over and above those required by the Secretary of State if it chose. The CCGs would also retain their powers to make such payments. Although I think it makes sense for it to be the NHS Commissioning Board that makes these payments, it would also be vital that there is a dialogue between local authorities and clinical commissioning groups as to how the funding could be best used. Of course, both will be involved, as members of health and well-being boards, in setting the strategic framework for health and social care commissioning through the joint health and well-being strategy. In addition, the existing powers in Section 256 for the Secretary of State to give directions on the conditions that should apply to such payments would apply. This is helpful because it would provide a mechanism for ensuring that the agreement of the health and well-being board is obtained as to how funds are spent.
The noble Lord, Lord Warner, has spoken with great conviction about the Bill’s importance, including the tangible duties to act to ensure that integration moves from being just an aim to being a reality—as, indeed, the Future Forum has emphasised that it must. I think that Amendment 148B meets all the criteria to ensure that that will be the case. I shall therefore be happy to support it if the noble Baroness should decide to move it. I hope that my noble friends will join me in supporting the amendment; I would urge them to do so. Given that commitment, I hope that the noble Lord, Lord Warner, will be prepared to withdraw Amendment 42.
Lord Warner
My Lords, I am grateful to the Minister for his explanations and reassurances. I certainly think that Amendment 148B is a better amendment than my provision on social care in Amendment 42. I am very happy also to accept his broad assurances that we will have a discussion and dialogue to see whether we can move forward on, in effect, a version of a pre-failure regime, while recognising the Government’s commitment to local decision-making on redesigning and reconfiguring services. On that basis, I am happy to withdraw the amendment.
Lord Hunt of Kings Heath
My Lords, I would like to echo my noble friend Lord Rea and noble Lords from the Cross Benches on the importance of this group of amendments. At its best, primary care can be brilliant, but at its worst it can be absolutely appalling. The variation in primary care is probably wider than in any other part of the National Health Service. As the changes take place we can see that this may cause many problems in the future.
We are all agreed about the need for an integrated approach and for a smooth patient pathway. Clearly, primary care potentially has a very important role to play. However, it needs to step up to the plate. If acute hospitals are to reduce the scale of their operations, more will be expected of primary care. Yet acute hospitals are open every hour of the day: primary care is not. Indeed, there are often very big issues about how primary care can be accessed out of working hours. The out of hours services are not always as effective as they might be, and there are some practices where patients know that it is very difficult to get attention unless they turn up at the convenience of the doctor, and so they then end up at the accident and emergency department. As I read where the NHS is going, this is no longer going to be acceptable. If money is being taken away from acute care and more money is being spent on primary care, which must be the logical outcome of clinical commissioning groups, unless those clinical commissioning groups can ensure that GPs do what is necessary to ensure that primary care takes up the responsibility, we are going to end in great difficulty, where acute care services will continue to be demanded by patients and money is being spent on primary care but it is not doing the necessary job. Therefore issues around the monitoring and performance management of primary care become very important indeed.
The Government have decided not to place the contracts of GPs within clinical commissioning groups. I understand that because clearly there is another potential conflict of interest. They are to be held at the local offices of the national Commissioning Board. However, there are real questions to be asked about how bureaucrats, as the Government seek to call them—I like to think of them as managers—are going to handle those contracts. What will happen within a particular clinical commissioning group if there is a group of GPs who simply will not do what is required of them to make a contract work with a local hospital? For instance, there may be a risk-share arrangement with a local hospital, where essentially agreement is made on the contract price, but part of it is very much about demand management, where there is a risk share between the clinical commissioning group and the acute trust. That will depend on all the GPs within a clinical commissioning group doing what is necessary, playing their part and contributing to demand management measures. Frankly, there are a lot of GPs who will not have anything to do with that. We know that at the moment. It is happening everywhere, up and down the country, with GPs who do not give a damn about anything to do with demand management. What will happen? Who will be able to intervene in those circumstances? Clinical commissioning groups do not have many levers when it comes to poor performance among general practitioners. I suspect that the national Commissioning Board will not have the expertise either. That is why this group of amendments is so important. We all know that primary care can make a huge contribution to a good NHS in the future, but we have to admit that, of all parts of the NHS, we can probably also find the poorest quality of service as well. That is why we are looking for reassurance from the noble Earl that this new system will be able to deal with those poor performers.
Earl Howe
My Lords, I am grateful to the noble Lords, Lord Kakkar and Lord Patel, for their contributions to this debate and, indeed, to other noble Lords who have spoken. We have heard some very powerful and persuasive arguments. I have listened very carefully to them.
Amendments 43A and 43B highlight the concerns that I expect all of us in this Chamber share in relation to the need to ensure high-quality primary care for all patients. The noble Lord, Lord Hunt, made some very telling points in that regard. Of course, there can be no doubt that good primary care contributes to good healthcare outcomes overall. I fully agree that the NHS Commissioning Board should be held to account properly for its performance in commissioning primary care. I do not think, however, that the right way to achieve that is to prescribe that this must be part of the mandate. Our aim is that the mandate should have at its heart the NHS outcomes framework, which covers the range of care that the NHS provides. I make the simple point that good primary care will be essential to improvement against the NHS outcomes framework.
More widely, the department will be keeping under review the performance of the board and the way that it carries out its functions, including its direct commissioning. What matters here are the accountability mechanisms and how those in the system are monitored and held to account. Just as the board will have a commissioning outcomes framework to hold CCGs to account for the quality of their commissioning, it will be important to have robust and transparent information to assess the quality of what the board commissions itself.
We come back to what the Bill already says: it places duties of quality on the Secretary of State, on the board and on CCGs, requiring each of them to exercise functions with a view to securing continuous improvement in the quality of services provided to patients. The Bill also sets out robust arrangements for holding those bodies to account for delivering quality improvement. As noble Lords will be aware, the Bill already requires the board to submit a business plan setting out how it proposes to exercise its functions, and a report setting how it has exercised its functions, to the Secretary of State on an annual basis. In turn, CCGs must also submit their commissioning plans and annual reports to the board. Both the board, in reporting to the Secretary of State, and CCGs, in reporting to the board, will be expected to demonstrate how they have fulfilled their quality improvement duty, including in relation to primary care. Consequently we expect, for example, that both the board and CCGs will wish to monitor the standard of care and services provided by all primary medical services providers in fulfilling their duties.
It is possible that we will need a dedicated objective relating to primary care in the mandate—I am not ruling that out. It would be better, though, not to prescribe that in primary legislation. What matters is that there are clear and effective accountability arrangements, and the Bill as it stands provides flexibility to ensure just that.
The noble Lords, Lord Kakkar and Lord Rea, asked about the QOF. I agree with the noble Baroness, Lady Finlay, that the QOF is a separate issue, but I can say that the whole of the QOF is kept under review in consultation with the profession to ensure that it reflects the best available evidence and supports continuous improvement in the quality of care for patients. Over the coming months we will continue to discuss with the profession and its representatives how to focus the QOF on securing better healthcare outcomes and what that means for existing GP contractual arrangements.
I turn to the final amendment in this group, Amendment 95A. The Bill already ensures that the board has the information that it needs to demonstrate how it has fulfilled its duties. CCGs are required to provide information to the board in the form of the annual commissioning plan and annual report. In addition, the board and CCGs are under a duty to co-operate. In the normal course of business we expect this to involve the sharing of information as necessary but, in the event that a CCG might have failed, be failing or fail to discharge any of its functions, the board’s powers enable it to require any information or documents that it considers necessary from CCGs.
The noble Lord, Lord Hunt, posited the situation that there might be reluctant GPs who did not fulfil their part of the bargain, whatever that was, with the acute sector. There needs to be a way of investigating allegations that actions by GPs in their practices are adversely affecting a clinical commissioning group. Where a general practice is operating in such a way that it is a barrier to a clinical commissioning group meeting its functions, it will be for the commissioning group to work with the members of that general practice to support it to improve and contribute to the work of the commissioning group as a whole. Ultimately, if it is unable to do so, a clinical commissioning group may need to refer such cases to the NHS Commissioning Board, along with the evidence of the failure of the practice and details of any support that the commissioning group has provided to the practice to help it overcome any perceived difficulties.
Among other matters, the board may wish to consider if the practice’s actions are in breach of the practice’s primary medical services contract. Separately, the NHS Commissioning Board will have the power to investigate the suitability of individual GPs under the medical performers list provisions. As the noble Lord will know, this power is currently with primary care trusts.
In a nutshell, therefore, the Bill already imposes a duty on CCGs in respect of the mandate and allows the board to ensure that CCGs fulfil it. Further specific requirements in relation to providing information to the board are therefore unnecessary, so I hope that what I have said reassures the noble Lords, Lord Kakkar and Lord Patel, sufficiently to enable them to withdraw their amendment.
Lord Kakkar
My Lords, I thank the Minister for, as always, his thoughtful response and consideration of the amendments. I remain somewhat anxious about whether there is going to be sufficient attention and opportunity to deal with the question of performance in primary care and the management of that performance to ensure that the very best clinical outcomes are achievable for all patients across the country.
I welcome much of what the Minister has said with regard to potential further consideration of how mechanisms other than a specification in the mandate on the question of primary care performance might work. I wonder whether it might be possible for him to enter into further dialogue on this matter so that there can be clarity. It would be unhelpful for the future if a great emphasis were placed—in fact, if there were a momentum—on moving practice from the secondary care environment, where there is a relentless evaluation of clinical outcomes and which has done so much to improve clinical outcomes for our patients because of the attention paid to those matters, into a primary care environment where an objective assessment of outcomes was not always possible and where, as a result, what we all hope will be achieved through the Bill—a health gain for patients and population—might therefore inadvertently be lost. With the opportunity to have a further conversation with the Minister prior to Third Reading, I beg leave to withdraw the amendment.
“( ) Requirements included in the mandate have effect only if regulations so provide.”
“( ) Revisions to the mandate which consist of adding, omitting or modifying requirements have effect only if regulations so provide.”
Health and Social Care Bill
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Wheeler
I am pleased to speak in support of the Government’s Amendments 56, 97 and 98, which take an important step along the route of making the Bill more explicit on the duties of the NHS Commissioning Board and clinical commissioning groups to promote patient involvement in decisions about an individual’s care and treatment. We particularly welcome the requirement for the board to publish guidance for CCGs on the patient involvement duty. We argued strongly for this in Committee. It will go some way to ensuring that CCGs are clear about what is required of them to meet the duty of involvement of each patient. We know that the evidence shows that many commissioners are currently unaware of the increasing evidence that involving individual patients in their care and treatment is proven to be more clinically effective, provides better patient experience and makes better use of healthcare resources. The guidance will enable strong signals to draw commissioners’ attention to the proven interventions that they require from their providers.
CCGs will need considerable help and support to bring about the changes we need, so clear and explicit guidance to them will be crucial. For individuals, participation must mean involvement in care planning and support for patients who manage their conditions. Sharing in the choice of treatment involves major cultural changes in the behaviour, approaches and attitudes of key professionals from across the specialisms. As we have stressed before, this means changing the way that patients and clinicians, in particular, relate to each other, and changing the way that the NHS relates to patients in terms of, for example, information provision, the organisation of clinics and the style of consultation that professionals have with patients.
Amendment 142 underlines the importance of the provision of information to patients and is supported by us. It includes the participation of the patient in monitoring systems that measure the impact of service delivery or the range of services available, and this is welcome. My noble friend Lord Harris has commented on Amendments 49A and 94A, and I endorse those comments.
