Medicines Act 1968 (Pharmacy) Order 2011
Earl Howe Excerpts(12 years, 6 months ago)
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EU: Food Labelling
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we welcome the new regulation. The UK has led the way in Europe in improving nutritional information for consumers. Access to nutritional information supports consumers in choosing a balanced diet and can help in controlling calorie intake. The regulation meets our main negotiating objectives and will give the UK freedom to maintain and build on existing practice.
Baroness Oppenheim-Barnes
My Lords, I am a little astonished by that response. Is my noble friend aware that I have campaigned for many years in your Lordships’ House for clear, uniform food labelling on pre-packaged goods for easy comparison? The FSA produced such labelling, which I understand was approved by all five Select Committees but was rejected by the EU, which has now produced something futile, pathetic and unenforceable, to put it mildly. Does my noble friend agree that it is time for the proverbial worm to turn and to tell the EU that we do not want its version—we prefer our own?
Earl Howe
My Lords, I am not sure that I would accept the epithets that my noble friend has applied to this regulation. We have led the way in these negotiations. It is true that it has taken some time but we have come away with most, if not all, of our key objectives met. Nutritional information will now be displayed in a consistent manner on the back of all pre-packed foods, which is a major plus. A voluntary approach has been secured for front-of-pack nutrition labelling and for non-pre-packed foods, including those sold by caterers. It will also be made easier for alcohol companies to include energy information on their products on a voluntary basis. This will give people the information they need to make informed choices about what they eat and drink, which is the whole idea.
Baroness Howarth of Breckland
My Lords, is that truly the view of the Foods Standards Agency? I understand that we have different policies being developed in England, Scotland and Wales, but without differences being truly ironed out. I also understand that we have three departments—Defra, the Foods Standards Agency and the Department of Health—working at this in England alone. Does the noble Earl not think that there is room for confusion and a lack of cohesion when we do not have better co-operation?
Earl Howe
I take the noble Baroness’s point. Obviously, the Government would like to see greater consistency in front-of-pack labelling. We know that, if we can achieve it, that is likely to increase consumer understanding and indeed the way that consumers use the information. Now that the regulation is finalised, we have the opportunity to discuss with all stakeholders the way to achieve that. It is advantageous that there is the flexibility available for us to do that.
Baroness Parminter
My Lords, this country has one of the highest rates of obesity in Europe. France is taxing sugary carbonated drinks and Denmark is taxing fatty foods. Regulation is one thing, but can the Minister confirm that the Government are looking seriously at the potential of such fiscal measures to address this ballooning health problem?
Baroness Thornton
My Lords, I congratulate the noble Baroness, Lady Oppenheim-Barnes, on her Question but I have to say that I think her target should not be the EU but actually her own Government. If you put “food labelling” into a search engine, you will get hundreds of different versions of how food can be labelled. It feels like we are going backwards because of the flexibility that the Government have sought through the EU regulations. What part have the Government’s relationships with the corporate sector played in this matter, and, indeed, if food labelling is going to become more confusing, will that not count against the drive to have good and well balanced diets?
Earl Howe
My Lords, as the noble Baroness will know, there are various points of view from various sectors of industry about what constitutes the best and most helpful form of food labelling. As a matter of fact, that has lain at the heart of the difficulty in reaching agreement in Europe, because there are so many divergent views around this. It is quite true that we do have very strongly held views—not least by the Food Standards Agency—about the value of traffic lights. We have equally strong views, held by certain sectors of industry, on the GDA model. As I said earlier in answer to the noble Baroness, Lady Howarth, it would be desirable to have consistency, but we are not there yet. We will continue to work at that objective.
Baroness O'Cathain
My Lords, first, has any research been done on the proportion of the population that actually reads these labels; secondly, are people able to read them; thirdly, do they understand them if they do read them; and, fourthly, what about magnifying glasses?
Earl Howe
One advantageous feature of the regulation, my noble friend will be pleased to hear, is provision on the legibility and font size of labels, which I am sure we all welcome. In 2009, the Food Standards Agency commissioned some research to examine which front-of-pack labelling system performed best, and the main finding was that the strongest performing front-of-pack label is one which combines the use of the words “high”, “medium” and “low”, traffic light colours and the percentage of guideline daily amount, in addition to levels of nutrients. That was the same across all socioeconomic groups.
Health and Social Care Bill
Earl Howe Excerpts(12 years, 6 months ago)
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Earl Howe
That it be an instruction to the Committee of the Whole House to which the Health and Social Care Bill has been committed that they consider the bill in the following order:
Clauses 1 to 6, Schedule