In Committee, noble Lords strongly supported the call from patient organisations and other key stakeholders for a definition of patient and public involvement to be included in the Bill. The guidance to CCGs will need to address this issue. I hope that the Minister will also ensure that it focuses on ways in which patients will be genuinely engaged during the development of the commissioning plans rather than just consulted on plans after they have been drawn up. Guidance will help patients, carers and their representatives make informed decisions. This group of amendments form the basis for moving forward. We look forward to the Government also looking favourably on the subsequent amendments, which would also provide real impetus to the patient involvement agenda that we need.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we have spent a good deal of time in debate on this Bill discussing the issue of patient involvement, and for good reason. Patients rightly expect to experience responsive health services where they are treated as individuals. It is central to the Government’s vision for the NHS for patients to become genuine partners in decisions about their health and treatment, with services designed around their needs. The Bill will lay the foundations to achieve that. So I understand completely the motivation behind my noble friend Lady Williams’s suggestions in Amendment 49A and 94A to place an additional duty on commissioning bodies when taking decisions to put the interests of patients above all other considerations, as far as resources allow. On the face of it, this sounds obvious, and I am deeply sympathetic to the principle. However, I think that I am going to have to seek to persuade my noble friend that it would be extremely hard to get this right.
Lord Hunt of Kings Heath
My Lords, this is a useful debate and I hope that the noble Earl, Lord Howe, will be able to describe how he thinks specialist services and services for less common conditions will be protected in the new arrangements.
We know that there have been problems with the current commissioning arrangements by primary care trusts, the issue being that if they are dealing with services that cover only a small group of patients they do not have the experience or expertise to commission services effectively. The possibility exists that clinical commissioning groups that cover even smaller areas than PCTs will have the same challenges to face. We know that the NHS Commissioning Board will be commissioning some services at a national level. It would be helpful if the noble Earl, Lord Howe, could explain the distinction between those services that will be deemed to be of national importance but there is clearly concern that CCGs will not be able to have the critical mass to commission locally, and so they fall to be commissioned nationally. Where will the line be drawn? There is a powerful case for highly specialist services and those that are known as services for less common conditions to be given some protection in the system.
Amendment 64ZA is rather different but it comes back to the point raised by my noble friend Lord Walton in our debates in Committee on the need for strategic direction on reconfiguration issues. I am sure that he is right, as indeed was the noble Baroness, Lady Finlay, to point out that decisions on emergency care and specialist networks are very difficult to make. We know that we probably have too many hospitals providing emergency care at the moment, but we also know that it has often been very difficult to reach local consensus. I know that the thrust of the Government’s legislation is for local determination but that is asking a lot. If you take a region you are asking for a huge number of clinical commissioning groups to come together and sign up to some kind of reconfiguration process which would lead to a more integrated approach in relation to emergency care. Without strategic health authorities and unless the local outposts of the national Commissioning Board are actually going to take an assertive role, there is a risk that we will not have the mechanism for making the kind of hard decisions that need to be made.
I am convinced that some strong, national leadership is required if you are to get movement on better emergency care and an acceptance that the current arrangements in some parts of the country simply will not do. It is interesting to see the debate in Mid Staffordshire following the problems in that trust and the recent publication of letters sent by the local clinical commissioning groups about the future of that hospital, causing a furore in the area. It shows some of the problems of an individual clinical commissioning group seeking to come to a view about the kind of reconfiguration of acute services. Of course, CCGs will need an input, but some external view and leadership would be very helpful to enable us to get better provision of services. As my noble friend Lord Walton says, one of the best examples of this is in relation to stroke services. The experience in London has shown, without any doubt, that pooling stroke services together in a limited number of acute centres has led to hugely enhanced outcomes. As a result of the London experience the strategic health authorities are requiring the same to be done throughout the rest of the country. The question I put to the noble Earl, Lord Howe, is: under the arrangements in the Bill, how can we ensure that that kind of national leadership will continue?
Earl Howe
My Lords, this has been another excellent debate. It is worth saying at the outset that I fully appreciate the importance of the board and CCGs paying due attention to the way they commission specialised services and services for less common conditions and indeed emergency services. I fully endorse the importance of services being delivered in an integrated way when that is in the best interests of patients. I listened very carefully to the case put forward by the noble Baroness, Lady Finlay, on Amendment 50A. She made a very persuasive case about the importance of only ever commissioning specialised services with a close acquaintance with the relevant guidance and evidence base. I could not agree more with her on that. Commissioning of specialised services requires specialist skills and this is precisely why we feel that the Commissioning Board is the right body to commission such services. The board will be able to draw on a great deal of expertise in doing so. I hope the noble Baroness recognises our shared commitment in this area. Very shortly we will be publishing a consultation document as a UK response to the EC recommendation on rare diseases. We hope to be able to do that within a few days. The consultation document and responses will form the basis of the UK’s plan. She will see in it that a great deal of thinking is going into how these services should be commissioned.
The noble Lord, Lord Walton, spoke with his customary authority about Duchenne muscular dystrophy. He may like to know that all regional specialised commissioning groups have undertaken reviews of neuromuscular services in their localities. Improvements to services are already being put in place. For example the NHS has invested in care co-ordinator posts which can reduce emergency admissions and readmissions. The national specialised commissioning group has also included neuromuscular disease as a priority in its 2012 work plans and it has been looking at emergency admissions as part of that work.
The noble Lord, Lord Winston, referred to rarer conditions, including those of genetic origins, as did the noble Baroness, Lady Masham, in relation to neuroblastoma. I identified closely with all that they said. Many of these conditions are extremely rare, fortunately. It is not possible for all health professionals and carers to have detailed knowledge of conditions which they will see only very rarely in their working life. However, already we are addressing this through such initiatives as NHS Choices. It is one of a number of initiatives that we have developed to provide comprehensive, clinically accredited information about health and health services. Comprehensive information to support clinical decision-making is also included on NHS Evidence, the new web-based portal hosted by the National Institute for Health and Clinical Excellence. It provides access to a range of information, including primary research literature, practical implementation tools and guidelines. I am not suggesting that it is the total answer to this conundrum but it is certainly a demonstration of the direction of travel. We want to see much more information available to commissioners at a local level.
I think there has been consensus in this debate as to the need to think long and hard about how and at what level particular services should be commissioned. I completely agree with that. It is not always clear cut and it does require careful thought. The Bill says that certain services will be for the board alone to commission. We expect these to include certain highly specialised services—I direct that assurance particularly to the noble Lord, Lord Walton. Other services will be by and large for CCGs to commission, but in collaboration if need be with other CCGs and supported by the board.
I appreciate the keenness of the noble Baroness, Lady Finlay, to ensure that the board’s commissioning of highly specialised services pays due regard to NICE guidance. However, we would prefer not to impose a blanket requirement on the board to exercise its functions in respect of specialised services, or any of its commissioning functions, in accordance with NICE guidance. NICE guidance will undoubtedly be relevant to specialised commissioning—that is obvious—but the amendment could well have the effect of requiring the board to have regard to it at the expense of other authoritative sources of advice. I have already referred to a couple. In exercising its duty to obtain expert advice, we would expect the board to draw on as wide a range of professional expertise as possible and not be constrained into prioritising that of NICE, valuable though that would be.
It is important for us to remember that CCGs must be competent to commission all services to meet the reasonable needs of all those for whom they are responsible. This includes services to meet the needs of patients with “less common” conditions, as Amendment 63A points out. CCGs will need to be well supported in developing as commissioners and the Bill provides a framework for just that. It provides for collaborative working, in Section 14Z1, between CCGs. The NHS Commissioning Board must publish guidance on commissioning, to which the CCG must have regard, which could also cover issues relating to commissioning for less common conditions.
The clinical senates and networks will be overseen by the board to ensure that CCGs can access specialist advice. Clinical commissioning, by giving responsibility for ensuring services meet the reasonable needs of patients to the very clinicians who deal with those patients daily and understand their needs, provides a far stronger basis for ensuring that commissioning caters to the needs of those with less common conditions than the current commissioning arrangements. GPs will be able through their membership of the CCG to seek to ensure that commissioning takes account of the less common conditions, which might not be of great significance across an entire geography but which are of great concern at the level of the individual GP practice.
I can assure the noble Baroness that the NHS Commissioning Board will be required to have a robust authorisation process to ensure that CCGs have made appropriate arrangements to discharge their functions competently, including consideration of the extent to which CCGs have collaborative arrangements for commissioning with other CCGs or local authorities as well as any appropriate commissioning support.
However, while I completely recognise the importance of commissioning services for this particular group of patients, I am afraid that I would prefer not to single out a requirement for authorisation to look at specific groups of conditions in the Bill. It would not make the NHS Commissioning Board’s process any more effective, but it might lead emerging CCGs to add undue weight to this if it was the only part of the services that CCGs will be responsible for commissioning that was specified in relation to the authorisation process.
I hope that it is recognised by your Lordships that in opposing Amendment 64ZA I do not wish to suggest that the concerns of that amendment, to ensure the quality of urgent and emergency care and the integration of its different elements to the benefit of patients, are unimportant—indeed, quite the opposite. The framework in the Bill for ensuring the competence of commissioners, securing continuous improvement in the quality of care and ensuring the promotion of integration applies to emergency and urgent care services every bit as much to as other areas of care. Commissioners will use the expert advice from senates and networks, and from other sources, to determine the best approach to commissioning integrated approaches to the delivery of urgent and emergency care, and within the context of a far-reaching national programme. As the House will know, we already recognise the importance of integration across the health service, particularly in urgent and emergency care. The introduction of NHS 111 will act as a driver for the redesign of local urgent and emergency care systems to create a more integrated system that is easier for patients to access and understand.
(a) the prevention or diagnosis of illness in the patients, or(b) their care or treatment.”
Baroness Wheeler
My Lords, we strongly support the amendments in this group, which underline the importance of the NHS Commissioning Board and CCGs seeking advice from healthcare practitioners from across the patient care pathway, including local clinical specialists and allied health professionals, and going beyond professional input to seek advice from organisations with expertise in the experience of patients.
We hope that the Government will recognise the strong case put forward by the noble Baroness, Lady Finlay, and other speakers to these amendments for also recognising the expertise of patients’ organisations in the Bill and ensure that commissioners seek their advice as well as that of health professionals. By this we mean patients’ organisations not just being consulted but being genuinely involved in helping to co-design or co-produce services. Many patients’ organisations, such as the Stroke Association for example, are key providers of local services such as reablement or information, advice and support services to stroke survivors, carers and family members across the country. They have first-hand, direct experience of the issues that matter most to patients across the whole care pathway, hospital and community. Involvement of patient groups would also help the patient voice in the clinical senates and networks, which the noble Baroness, Lady Masham, also mentioned. To remind the Government, this approach was supported by the clinical workstream of the Future Forum, round one, but was overlooked in the Government's response. Now is a good opportunity to address this issue.
Amendment 65, tabled by the noble Lord, Lord Patel, and the noble Baroness, Lady Finlay, deals with information collected by the board on the safety of services provided by the health service being made available to healthcare providers, the Care Quality Commission and HealthWatch England, local authorities and professional organisations in healthcare. We fully support this, along with the caveat provided by Amendment 66 that the information should be freely available without charge. I hope that the Minister will accept the need to make progress on this important issue and reassure the House about the involvement of healthcare professionals and patient organisations in developing the commissioning plans.
Earl Howe
My Lords, this has been an interesting and worthwhile debate and I appreciate the concern that the noble Baroness, Lady Finlay, and other noble Lords have demonstrated throughout the Bill’s proceedings to ensure that the board and CCGs benefit from as wide a range of advice as possible. The Government have been clear that everyone with a role to play in securing the best possible services for local people should be able to do so. The NHS Future Forum recommended that we strengthen the legislative duties to help achieve this, which is why the duties on the board and CCGs to obtain appropriate advice were strengthened in another place to incorporate the wording used to define the comprehensive health service and to ensure that it was clear that such advice should come from persons who, taken together, have a broad range of professional expertise.
I mentioned clinical senates on the last group of amendments. Of course we envisage a role for clinical senates in the arrangements for how these duties are fulfilled, providing not just clinical but multidisciplinary advice from professionals from public health and social care alongside patient and public representation and other groups as appropriate. The noble Baroness, Lady Masham, asked me specifically about clinical senates. They will be established as strategic advisory bodies, with a clear focus on quality improvement and improving outcomes. They will bring together clinicians with strong clinical credibility, drawn from across the disciplines, as I have mentioned. They will include patients and members of the public as well. They will have a role, too, in advancing public understanding of health and healthcare.
Why do we need clinical senates? Commissioning is at its best when it is a collaboration of professionals, based on a shared drive for continuous quality improvement. Maximum participation will be key here. The Future Forum report showed:
“There was universal agreement that people would be”,
better served if their,
“care were designed around their needs and based on the input of the public, patients and carers, health and social care professionals”,
the voluntary sector, “and specialist societies”. The exact detail of who will be part of the clinical senates, the number that will exist and the roles that they may have are all to be determined through a process of discussion and engagement, but I hope that I have outlined, at least in broad terms, what they will be there to do.
Earl Howe
My Lords, they will come under the aegis of the NHS Commissioning Board. They will be part of the board.
Having said all that, I remain unconvinced that imposing specific duties as to where advice should come from, including specifying particular sources of advice such as in Amendments 57 and 99, is the right way forward. I am afraid that if we were to do that, there would be then justifiable demands to include in the Bill other clinicians and groups of people who commissioners should seek advice from when exercising this duty. My view is that this is horses for courses, and that it is appropriate that the board and CCGs should have the freedom to determine what advice it is appropriate to seek in each instance. That is why the emphasis in the duties as they stand is rightly placed on ensuring that the commissioner obtains “appropriate advice” from people with a broad range of professional expertise. It is that breadth of expertise which is important, not the particular professionals involved.
Amendments 58 and 100 are admirable, if I may say so, in that they seek to require that the advice should come from across the care pathway. I have every sympathy with the noble Baroness’s intentions there. Again, however, I think that this is already provided for in the duty which—in its reference to expertise in the prevention, diagnosis, or treatment of illness, and the need to obtain advice from persons who, taken together, have a broad range of professional expertise—is designed to be of maximum scope, and I am confident that it will be interpreted as such.
We have also just discussed the important role that both patients, and the organisations that represent their interests, can bring to the commissioning process. However, I think that Amendments 59 and 101 are unnecessary. Let us be clear that while these duties refer to obtaining advice from people with expertise in relation to the health service, this is not confined to clinical expertise. There is nothing to prevent the board or CCGs securing advice from patients’ organisations, or those with expertise in the patient experience. The board can also draw on the advice of national and local healthwatch as a conduit for such advice. CCGs, similarly, are able to draw on the advice of local healthwatch.
However, to reiterate the point that I made in Committee, there is a risk in becoming too prescriptive. In reality, we have to trust them to build these relationships themselves and judge them on the outcomes that they achieve. If we commission for good outcomes, we will, as night follows day, secure the appropriate knowledge and advice to enable us to do that.
It will also be an important part of the board’s remit to produce advice and guidance to prevent the recurrence of incidents that jeopardise patient safety, just as the National Patient Safety Agency does now. It is important that the board is able to share relevant information relating to patient safety. The noble Lord, Lord Patel, is absolutely right that information that can inform and enhance patient safety in the NHS should be made available to all those who would benefit from it. The NPSA, as he will know, currently shares this information with a number of bodies with a particular role in relation to patient safety—for example, the MHRA and the CQC—and this will continue to be the case. Indeed, if it did not make important information available to those who it thought could reasonably benefit from it, the board would be in breach of its duty.
In addition to NHS bodies, this information is currently also used to develop products for use by non-NHS organisations, by the devolved Administrations and international organisations, for which the board may determine it appropriate to charge a fee. It is for those reasons that we have framed the duty to share information in broad terms, and we would not want to be more prescriptive in the way that Amendment 65 proposes. Neither would we want to prevent the board charging a fee when appropriate, as would be the effect of Amendment 66. I think that it is reasonable for the board to determine how and in what circumstances it may impose charges for the information it provides. The power is intended to allow the board to seek adequate compensation for the services that it provides to other bodies where there would otherwise be no benefit to the health service. However, there is no scope for the board to charge for the advice and guidance that it would be required to provide for the purpose of maintaining and improving patient safety, and although there is provision for the board to impose charges, Clause 22, which inserts new Section 13Q(4), makes it clear that the board must give, not sell, advice and guidance to appropriate bodies to maintain and improve the safety of the health service. I hope that that is reassuring to noble Lords.
The noble Baroness, Lady Morgan, asked me about the monitoring of advice and what happens if they fail on that duty. CCGs will have an annual performance assessment by the board, which would assess how well they discharge their functions, including this duty to obtain advice. If a CCG fails to perform any of its functions, effectively the board can intervene and can take action. I hope that the clarification I have given is helpful and that I have sufficiently reassured noble Lords to enable them to withdraw their Amendments 57, 58, 59, 65 and 66.
Baroness Finlay of Llandaff
I thank the Minister very much. I beg leave to withdraw the amendment.
Baroness Thornton
My Lords, I support this group of amendments from the noble Baroness, Lady Morgan, which call on the NHS Commissioning Board to promote research supported by the health service for the purpose of protecting the public from disease and other dangers to health. These amendments also include the need for the board’s business plan to explain how it proposes to discharge its duty in respect of these issues to promote the NHS constitution and for the annual report, in particular, to contain an assessment of how effectively it has discharged this duty. We support these too.
The amendments underline the importance of embedding research in the NHS and we welcome the introduction of a research duty on the Commissioning Board and the intention to ensure that research is genuinely an integral part of the health service, as my noble friend, Lord Turnberg, and the noble Lord, Lord Willis, said. This is one part of the Bill which has genuinely been recognised and improved on by the Government. However, ensuring that the intention of their duty is clearly understood and sufficiently comprehensive is crucial. These amendments are designed to ensure this. Amendment 66A would ensure that there are clear commitments to research for which the board is accountable and Amendment 67AA requires the board to explain activity relating to the research duty. Both these provisions ensure that there are important monitoring mechanisms in place in the board’s business plan and annual report. As the noble Baroness, Lady Morgan, has stressed, they address an apparent anomaly which requires the board to report on improvement in the quality of services and on public and patient involvement but not on research, as the noble Lord, Lord Willis, said. We hope that the Government will accept these amendments in that spirit.
Earl Howe
My Lords, we had a very positive debate on the importance of research at an earlier stage of Report. I was grateful to the noble Baroness, Lady Morgan, for the support she expressed for the changes the Government have made to the Bill. I am more than happy to respond to these amendments this evening. I sympathise and agree with the noble Baroness’s championing of research in this Bill. She and my noble friend Lord Willis have been particularly vocal and well informed on this subject. Nevertheless, I am afraid I am reluctant to agree that the Bill needs yet more amendment. Having said that, I hope I can reassure the noble Baroness going forward.
On Amendment 60A, the duties on the Secretary of State, the board and CCGs to promote research and the powers to conduct research all apply to the health service in its widest sense. This encompasses both NHS and public health services under the 2006 Act. In relation to the board’s duty in new Section 13L, the duty to promote research on matters relevant to the health service already covers public health protection. Public health protection is a function of the Secretary of State under Section 2A of the 2006 Act and therefore part of the health service.
There are also other clauses in the Bill that focus specifically on research into health protection. Clause 10 lists research and other steps for advancing knowledge and understanding as examples of action that the Secretary of State may take under his wider duty in relation to protecting public health. Public health and health protection in particular will, of course, be predominantly the responsibility of Public Health England rather than the board. It is not therefore necessary for the board’s functions to cover such matters but there will, of course, be close working between them and there are powers under Clause 21 for the Secretary of State to arrange for other bodies, including the board, to undertake any of his public health functions if necessary.
Turning to Amendments 66AA and 67AA, we have had a number of debates about exactly what the board should give particular attention to in its annual business plan and its annual report. I would like to remind your Lordships that the board is already required to set out in these documents how it intends to exercise its functions including how it will meet the various duties placed on it under the Bill.
The Bill emphasises a very few key duties that the board must look at in particular in its business plan, annual report and performance assessments, and that CCGs must look at in their commissioning plans and annual reports. We feel that we have chosen the right duties in each instance. As to the board’s and CCGs’ annual reports, it is more important that they focus on the outcomes that have ultimately been achieved through the provision of services, rather than on the way in which those services are being delivered. On the whole, that is the distinction we have tried to draw.
My noble friend Lord Willis asked about Dame Sally Davies and her reporting lines. I am sure my noble friend will remember that I wrote to him on 17 November and briefly covered this point. In short, as he knows, the National Institute for Health Research is and will remain part of the Department of Health. Its budget is held centrally by the department. The Chief Medical Officer is and will remain responsible for the NIHR and its budget. In her capacity as Chief Scientific Adviser and head of the NIHR, she will report to Ministers and the Secretary of State, but she will be there to give advice to the NHS Commissioning Board if asked to do so on matters relating to research. Similarly, in her capacity as CMO, she reports directly to the Secretary of State, but will be there to provide advice to Public Health England. I hope that that is of help to my noble friend.
The noble Lord, Lord Turnberg, asked me how the local authority role in promoting research would be assisted and how that would manifest itself in practice. I should like to write a letter to him on that point because the planning on that is, if I can put it this way, work in progress and I hope that I will be able to tell the noble Lord a little more in writing in a few days’ time.
Lord Willis of Knaresborough
Before he sits down, will my noble friend tell the House whether he has made it clear in his remarks that the chief executive of the Commissioning Board will not have a direct relationship in terms of research, and will not have responsibility that will, in fact, be with the Chief Scientific Officer—the head of the NIMR? If that is the case, how on earth will the Commissioning Board have a relationship with the commissioning groups in terms of their duty to promote research?
Earl Howe
My noble friend is not correct. The board will have a duty to promote research, and we have debated that point. What it will not have is the budget for the National Institute for Health Research, which is held centrally. I think that noble Lords have welcomed that because it will mean that that budget is held separately from the board’s own budget. However, that does not absolve the NHS Commissioning Board from responsibility for promoting research. Indeed, it will do that and have responsibility in particular for ensuring that the health costs of research carried out in NHS establishments are covered under the various tariffs. That will be a major part of the board’s work.
I hope that I have reassured the noble Baroness sufficiently to enable her to withdraw her amendments, but I should of course be happy to talk to her outside the Chamber if there remain points that she would like to raise with me.
Baroness Morgan of Drefelin
There is one matter on which I should be really grateful for the noble Earl’s help. In his helpful response to this debate, he said that there will be some key duties on which the Commissioning Board will need to report in particular. Will he also remind us that the Commissioning Board should report on all its duties, because I am not feeling that reassured at the moment?
Earl Howe
I apologise to the noble Baroness. I thought I had made it clear that of course there will be a duty on the clinical commissioning groups to assure the board that they have fulfilled all their functions. We fully expect that research will be covered in that. These particular duties have been mentioned in the Bill only either because they are absolutely integral to the delivery of outcomes, or because they relate to a fundamental strand of accountability—namely, the duties to reduce inequalities, to improve the quality of services, and to promote public involvement and consultation. These really are central to everything that the board and CCGs will do. It is not because there is any greater obligation on the board to comply with them than there is in respect of any of their other duties. The same applies to CCGs.
Baroness Morgan of Drefelin
I thank the Minister, not only for giving me double reassurance in this debate, but also for the work that I know he has done personally to ensure strengthening of the research duty in the Bill in the first place. I also thank all noble Lords who took part in this debate. I withdraw the amendment.
“13LA Duty as to promoting education and training
The Board must, in exercising its functions, have regard to the need to promote education and training for the persons mentioned in section 1E(1) so as to assist the Secretary of State in the discharge of the duty under that section.”
Lord Beecham
My Lords, I warmly congratulate the noble Lord, Lord Mawson, not only on the substance of his amendments but on his sense of timing, because we are now very familiar with complaints from the voluntary and community sector in relation to the welfare-to-work programme. It was anticipated that the sector would be heavily involved in helping to place people into work, but, in practice, we have seen most of that endeavour carried out by much larger companies, with the sector playing a very limited role. It is precisely to avoid that outcome that the noble Lord has tabled his amendments. In particular, I am attracted to and wholly support subsection (2) of the new section proposed by Amendment 64A, which would confer on the board the capacity to,
“take specific action to support the development, including capacity building, of the voluntary sector, social enterprises, co-operatives and mutuals”.
That seems to me the kernel of the two amendments, which we very much endorse. In a mixed economy of provision, that sector needs to be developed and supported.
A further potential opportunity is raised by new Section 13W, on page 23 of the Bill, which confers on the board a power to,
“make payments by way of grant or loan to a voluntary organisation which provides or arranges for the provision of services which are similar to the services in respect of which the Board has functions”.
That may be implicit in subsection (2) of the amendment, although new Section 13W appears to limit that power to grant or loan to a voluntary organisation, which would not necessarily include the social enterprises, co-operatives and mutuals referred to in the noble Lord’s amendment. Perhaps the Minister, if he is sympathetic to the amendment, will look at whether the provision about grants and loans in new Section 13W might be expanded.
It is never too late for a little pedantry. I want to raise with the noble Lord, Lord Mawson, a couple of questions about the wording of parts of his amendments. Proposed subsection (1) of the new section proposed by Amendment 64A refers to the board exercising its functions,
“so far as it is consistent with the interests of the health service”.
I think that he means the interests of patients, rather than the service as such, which I would have thought more consistent with the general approach.
There is also a potential problem with subsection (3), which seeks, understandably, to provide that the board should take such steps as might produce,
“a level playing field between providers … meaning that one sector of provision is not more disadvantaged than another and relative benefits can be taken into account”.
That seems potentially to conflict with Clause 146 of the Bill, which would appear to rule out such a deliberate adjustment in favour of the sector. That is one good reason why my noble friend Lady Thornton will move an amendment to delete that clause and I hope that the noble Lord will support it.
A further question concerns a matter touched on by the noble Lord, Lord Newby, and relates to the second amendment, which, I confess, I do not quite understand. The amendment provides that the board may promote the inclusion of weightings in the procurement process,
“which reflect wider social, economic and health outcomes for each local health area”.
Does that relate to the conditions that exist at the time of the procurement rather than outcomes? I do not see how outcomes would fit and I am not clear what the weightings are. They cannot be only financial weightings. Is it to be a consideration to encourage the letting of contracts to the voluntary and social enterprise sector because of the particular nature of the locality? It is not clear and perhaps when the noble Lord replies he will—at least for my benefit— touch on that.
Interestingly, the two amendments relate to the part of the Bill dealing with the functions of the National Commissioning Board but purely to the health service provision, whereas proposed new Section 13M on page 19 refers to both health and social care provisions. I can understand why the amendment is limited in the way that it is, but I assume—again perhaps the noble Lord will confirm this—that he would envisage ultimately the same principle being applied to the provision of social care services. Is it not an illustration of the failure to develop the social care part of the Bill, which we touched on earlier?
Having said that, I strongly support the thrust of the noble Lord’s amendment and repeat my congratulations to him.
Earl Howe
My Lords, my noble friend Lady Tyler was quite right because the noble Lord, Lord Mawson, has spoken compellingly, as he always does, and I, for one, am grateful to him for the insights that he gave us.
I begin with an observation which I hope is incontrovertible: voluntary organisations, staff mutuals, co-operatives and social enterprises all play vital roles in delivering innovative, high-quality, user-focused services within their local communities. The Government firmly believe that such organisations have a strong role to play in the health and social care system. This is due to the experience, expertise and insights that they can offer to commissioners and the system more widely.
As I hope your Lordships will recognise, the Bill shows the Government’s commitment to fair competition that delivers better outcomes and greater choice for patients and better value for the taxpayer. We want to see providers from all sectors delivering high-quality, person-centred health and care services: we do not want to favour one type of provider over another.
The Government are also supportive of everything that the noble Lord said about the importance of social value and the key role that social enterprises and other organisations can have in building and promoting it. On my visit a few months ago to the Bromley by Bow Centre with the noble Lord I was able to see first hand the excellent work that Andrew Mawson Partnerships has done in reviving and stimulating the local community. One cannot fail to be impressed by this model and vision, which we know works and want to see more of.
Having said that, we need to pause and reflect because these amendments are unnecessary. Amendment 64A is not appropriate because it cuts directly across the role of the NHS Commissioning Board. Simply put, the role of the board is to be a commissioner, not to build providers. We are clear that no provider, whether due to its size or organisational form, should be given preferential treatment in the new system. The provisions introduced by Clause 22 prevent the board, and the Secretary of State and Monitor likewise, giving preferential treatment to any particular type of provider, be they public, for profit or not for profit.
I know that this has generated some concern among voluntary and community organisations. I would like to assure noble Lords and the sector that the board will still be able to make grants and loans to voluntary sector organisations. It will not be able to do that for the sole purpose of increasing the proportion of services provided by the voluntary sector. The board could, however, invest in voluntary organisations where they bring the credible voice of patients, service users and carers to inform commissioning and the development of care pathways, or where the sector’s expertise could contribute to the commissioning support required by CCGs and the board. Those are just some examples. The power—which we included in the Bill through an amendment in Committee in another place—mirrors the power that the Secretary of State has now under Section 64 of the Health Services and Public Health Act 1968, which is exercised by strategic health authorities and PCTs. Equivalent provision is also provided in the Bill for CCGs in Clause 25, inserted as new Section 14Z4 of the National Health Act 2006. Voluntary organisations should therefore have no reason to fear that they will be unduly affected by the new system. However, as drafted, Amendment 64A would disadvantage NHS trusts and foundation trusts for profit providers. As a result, I cannot accept it.
Lord Beecham
I thank the Minister for giving way. Could he clarify the situation? Does the voluntary sector, as he has described it, relate also to social enterprises, co-operatives and mutuals, or are they regarded as being in a different category and therefore not eligible to receive grants and loans under the provisions of the Bill as it now stands?
Earl Howe
My Lords, as regards grants and loans, we are clear that voluntary sector organisations and social enterprises—and I include bodies of that kind in the same grouping—are and will still be eligible for grants. The key is that those grants must not be given solely because they are voluntary sector organisations or social enterprises. It is a nice distinction, but really it means that voluntary sector organisations and social enterprises will still have to compete fairly for a contract on a fair playing field with other providers. As I have indicated, that means that NHS providers and others are not disadvantaged in the market for NHS-funded services. Nevertheless, the scope will still be there, and they are indeed classed as voluntary sector.
I am also grateful to the noble Lord for raising the important issue of social value. I can assure him that the Government are sympathetic to these principles. That is why the NHS procurement guide already enables NHS commissioners to take account of social and environmental outcomes in their procurement. The Department of Health has also, through its social enterprise fund, invested more than £80 million in the health and social care sector. To answer my noble friend Lord Newby, I am also fully aware of the support for these principles in the Public Services (Social Value) Bill currently being considered by noble Lords. Put simply, if that Bill receives Royal Assent, Amendment 64B will not be necessary. The Public Services (Social Value) Bill will make NHS organisations have regard to economic, social and environmental well-being in procurement, and the Government welcome that. The NHS procurement guide, as I said, already enables NHS commissioners to take into account other outcomes in procurement, and we will continue to encourage them to do that, so I think, in the NHS at least, commissioners will notice little change in the guidance that is given to them. Make no mistake, we see a valuable role in the future healthcare system for voluntary sector organisations, social enterprises, staff mutuals and co-operatives. However, that cannot be at the expense of other types of provider, including particularly NHS providers. I hope very much that your Lordships will agree that these two amendments are therefore unnecessary.
Lord Mawson
My Lords, I am most grateful to the Minister for what he has had to say. I am trying not to be difficult but to be practical. The future of the health service depends on practical details being got right in the machinery of the NHS, which is where I seek to draw the Minister’s attention. For me it is not about words about whether it is the health service, or patients, or words in an amendment; it is about what is actually going on in the machinery. I fear that the practice is still too little understood and that there is more work to be done here. I know that this is the beginning of a journey and that we have further to go with the various elements of the jigsaw.
The purpose of the amendments was really to draw the attention of the Minister and the Government to this and to encourage them to focus on the detail, and to encourage colleagues within the NHS to spend a bit of time with practical entrepreneurs who have to try to make this work. We want them to examine in a few details some real pieces of work where people have attempted through weightings and other mechanisms a level playing field—because people like me do not want special favours, but we do want a level playing field. All that I can say is that in practice it is not level. The Government aspire to a broader involvement in the health service with social enterprise and others in the voluntary sector but, unless those practical details are better understood and addressed, I fear something quite different will happen.
Having said that, I thank all those who have taken part in this debate and who helped me with the amendments—particularly the noble Lord, Lord Rooker, who is not in his place, but who has been very helpful. The noble Baroness, Lady Tyler, has also been very helpful. This is not a party-political debate; it is a practical matter that seeks to help to move the NHS on into new, more patient-focused reality. The amendments are simply an attempt to flag up yet again the issues. I beg leave to withdraw the amendment.
Health: Smear Tests
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Hussein-Ece
To ask Her Majesty’s Government whether they have any plans to reduce the age at which women in England first undergo smear tests, to bring it into line with that in Scotland, Wales and Northern Ireland.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, there are no plans at this time to extend cervical screening in England to women who are aged under 25. In England, cervical screening starts at age 25 in line with the recommendations of the World Health Organisation and the independent advisory committee on cervical screening.
Baroness Hussein-Ece
I thank the Minister for that reply. He will be aware that in Scotland and Wales the age when women are first called for a smear test remains 20. Is he further aware that around 1,000 women a year die from cervical cancer? Does he think that there is a real problem that not going for cervical screening is one of the biggest risk factors in developing this cancer, and almost half the women who develop it have never had a cervical screening test? Does he agree that while it is not possible to lower the age at this time of budgetary constraints, far more needs to be done to raise awareness to ensure that more women survive and these deaths are prevented?
Earl Howe
My Lords, I should make clear that it is not budgetary constraints that have prevented a lowering of the age but clear clinical advice. However, my noble friend is right about uptake. We are working with the NHS cancer screening programmes and stakeholders to refine the information that we provide to women when they are invited for screening so that all are fully supported to make an informed choice to attend. To tackle the issue of low uptake among women, particularly younger women aged 25 to 29, the National Institute for Health Research health technology assessment programme has recently commissioned a study, the strategic trial, to determine which interventions are effective at increasing screening uptake among women receiving their first invitation from the programme. This is work in train and we await the results with interest.
Lord Patel
Does the Minister agree that what might be important for reducing the incidence of cervical cancer is not so much the age when the screening starts but the vaccination against HPV in younger girls? I understand that the uptake of that is now rising.
Baroness McIntosh of Hudnall
Following that question, will the Minister tell the House how widespread uptake is and to what extent there is any difference between the various groups of young people in being prepared to take up the offer of vaccination? This is clearly the best hope that we have of bringing down the incidence of cervical cancer in the long term.
Earl Howe
The latest figure I have is that there is around 82 per cent uptake among eligible girls. However, for screening the uptake is lower. The figure I have for 2010-11 is that 78.6 per cent of eligible women had a test result in the past five years and 3.4 million women were screened. In the case of screening, it depends on whether the women themselves respond to the screening call. In the case of vaccination, it will depend on the attitude of parents and medical advisers.
Baroness Tonge
My Lords, will the noble Earl remind the House of what arrangements are being made for cervical cytology should the Health and Social Care Bill ever become law? Will he also reassure us that the excellent cervical smear campaign will not fall foul of the competing interests of local authorities and the clinical commissioning groups?
Earl Howe
My Lords, inoculation is not being offered to boys as part of the national programme. As I am sure the noble Lord knows, the aim of the programme has always been to prevent cervical cancer in women. Clearly, the best way to do that is to vaccinate girls and young women. However, these vaccines can be purchased privately and health professionals should exercise their clinical judgment when prescribing products for specific indications.
Baroness Hollins
My Lords, will the Minister explain what efforts are being made to ensure that uptake of both vaccination and cervical screening is good among girls and women with learning disabilities, particularly given their low awareness of the risk of cervical cancer and the high rate of sexual abuse among this population?
Earl Howe
My Lords, as ever, the noble Baroness raises an extremely important point about those with learning disabilities. I will need to write to her because my brief does not contain an explicit reference to them. However, I feel sure that the work to which I referred earlier—the strategic trial—will incorporate work to embrace all sections of the female population. I will write to the noble Baroness about that.
Health: Stroke Care
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Wall of New Barnet
To ask Her Majesty’s Government what assessment they have made of the consistency of care for stroke patients across England, and whether the progress made in London will inform the development of their policy on stroke care.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, stroke patients are getting faster and better treatment than ever before. The latest data show that more than 80 per cent of stroke patients spend the majority of their hospital stay on a stroke unit—a 20 per cent improvement since 2009. We want the stroke community to share and learn from what works, such as the London model of providing stroke services. The stroke improvement programme plays a central role in disseminating this knowledge.
Baroness Wall of New Barnet
I thank the Minister for his response. I remind him of the debate on stroke that we had very recently. The evidence is very clear that early intervention with stroke, as with many other diseases, plays a key part in ensuring that the cure is of longer standing. The noble Earl will know that last year’s CQC report highlighted the huge differences and inconsistencies in what happens. It would be good if we could have an assurance that the London model will be rolled out and taken on board by the national commission.
Earl Howe
My Lords, I agree with the noble Baroness that the London model has, indeed, been a model for others to follow. All Londoners now have 24-hour access to hyper-acute stroke care regardless of where they live, and London has one of the highest rates of thrombolysis for any large city in the world. It may not be appropriate to replicate precisely a model of care which works well in a densely populated capital as regards more rural areas, but that is where the expertise of the stroke improvement programme is essential in working with stroke networks across the country, sharing best practice and improving outcomes for stroke patients.
Baroness Gardner of Parkes
My Lords, is the Minister aware that although the London system is good, London has not always been at the forefront of this area? As the noble Lord, Lord Walton of Detchant, is not here to make the point, is the Minister aware that thrombolysis—the “clot busting” system—was introduced in Newcastle and was used there very effectively long before it reached London?
Baroness Gould of Potternewton
I, too, refer to the debate that we had recently on stroke. The Minister greatly praised the work of an organisation called Connect. I declare an interest as my daughter is a director of it. It is a third-sector organisation which works across the country but mainly in rural areas. Connect and many other third-sector organisations are worried that, in light of the squeeze on local authority and NHS budgets, their funding will cease and this wonderful and vital work will be lost.
Earl Howe
My Lords, we are well aware of the issue raised by the noble Baroness. Indeed, it was raised during the listening exercise last year. PCT commissioners are identifying all their clinical contracts as part of a stocktaking exercise and over the next year will be using the information collected to identify those contracts that are due to transfer to the new commissioning organisations next year. We will work with both providers and commissioners to ensure that there is a smooth transition and continuity of care for patients and service users.
Lord Clinton-Davis
Is the Minister able to give an assurance that stroke care networks and the help given by the NHS stroke improvement programme will survive after the current review undertaken by the Government?
Baroness Barker
My Lords, have the Government monitored the impact of individual health budgets which were introduced by the previous Labour Government? What effect have individual health budgets had on the commissioning and delivery of stroke services?
Earl Howe
My noble friend is right: individual health budgets have enormous potential in the case of stroke patients. I do not have any specific data on that in my brief, as it is still relatively early days for the personal health budgets. However, if I have further information to give her, I will gladly write.
Baroness Wheeler
My Lords, the CQC report highlighted huge problems for stroke patients in consistency of care and support after hospital discharge and for long-term stroke survivors in the community. Early supported discharge from hospital involves the majority of rehabilitation taking place at home and is therefore geared to the home setting, yet it is available in only 37 per cent of PCT areas. This is such an important area for progress and obviously a key way of refocusing resources into the community. How will the Minister ensure that this situation is addressed now and under the new health structures? Can he confirm to me that the CQC will continue to monitor the progress of the national stroke strategy and produce further special reviews, given that I understand the team which delivered this last report has now been disbanded?
Earl Howe
My Lords, the unwarranted variations in services are quite clearly unacceptable. The value of the CQC report is that it shines a spotlight on where variations in care need to be addressed. We believe that that will help all stakeholders involved in improving opportunities for people who have experienced a stroke. As regards post-hospital care, on which the noble Baroness rightly focuses, the accelerating stroke improvement programme, which is quite new, is already doing very good work. It was developed specifically to improve care in areas where progress needs to be faster, and that work will most certainly continue.
Lord Reid of Cardowan
My Lords, has the Minister yet had a chance to reflect upon this morning’s report that illustrates that survival rates and the reduction in the death rate from strokes, cancer, heart attacks and many other serious diseases have improved considerably over the past few years? By any standards, when comparing productivity in terms of quantity and quality, there has been a huge increase in productivity. Since the premise behind the Health and Social Care Bill was that there had been little or no increase in productivity in the National Health Service, will he share with us his reflections on that report?
Earl Howe
The premise of the Health and Social Care Bill is rather different from the one that the noble Lord cites. We believe that there is a damaging and avoidable variation in care across the country. Of course the outcomes in many areas of clinical care have improved immeasurably, as he rightly says, over the past few years—not least in heart attack and stroke. However, we still have some way to go and clinical commissioning, we believe, will take us in the right direction. Stroke features in two of the domains in the NHS outcomes framework, representing work that we have put in train: domain 1, “Preventing people from dying prematurely”; and domain 3, “Helping people to recover from episodes of ill health or following injury”. It is those measures to which the NHS will be held to account.
NHS: Management Consultants
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Royall of Blaisdon
My Lords, I beg leave to ask a Question of which I have given private notice.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Health and Social Care Bill and all related programmes require input from a wide range of civil servants, lawyers and other experts. Management consultants have been assisting Monitor, the developing Commissioning Board and others on specific issues. Consultancy spend has reduced very substantially since before the election. We have been transparent around spend of over £25,000 and on hospitality received by Ministers and civil servants. We have also answered all Parliamentary Questions and FOI requests on these issues, showing our commitment to openness.
Baroness Royall of Blaisdon
My Lords, I am grateful to the noble Earl for that Answer. Following recent press reports, I want to ask him about a specific management consultant, McKinsey. What payments has it received since May 2010 from the Department of Health and all other taxpayer-funded health bodies? If he is not able to tell the House that now, will he undertake to place this information in the Library of the House? Given that McKinsey seems to be setting the rules of the game in relation to the Government’s health Bill and then benefiting from the outcome, can the Minister declare unequivocally that there is no conflict of interest between McKinsey’s role in advising the Government on their health reforms and its commercial relationships with other clients?
Earl Howe
My Lords, I received notice of this Question just over an hour ago so I do not have precise figures about McKinsey. What I can say is that whereas the previous Administration in 2008-09 spent £100 million in the Department of Health on consultancy, my department has spent under £10 million on consultancy this year—very considerably less.
I read the article in the press this weekend which probably prompted the noble Baroness’s Question. I think we need to be careful before casting doubt on the integrity of public servants—and, indeed, of McKinsey. The article referred to Monitor. Those at Monitor are bound by very strict rules and procedures to ensure transparency and openness in all their dealings and to avoid any possible conflicts of interest. They follow those rules and procedures to the letter.
Lord Laming
My Lords, does the noble Earl take from this important Question the significance of having in place a robust implementation strategy should the Bill become law, because translating the aspirations of the Bill into day-by-day practice will be a considerable challenge? Can he assure the House that that will be attended to in the proper way?
Earl Howe
Yes, I can. The reform of the NHS is a major project. Frankly, it would be irresponsible if the Government were not to commission expert professional advice in undertaking a project of this kind. Consultancy, if used judiciously, can be highly cost-effective. I assure the noble Lord that the implementation of the Health and Social Care Bill is occupying our minds night and day and, so far, I am pleased to report that it is going well.
Baroness Jolly
Can my noble friend tell the House how many reports were written for the Department of Health by McKinsey between 1997 and 2010?
Earl Howe
I do not have the figure that my noble friend asks for. I do have a figure for the spend by the previous Administration between 2006 and 2010 on consultancy from McKinsey. That amounted to nearly £30 million. In 2005-06, just one year, the previous Government spent more than £170 million on consultancy services with Accenture plc.
Lord Campbell-Savours
Have civil servants been sharing information during the course of meetings with McKinsey people which McKinsey has been giving to its corporate clients? In other words, has McKinsey been discussing what has been going on in the formation of the Bill and the potential business benefits which arise from the Bill with its corporate clients? Have civil servants at any stage received any sponsorship for their travel or entertainment from McKinsey during the development of the Bill? Is it true that some meetings with civil servants and McKinsey have taken place at McKinsey headquarters in Jermyn Street in London? Does not that whole area of activity by McKinsey suggest that there is a conflict of interest which the public should know about at this stage in the development of the Bill?
Earl Howe
The noble Lord is, I think, insinuating some impropriety on the part of McKinsey and, perhaps, on the part of civil servants. I know of no such impropriety. Indeed, as I said earlier, there are clear and strict rules about transparency and openness. Declaring hospitality received is something that all civil servants and Ministers have to do. The results are published regularly. I will of course ask the question of McKinsey, which I have not yet had time to do. If I discover that there is any substance to the questions that the noble Lord has asked, I shall of course write to him and place a copy in the Library, but I very much doubt that I shall find any substance to them.
Lord Naseby
My Lords, as the Question refers to consultants and not to any specific consultant, is it not a fact that consultants provide a good interim role of management, suggestion or policy for consideration for Her Majesty's Government rather than their taking on ever more central staff? Is that not particularly appropriate, bearing in mind that the Prime Minister held a consultation on the whole of the Bill, as a result of which, as I understand it from listening to the debates in this House, changes have been made to the Bill which will have to be implemented pretty quickly? One can understand why consultants are brought in at the centre of the National Health Service. Surely on the whole it can only be healthy to have consultants there to speed up the implementation of this very important Bill.
Earl Howe
My noble friend is quite right. As I said earlier, the use of consultants—provided that that use is judicious and they are engaged in open competition processes—can be very cost-effective. It is a very flexible way of obtaining high-class advice without incurring long-term costs.
Lord Hughes of Woodside
Has McKinsey been given access to the risk assessment studies, which have been subject to some controversy in this House?
Lord Hamilton of Epsom
My Lords, surely one of the problems of the National Health Service is the wall of money that was thrown at a totally unreformed NHS by the last Government? Do we not need management consultants now to show us the way forward on the savings that need to be wrung out of the NHS so that it can survive into the future?
Earl Howe
Yes, we do, my Lords. Part of the benefit of the modernisation programme will be to streamline the architecture of the NHS so that year by year we will be saving £1.5 billion in administration costs and £3.2 billion net during this Parliament. We need good advice in order to achieve that.
Lord Winston
My Lords, the noble Earl said that this Government have spent less on consultants than the previous Government. Does he agree that, perhaps had they spent a bit more, we might have had a Bill that damaged the health service a great deal less?
Lord Brooke of Sutton Mandeville
My Lords, is my noble friend aware of the age-old aphorism among management consultants, of whom I was once one, although not at McKinsey, that 10 per cent of the work is diagnosis and 90 per cent is persuading the client to accept the advice?
Health and Social Care Bill
Earl Howe Excerpts(13 years, 4 months ago)
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Lord Hunt of Kings Heath
My Lords, I support Amendments 13 and 16. This debate follows on from our useful discussions on education and training last week. Once again, we see a tension between the need for a national strategy on education and training and the need for local ownership. Amendment 16 in the name of the noble Lord, Lord Patel, gives us that, and I hope that the noble Earl will be sympathetic to it.
We all know about the problems that have arisen in the past where there has not been sufficient national leadership. Decisions about training places have been left to local bodies and the budget has been squeezed, the result being that a few years later there have not been enough people coming into the National Health Service, which has had a very damaging impact. I think there is unanimity in your Lordships' House that there has to be a very strong national strategy.
I very much take the point made by the noble Baroness, Lady Emerton, that there must be co-ordination in workforce planning between Health Education England, as the national strategic body, and commissioners, but I would add providers because it is they who will employ the staff who have been trained. It is essential to get our workforce planning and our commissioning at a national level into sync. It is more an art than a science, and I suppose that it has never been achieved to 100 per cent satisfaction. None the less, that is what we should strive to do. Speaking as a foundation trust chair, I say to noble Lords who have discussed the national element of this that it is vital that NHS trusts and foundation trusts play a full part in the discussions. At the local level, the local education boards have a crucial role to play.
I very much support the argument of the noble Lords, Lord Patel and Lord Kakkar, on independent chairs and transparency. That is important, but it is also important that the education providers feel sufficient challenge from local NHS bodies when it comes to the quality of their education and training. I am sure that we will come later to the issue of nurse education and training. There are some real issues about the quality of nurse education and training in our universities. It is important that the local education bodies and employers provide sufficient challenge to the work of the universities. I hope that in accepting the need for an independent chair, noble Lords will agree that there should be no cosy relationship between commissioners, who ultimately have no real responsibility for the employment of staff, and universities. Unfortunately, the current system has led to too cosy a relationship. I look to the noble Earl, Lord Howe, for recognition that NHS trusts and foundations have to be very much around the table.
It would be useful if the noble Earl replied to the noble Lord, Lord Kakkar, and gave some sense about where postgraduate deans are to be placed within the new structure. I also hope that postgraduate deans will be able to recognise that in the new circumstances they can have a huge impact on NHS trusts and foundation trusts when it comes to their visitations. I also hope that clinical commissioning groups will recognise that if they are going to start shifting resources away from NHS bodies, that might have an impact on their capacity to provide education and training in the future.
That brings me to the point raised by the noble Lord, Lord Kakkar, about whether private providers will have contractual obligations with regard to education and training. It is important that there is a level playing field. If the Government insist on more contracts being placed with private sector providers in the future, there will have to be obligations on the part of providers. It would be grossly unfair and in the end it would not lead to the establishment of a national coherent system if private sector providers did not pay their fair share.
On governance, again, the noble Lords, Lord Patel and Lord Kakkar, made some substantive points about local education and training boards. It would also be helpful if the noble Earl responded to the point raised about academic science networks. We all agree that we must make the most of the fantastic basic education and science capacity in this country, and the links with the provision of patient care and the pharmaceutical industry. They have great potential. It would be useful to know how the noble Earl thinks they will fit into the new structure and particularly how they will link to the postgraduate deans and the academic science network. Overall, I am sure that the noble Earl will be able to come forward with a constructive response and I certainly hope that he is prepared to accept Amendments 13 and 16.
Earl Howe
My Lords, as I set out in our previous discussion on education and training, the Government are putting in place a strong national system for education and training, with a strengthened focus on quality outcomes.
We have introduced a clear duty on the Secretary of State to ensure that such a system is in place, and are now making good progress with establishing Health Education England and the local education and training boards. We are acutely aware of the importance of a safe transition to the new system and are proceeding with care and at a sensible pace to ensure the new system is fully up and running by April 2013.
As noble Lords will be aware, we have confirmed that we will set up Health Education England as a Special Health Authority in June 2012, so that it can take on some operational functions from October 2012 and be fully operational from April 2013, when it will take on the strategic health authority education and training functions. I repeat those assurances today. It will have an independently appointed chair and non-executive appointments. For this reason, we do not think that that part of Amendment 16, tabled by the noble Lord, Lord Patel, and others, which would place a duty on the Secretary of State to set up Health Education England as a new special health authority, is necessary.
I hope that the undertaking will be sufficient by way of reassurance to noble Lords on that score. Nevertheless, in addressing the more detailed issues set out in that amendment, it would be helpful to elaborate a little on what I was able to tell the House last week.
Lord Hunt of Kings Heath
On that welcome news, I assume that would mean that it would also not involve having a higher education chair and that, in fact, to have an independent chair means that they should be independent of commissioning, providing and university providing.
Earl Howe
That is a logical inference but, if I can get further and better particulars for the noble Lord, I would be happy to do so. Each local board will set up local advisory arrangements to reflect the breadth of local interest and ensure that its decisions are informed by clinicians, clinical networks and education providers. My noble friend Lord Willis and the noble Lord, Lord Winston, asked about “any qualified provider” and whether non-NHS providers will have to play their part. Yes, indeed; all providers of NHS services will be expected to participate in education and training activities, and Health Education England will invest only in organisations which do that. The answer to the question from the noble Lord, Lord Hunt, is indeed yes. He is correct.
By April 2012, we expect the strategic health authorities to establish sub-committees that will develop the emerging local education and training boards. The role of strategic health authorities to lead on education and training has been extended until April next year. When Health Education England is fully functional as a special health authority from April 2013, it will then, as I have explained, take on the responsibility for hosting the local boards. There are plans for a safe and effective transition to the new system, which will ensure that the strategic health authority functions for education, training and workforce planning, including the work of the postgraduate deaneries, are continued. LETBs will take on these education and training functions and it is expected that many SHA and deanery staff will migrate to the local boards to ensure continuity and essential skills and knowledge for the future, subject to affordability.
As I emphasised in our earlier debate, postgraduate deans will continue to be a critical part of the medical training arrangements. We expect LETBs to be able to demonstrate that their postgraduate deans will be able to act independently so as to be able, among other things, to provide challenge where necessary—a point raised, quite rightly, by the noble Lord, Lord Hunt. There will be systems and indicators in place to hold local education providers to account for the quality of education delivered by individual providers. Postgraduate deans will have all the powers that they have now to respond to any concerns about the quality of training, and to take action where required to improve standards and to assure the professional regulators, and indeed Health Education England, that poor performance is being tackled. In the new system, they will have support from the LETBs themselves and, if necessary, from Health Education England to challenge poor quality and behaviours.
Our proposed funding mechanisms reinforce that focus on quality by putting responsibility for education and training decisions in the right place, to be transparent so that funding follows the student on the basis of quality and value for money. The MPET budget will, as now, be predominantly provided to support the next generation of clinical and professional staff. Local boards will have some flexibility to invest in innovative approaches to continuing professional development and the education and training of the wider workforce. Health Education England will be responsible for developing a more transparent allocations policy for distributing education and training funding to local boards.
Now that the policy framework has been worked out, we need to push on and get the foundations of the new education and training system in place. We are doing that by establishing Health Education England and supporting the development of the emerging LETBs. It remains our intention to consolidate the functions of Health Education England by establishing it in primary legislation as a non-departmental public body. That will enable it to operate on a permanent statutory basis at arm’s length from the Department of Health while remaining accountable to the Secretary of State.
We want to do all this on the basis of consensus. We want to ensure that people with an interest have the opportunity to comment on and feed into the design of the new system, ahead of bringing forward the primary legislation in a second Bill. With that in mind, we intend to publish draft clauses on education and training for pre-legislative scrutiny in the second Session to ensure that the legislation is fit for purpose and to give Parliament an additional opportunity to scrutinise the proposals. I add that our vision for an education and training system that gives greater responsibility to employers and health professionals has been warmly welcomed.
As noble Lords will see, we have tabled amendments to strengthen links with the wider system. We have already discussed government Amendments 61 and 104, which would place duties on the board and on CCGs to promote education and training. These amendments were accepted in a previous debate. They are designed to ensure that commissioners of NHS services consider the planning, commissioning and delivery of education and training when carrying out their functions. The noble Lords, Lord Patel and Lord Warner, have tabled the very similar Amendments 62 and 106, and I hope that they will be reassured by the amendments that we have tabled and will feel able to withdraw them.
The noble Lord, Lord Patel, has tabled Amendment 13 on the role of providers. I say straight away that I am sympathetic to his intentions and I have given the amendment significant thought since it was first put down. In the beginning I thought that an amendment might not be needed, given that, in order to be established, LETBs will need to demonstrate that they meet robust authorisation criteria set by Health Education England, including demonstrating that all providers of NHS-funded services are fairly and properly represented in the LETB’s business.
At this point I shall answer the question posed by my noble friend Lord Mawhinney about the estimated costs of the amendment. I understand that Amendment 13 would be delivered by requiring commissioners to place a duty of this kind in their commissioning contracts. We do not anticipate any additional costs as a result of the amendment. Employers have told us and the Future Forum that they are keen to participate and play a leading role in the planning and commissioning of education and training through the LETBs, and of course we plan to legislate further for education and training, which will provide the opportunity to consider any duties that might be required of providers.
However, the amendment is satisfactorily drafted. In the light of what the noble Lord and others have said today in support of it, and in recognition of the strength of feeling on the issue, I can tell the noble Lord that I am willing to accept his proposal and support the amendment.
Lord Patel
My Lords, how can I put this? I am enormously content with all the things that the Minister has said about Amendment 16, which was badly drafted and defective but he has answered all the questions. I hope that all noble Lords who supported me will feel content that he really has been helpful. As far as Amendment 13 is concerned, I would much rather win it this way than by going through the Lobbies. I thank him enormously.
“( ) this Act,( ) the Health and Social Care Act 2008,( ) the Health Act 2009, and( ) the Health and Social Care Act 2012.””
Baroness Wheeler
My Lords, on behalf of these Benches, I would like to support Amendment 17 in the name of the noble Baroness, Lady Masham, to which I have added my name. As we did in Committee, we have again had an excellent debate, which I believe has gone a long way towards addressing the concerns expressed by some noble Lords during Committee and during this debate about making the duty of candour statutory, as well as demonstrating why the Government’s approach of relying solely on a contractual duty will not work or lead to the sea change in culture in the NHS that is needed to ensure openness and honesty when things go wrong in the care and treatment of patients.
The case for the introduction of a statutory duty has been forcefully made by the proposers and supporters of the amendment, and I shall not go over the issues again in detail. The amendment from Committee has now been substantially redrafted to ensure that there is no duplication or clash with the professional regulation and that the duty of candour applies only to actual patient-safety incidents, as already defined in statute. Thus we would no longer face the problem of how to define whether or not an incident is serious or harmful or whether it could lead to potential harm in future, a consequence feared by some noble Lords and by the Minister in his response to the Committee debate. Instead, our amendment would amend the current Care Quality Commission (Registration) Regulations by drawing on the actual text used in those regulations, requiring patient safety incidents which cause harm to patients to be notified to the CQC. The effect would be to place a statutory duty on any organisation registering with the CQC to,
“take all reasonable steps to ensure”,
openness with patients when things go wrong and cause harm. The definitions of harm and the organisations to which the duty would apply are exactly the same as those currently used to require notification of incidents to the CQC.
The Government's main arguments against statutory duty of candour are threefold: first, that implementing the contractual duty would suffice, and bring the responsibility for requiring openness closer to patients and with clinician-led commissioners; secondly, that the current consultation exercise on the contractual duty has only just closed and the Government need to analyse the responses—not much of an argument when the Government ruled out introducing the statutory duty in that consultation; and, thirdly, that existing provisions including the professional codes of practice, National Patient Safety Agency policy guidance and the requirements of the NHS constitution, with the new contractual duty, will address the problem.
However, as noble Lords have said, existing provisions exhorting NHS organisations to openness and health professions to openness and disclosure are not changing the culture of denial, obfuscation and blame that is so deeply embedded in many parts of the NHS when things go wrong. The instances of serious failure in care and treatment that have led to the campaign by patients’ organisations are, as we have heard, deeply shocking and tragic. Expecting CCGs to have the strength and will to take on powerful providers that have failed to be open and to enforce remedial measures without the support of a statutory authority will not achieve the changes we need.
On the role of the CQC, noble Lords have more than answered the Government's reservations. It is an appropriate role for the regulator and the new duty of candour would not require detailed monitoring of individual incidents or communications with patients, but could be reinforced by the CQC by using its guidance already in existence and setting it alongside all the other essential standards of quality and safety which have statutory force. I hope the Minister will reconsider his position and accept in principle that the duty of candour should be statutory, and incorporated into the Bill.
We of course recognise that there would need to be considerable work and consultation undertaken with all stakeholders to introduce and implement the statutory duty of candour. The work around implementing the contractual duty could be put to good use in this effect, as it would complement the statutory duty. Moreover, putting the principle into the Bill and working out later how it is to be implemented has been a central feature of most of the Bill's provisions, so it can be applied in this case. Tuesday’s letter in the Daily Telegraph from all the leading patient organisations emphasised that the introduction of a statutory duty of candour,
“would be a historic step forward for patients’ safety and rights”.
On these Benches we endorse this, and I hope that the Minister will now reconsider his position and accept this amendment.
Earl Howe
My Lords, this has been an excellent debate and I would like first to pay tribute to the noble Baroness, Lady Masham, for her tireless advocacy of the need for openness and transparency in the NHS. She spoke very powerfully. What struck me from the debate is the consensus that there seems to be on all sides of the House on three key points. First, there is agreement on the importance of openness and candour in healthcare, and I think we would all accept that the NHS could only call itself a world-class health service if it embraced openness wholeheartedly. Secondly, there is agreement that at present there is significant room for improvement, the story of my noble friend Lady Hussein-Ece being a case in point. While areas of the NHS, such as Barnet and Chase Farm, are already providing exactly the transparency we wish to see, that is not by any means universal. Thirdly, there is agreement that something needs to change.
I, too, am in complete agreement with those points. I agree that we must do all that we can to encourage the development of a culture within the NHS that supports people to disclose where errors have occurred, so I am at one with the noble Baroness in her intention in tabling her amendment. The question before us is not whether we should do something but what we should do. We need to ensure that the route that we choose gives that good intention the best chance of succeeding. I note from today’s debate that opinion has not been all one way.
Lord Harris of Haringey
My Lords, is not the point that the contractual obligation that the Government are proposing would in effect be triggered only by the reporting of an incident to the CQC? Is it not also the case that the contractual obligation that the Government are talking about would not apply to primary care?
Earl Howe
I will move on to primary care in a moment, but I do not agree with the noble Lord at all on his first point. What we see happening from a contractual requirement is a process of culture change taking the form of conversations between management and clinicians about the fact that this was something that the organisation had to focus on. I do not agree that it will arise simply by reason of reported incidents.
As I said, any disagreement that I have with the noble Baroness is not out of any difference of intent; it is because of a difference of opinion about what we feel would work. Her amendment would require the Secretary of State to act with a view to securing that any CQC-registered organisation providing healthcare was required—we should perhaps log that word—to take all reasonable steps to ensure that a patient or their relatives were informed of a serious patient safety incident.
The key points here are around a requirement in relation to CQC-regulated healthcare. Any requirement must come with enforcement, otherwise it is not a requirement. The amendment as drafted would extend to providers of purely private healthcare—that is, non-NHS-funded healthcare—which suggests that any requirement would have to be enforced by the CQC. I and my officials have spoken at length with CQC colleagues regarding this. In response, the CQC has clearly stated that it would not be able to routinely monitor and enforce such a duty. This is not due to attaching less importance to this issue than to the others areas that they regulate. It is the very nature of openness that when errors occur, it is not easy to detect routinely where a lack of openness has occurred. When a patient or their relatives are not told of an error and the incident is not reported, it is often very difficult to discover that there has been a failure by an organisation to be open. The only way to fulfil this requirement would be to verify that openness was happening and, given the very nature of the issue, that would not be possible for a national regulator. It would require it to prove a negative—in this case, that people were not told about something going wrong with their healthcare.
Lord Harris of Haringey
I am grateful to the Minister for giving way again, but I am now genuinely confused about why this is different. His argument seems to be that a contractual arrangement—we will come back in a moment to the question of who that will cover and whether it will cover primary care—would magically produce a change in culture but that a statutory obligation, applying to all providers registered with the CQC, somehow would not. This is not about requiring the CQC to monitor every interaction with a patient; it is about creating that culture change and a clear sense of obligation—you cannot be registered as a provider with the CQC unless you are committed to doing this.
Earl Howe
My Lords, I hope that the noble Lord will allow me to remind him very respectfully that we are on Report and not in Committee. I am trying to work through my arguments, which I hoped would have a flow to them, but my flow has been interrupted. I am getting to what I hope he wants me to get to.
I was saying that the amendment would effectively require you to prove a negative—in this case, that people were not told about something going wrong with their healthcare. If they were not aware of the error, they would not be aware that they had not been told about it, and the volume of incidents is such that a single national body could not possibly verify compliance with that requirement.
I know that the noble Baroness advocates that the CQC should not routinely monitor this duty and instead should require organisations only to provide evidence that they encourage openness through having appropriate procedures and policies in place. Unfortunately, what that creates—this point was made by my noble friend Lord Ribeiro—is a tick-box exercise. Organisations can provide all the assurances in the world that processes are in place and therefore they are considered to be compliant, when in actual fact it could be that patients were still not being told about errors in their care. That is not acceptable and would not deliver the culture change that we need. We must have a requirement that ensures that patients are told of errors, not one that pays lip service to this and allows organisations—
Baroness Young of Old Scone
I was not intending to speak on this amendment but, as the former chairman of the Care Quality Commission, I have to make a point.
Baroness Young of Old Scone
I merely want to ask the noble Earl what the material difference is between this requirement being laid on organisations by the CQC and many of the other basic requirements that are laid on organisations by the CQC. Those organisations are not inspected in detail on an ongoing basis, but the requirement is intended to seek from providers of health or social care an outline of how they intend to deliver that requirement, without their being inspected regularly in all cases.
Earl Howe
My Lords, I hope I have already explained that. In our conversation with the CQC, it made very clear that this would not be like any other requirement placed upon it. A requirement to prove candour will require the CQC to engage in a much more continuous and intensive process of monitoring than some of its other requirements. That was the distinction that it made and that is why it said that it did not have the capacity to fulfil this duty if it were built into the Bill.
I am afraid that the amendment would not be effective in meeting our shared objective. That is my problem with it. I have listened to the arguments put across by noble Lords in relation to primary care. I want to see openness in primary care as much as I do in secondary care. However, we still need to consider which requirements would work best in primary care.
Baroness Kingsmill
Can the Minister explain the distinction and why we cannot have both? It seems that culture change is best reinforced by legislative change, and the contractual point that the Minister made is a good idea.
Baroness Northover
For clarification, can I point out that only the mover of an amendment or the noble Lord in charge of a Bill should speak after the Minister on Report, other than for short questions of elucidation to the Minister or where the Minister speaks early to assist the House in debate? As this makes very clear, it is possible for a noble Lord to ask a short question about what the Minister has just said, but he or she should not introduce other speeches.
Earl Howe
The question of the noble Baroness relates back to something that I said some time ago. The answer is that we believe that culture change stands the best chance of happening when you bring home to those with direct responsibility for patient care that it is in the contract of the organisation that it must be candid. There are different views about this. I do not disagree with the noble Baroness that, in some cases, regulation is the right way to go. I will say a little more about that in a moment, as I wind up.
I was just talking about primary care in sympathetic terms. We need to remember that other requirements for openness still apply to all NHS services. All primary medical service contractors must have regard to the NHS constitution, professional codes of conduct, any guidance issued by PCTs or the Secretary of State and so on in relation to openness. Once they are registered with the CQC, a failure to be open with patients contravenes clear expectations set out in CQC guidance. The CQC can then take action. Therefore, primary care contractors currently have no excuse to avoid telling their patients about things going wrong with their healthcare. However, I acknowledge the concern of the noble Baroness, Lady Finlay, and others that primary care contractors will not be covered by the current proposals for a duty of candour in the NHS standard contract. Any contractual amendment in relation to primary care contractors is a more complex process, requiring amendments to secondary legislation, among other things. Specifically because of this, we asked for views on this in our recent consultation, which closed at the end of last month. I can confirm to the House today that we are giving further thought to the issue of primary care and the duty of candour in light of the consultation responses we have received. They are complex issues. I hope noble Lords will understand that I cannot prejudge the careful analysis that is already under way in deciding how we go forward in this area. However, it is something that we are actively considering.
Earl Howe
My Lords, during the passage of the Bill we have had much discussion about the importance of freeing front-line professionals from needless bureaucracy and ensuring that they are able to focus on patient care—not least when we considered the duties of autonomy. This is one area where the House is in agreement. Certainly one aim of the Bill is to reduce bureaucracy and micromanagement, prevent politicians in Whitehall second-guessing the decisions of doctors and nurses, and streamline the architecture of the NHS.
The noble Lord, Lord Hunt, indulged himself in one of his occasional rhetorical forays, which I enjoyed. However, the amendment is rich coming from him. Perhaps I should remind the House that the previous Government did to management costs what the noble Lord accused us of doing. Since 2002-03, the management costs of PCTs and SHAs have increased by more than £1 billion—a rise of more than 120 per cent. The Bill aims to get a grip on a problem that under the previous Government simply got out of control. The noble Lord will know that my department has confirmed an overall running-cost budget of £492 million. That represents a 50 per cent reduction in costs and staff compared to the current cost of functions that will transfer to the board. At board level, the work previously done by 8,000 people will be done in future by approximately 3,500 full-time equivalent people. That is a major reduction.
The amendment tabled by the noble Lord seeks, first, to introduce a new duty on the Secretary of State to prevent bureaucracy and, secondly, to minimise the layers of management tiers within the Commissioning Board. The noble Lord produced a confection of arguments to bolster his case that bureaucracy in the NHS is increasing rather than diminishing. I can tell the House that the opposite is true. In saying that, I should stress that I am not in any way denigrating NHS managers. I have never done that and I will never do it.
Setting aside the noble Lord’s knockabout routine and getting back to earth, I agree with the principle behind this amendment. Noble Lords will already be aware of the autonomy duties, which we have recently amended, in no small part due to the Constitution Committee. Those duties ensure that proper consideration is given to whether any requirements or objectives set by the board or the Secretary of State will place unnecessary burdens on the health service or distract from good quality patient care. In addition, the Bill places duties on the NHS Commissioning Board, CCGs and other bodies to exercise their functions effectively, efficiently and economically. That is in new Section 13D of the National Health Service Act 2006 for the board and new Section 14P for CCGs. Together, I believe that these provisions ensure that the duty to maximise efficiency and minimise bureaucracy is embedded throughout the system. We do not need anything further.
The noble Lord, Lord Warner, asked me a question that I have been asked before in these debates. It concerned why we did not simply reform the PCT model. We chose not to try to reform the PCT model because it would not have delivered the empowered clinical commissioners we want to see and, indeed, the Opposition want to see. This Government supported the principle of practice-based commissioning, but there is one thing to say about practice-based commissioning: it was not working. It did not live up to the ambitions that people had for it. Central to this was clinical commissioners’ lack of autonomy. Only by conferring functions directly on clinical commissioners, as this Bill does, can that autonomy and responsibility be properly established.
Subsection (a) of the noble Lord’s amendment refers rather bafflingly, as my noble friend Lord Fowler pointed out, to a minimum level of management tiers. I am not quite sure how that would be interpreted by the courts, but I believe that the noble Lord is drawing attention to the published proposals for the board’s organisational structure. In line with the vision we set out in the White Paper, the proposals put forward make clear that the board will be a single nationwide organisation that will work across the country to improve quality and outcomes. However, there are some who have focused on the board’s proposal for a maximum of five layers of management, claiming that this represents some sort of increase rather than a reduction in bureaucracy. That is not the case. The structure proposed by the board is based on sound and well recognised principles of effective organisational structure. The proposed organisational structure for the board is designed above all to support it in its overarching role to improve health outcomes. What surely matters is the board’s efficiency and effectiveness. In fact, as I have already said, the board will operate with a 50 per cent reduction in running costs in comparison with the current system. I am not attracted to the part of the amendment that requires the Secretary of State to influence the number of management tiers in the NHS Commissioning Board. Apart from being inappropriate, it is unnecessary. The Bill already makes clear that the Secretary of State sets the resource limit for the board and new Section 223E of the 2006 Act allows him to impose a cap on administrative spend. Together these provisions ensure that financial limits are placed on the board, which will necessarily influence the way in which it is structured. However, I believe it would be inappropriate for the Secretary of State to go any further than this in influencing the organisational design of the board. The board is the body best placed to determine how to organise itself in the most effective and efficient way. It is therefore our intention to allow it as much autonomy as possible in determining its own membership, structures and procedures.
All our proposals for modernising the NHS, including the provisions in the Bill, are designed to minimise bureaucracy, micromanagement and unnecessary waste to enable the whole system to focus on what really matters, which is patient outcomes. For example, the outcomes framework will directly link quality improvement and outcomes with commissioning; clinically-led commissioning groups will be judged, through the commissioning outcomes framework, on whether they improve patient outcomes and experience rather than process targets; the NHS Commissioning Board will hold GP commissioners to account for their performance against NICE indicators; and CCGs will hold providers to account for driving up quality improvement using contracts and incentives. It is quality and outcomes that matter and with the safeguards already in place to limit administrative spend throughout the system, I believe that the noble Lord’s amendment is unnecessary. I hope that he will feel able to withdraw it.
Lord Hunt of Kings Heath
I must say that I am really rather disappointed by the noble Earl’s response to my constructive amendment. He does not seem to have answered the charge that is being made. First, I think we are all agreed that when we talk about bureaucracy we are not talking about the fine managers that the NHS has to whom we owe so much. This is an argument about the structure, the layers and the cost of a market that the Government wish to bring in to the health service. It is not about managers in the health service.
The fact is that the Secretary of State and his colleagues, including the noble Earl, have continued to intervene in the health service on a daily basis. They have yet to explain how, if this Bill eventually receives Royal Assent, at that point, magically, Ministers are going to step back and simply let this new system continue. I do not believe a word of it. What I believe will happen is that on the one hand you will have this complex structure where the mantra is that it is all arm’s length, it is all down to the clinical commissioning groups, the market and the gentle guidance of Sir David Nicholson and his colleagues at the national Commissioning Board, and Ministers can simply step back. It will not happen. What we will have is the system that the Bill enacts, if it is enacted, and Ministers continuing to micromanage. It is inevitable that Secretaries of State are accountable to Parliament, and they will be required by the very process of parliamentary democracy to continue to intervene and to take a close interest in what is happening. That is the charge I put to the Government as to why I believe that this is going to be a very complex situation indeed.
It is always good to debate with the noble Lord, Lord Fowler. Twenty years ago, I enjoyed debating with him issues mainly to do with the funding of the National Health Service. I think the National Association of Health Authorities and Trusts was a very modest organisation. It was very lean and certainly not subject to the strictures of the noble Lord who suggested that it was part of the bloated bureaucracy that I think he was implicating me in. He does not like the idea of declaratory law. That is all very well, but what is Clause 4 but a declaratory statement: “The Secretary of State’s duty as to promoting autonomy”? Indeed, the noble Earl, Lord Howe, referred to it in his winding-up speech. I have to say to him that if the duty of autonomy were currently on the statute book, I do not think that he could have brought this legislation in under it because it states that,
“unnecessary burdens are not imposed on any such person”.
This whole edifice is going to impose enormous burdens on many such people within the National Health Service.
The noble Lord, Lord Fowler, referred to the Griffiths report—at 24 pages, it was a remarkable letter which had a long-term impact on the health service. He will recall that we were very strong supporters of the introduction of general management. I am very concerned about the structures that are now being brought in because they may well inhibit the kind of leadership and clinical engagement that we saw as a result of the Roy Griffiths management inquiry.
I have to say to my noble friend Lord Harris that the description of Sir David Nicholson as the chief inquisitor was a little unfair.
Lord Hunt of Kings Heath
My Lords, Amendment 19 comes back to a theme which takes us to the overriding responsibility of the Secretary of State for a comprehensive health service and to the relationship between the Secretary of State and the national Commissioning Board. I do not want to go over the ground that we went over in the previous debate but I want to make just two or three points.
The Minister will recall that in Committee we debated the whole question of the concurrent power being given to the national Commissioning Board in relation to the Secretary of State’s responsibilities in Clause 1. Given Clause 1 and our really important debates on it, and the welcome agreement on the first day on Report regarding the way in which an amendment was accepted to make clear that the Secretary of State is accountable to Parliament for NHS provision, I remain concerned as to whether it is right that a body such as the national Commissioning Board should carry such responsibilities as well—that it should have a concurrent responsibility and duty.
Surely, ultimately, the national Commissioning Board is a secondary body as compared to the Secretary of State. The very fact that there is a mandate in which the responsibilities and duties of that board are laid down on a regular basis by the Secretary of State reinforces the proper relationship between an unaccountable body, such as the national Commissioning Board, and an accountable person, such as the Secretary of State. I should be grateful if the Minister would give further reflection as to whether a concurrent power really is the appropriate way in which that relationship should be set out.
Of course, that is associated with the power of intervention by the Secretary of State. It seems to me that in the end, since the Secretary of State is accountable to Parliament for provision and for ensuring a comprehensive service, if he feels that the national Commissioning Board is not doing the right thing or that there is a matter which requires the intervention of the Secretary of State, it is right that that intervention can be taken out without obstruction or legislation. In my view, that would lead to a confusion of role as between the Secretary of State and the national Commissioning Board.
When we discussed this issue in Committee, I asked the Minister what would happen if there was an issue. Let us take, for instance, some of the recent interventions by the Secretary of State. He has expressed concern about the way in which primary care trusts have manipulated waiting lists. Rightfully, in my view, he sought to intervene. How would you do that under the new arrangements if clinical commissioning groups or some individual clinical commissioning groups were not doing what the Secretary of State thought to be appropriate?
From our debate in Committee, I had the impression from the Minister that in those circumstances provision could be made in the mandate set for the board by the Secretary of State. I can see that every so often you can alter the mandate to deal with an issue like that. But sometimes he will need to intervene rapidly rather than have to wait for the process of a mandate to be set. I also suspect that there is a risk that the mandate could become very detailed and prescriptive—in other words, the micromanagement that the Minister is so keen not to see introduced. There will be issues that arise during the year which might not have been envisaged when the mandate was drawn up.
The noble Earl may well say that we will have the intervention powers set out in proposed new Section 13Z1 set out on page 24. My problem with this is that the wording constrains the intervention because it has to be based on a failure to discharge or a failure properly to discharge any of its functions, and the failure is significant. Of course, the intervention none the less is based on what the Secretary of State himself considers, and no doubt he would always be properly advised by his officials and, in extremis, the Government Law Officers. But I can envisage situations in which the NHS Commissioning Board actually rejects the Secretary of State’s view and where it would be deemed that the issue is not one that comes under the auspices that could lead to intervention under Section 13Z1. I think that there should be a clear right in the Bill for the Secretary of State to have a power of direction.
In the end the sole accountability of the national Commissioning Board has to be through the Secretary of State and thus to Parliament. The board is not elected; it is an appointed body. There has to be full accountability, and for me, one element of that accountability is that the Minister responsible to Parliament has the right to tell that body what to do. I feel very uncomfortable with a body that is floated off. Okay, we have the mandate, but in the end it is not an accountable body except through the relationship it has with the Secretary of State, so it is right that the Secretary of State should issue direction powers without being fettered as I believe he is in Section 13Z1.
I do not think I need to mention the other two amendments at great length. Amendment 23 merely tries to encourage the noble Earl to say that clinical commissioning groups have the function of safeguarding the comprehensive provision of NHS services. It is very important that within all the autonomy that the Secretary of State wishes to give the clinical commissioning groups, it is made clear that they must, none the less, sign up to the overriding responsibility of anyone involved in the NHS to ensure that comprehensive provision is safeguarded. Amendment 70 is really consequential on Amendment 19. I beg to move.
Earl Howe
My Lords, Amendments 19 and 70 seek to reintroduce the Secretary of State’s powers to direct the health service. I have listened with care to what the noble Lord has said, but I continue to believe that this would be a retrograde step on every count, not least that of transparency. Under the Bill as it stands, the Secretary of State will be able to set objectives and requirements both through the mandate and through “standing rules” regulations under Clause 19, but unlike directions, these would be subject to full scrutiny, and the Bill creates a clear expectation that they would be set only once a year in order to provide certainty for planning. Ministers would also have robust intervention powers in the event of significant failure, as the noble Lord mentioned.
The system we are creating is designed to be predictable, transparent and structured, and will provide stability for the health service. I think that this is a better approach than allowing the Secretary of State to direct the health service whenever he wants, which risks returning us to the unpredictability and opaqueness of the current system. The noble Lord described the Commissioning Board as “unaccountable”. I must scotch that myth. The Secretary of State will have wide-ranging powers over the Commissioning Board, most prominently through the mandate and the standing rules, which will enable the board to be held rigorously to account. In addition, the board will have to meet in public, produce a business plan and an annual report, both of which will have to be laid before Parliament. Further, I would remind the noble Lord of Clause 51, which covers the,
“duty to keep health service functions under review”.
The process of holding the board to account is not a once-a-year task. In turn, the Commissioning Board will hold CCGs to account for the quality outcomes they achieve and for financial performance—and, again, will have the power to intervene where there is evidence that CCGs are failing or likely to fail to fulfil their functions. If the Commissioning Board fails to hold CCGs to account, the Secretary of State could then direct the board to do so. If the board failed to comply with that instruction, the Secretary of State could either discharge the function himself or make arrangements for another body to do so on his behalf. So it is quite wrong to say that there are no levers available to the Secretary of State.
I turn now to Amendment 23, which emphasises the need for clinical commissioning groups to safeguard,
“the comprehensive provision of NHS services”.
Noble Lords will recall that the House has already agreed an amendment to Clause 12 which explicitly requires CCGs to act consistently with the discharge by the Secretary of State and the Board of their duties to promote the comprehensive health service, and with the objectives and requirements in the mandate.
I fully appreciate and support the intentions behind this amendment, and I hope that the discussion we have already had and the amendment we have already discussed to Clause 12 will offer the noble Lord a reassurance that the effect of this amendment is already covered in the Bill. In the light of what I have said, I hope that he will feel able to withdraw the amendment.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl, Lord Howe, particularly for his remarks in relation to Amendment 23. Clearly we are not going to agree about this matter. I do wish that the late Lord Marsh could still be present because he would have enjoyed these debates. I think that he would have reminded us of the traditional relationship between the chairman of the board of a nationalised industry and the Minister responsible to Parliament. Although we have lost those nationalised industries, in one sense the Department of Health is now busily engaged in setting up the kind of structure that in many ways is akin to those industries. That is because the chairman and chief executive of the national Commissioning Board are, in essence, being handed a huge amount of power by the Secretary of State. They are to be given the budget, the mandate and the standing rules, and are to be told to get on with it. If we go back to our experience with the nationalised industries, of course it never worked because there was a continuous tension between the board of a nationalised industry and the Minister which arose from the fact that the Minister was accountable to Parliament for the running of the railways, iron and steel and the coal board.
That is exactly what we are constructing today. We have the myth that simply by having a mandate and standing rules, we can say to the national Commissioning Board, “Get on with it. I as a Minister will no longer intervene unless in extremis”, under the circumstances set out in Bill. Life is not like that. Parliament will continue to debate the health service, issues will arise and Ministers will make pronouncements. I do not believe for a minute that the 12 or so pronouncements we have heard from Ministers over the weeks that this Bill has been in your Lordships’ House will not be followed by similar pronouncements under the new structure. They will be forced to do so because Parliament will require it. That is the risk and why I believe it is such a complex system. On the one hand there is a structure which is based on an arm’s-length relationship, a market, with clinical commissioning based on a mandate, while on the other hand there is still the Secretary of State who will be fully held to account in Parliament. There will be enormous tension and great confusion within the National Health Service. For that reason, there is a strong argument for accepting that, in the end, the Minister is accountable and ought to have a power of direction. Saying that this can be done through a mandate and standing rules is not realistic, and no doubt, if the Bill is enacted, we will see this played out. I do not think anyone should be under the misapprehension about the fact that we are building into these arrangements a very unstable situation. But we have had a good debate, and I beg leave to withdraw the amendment.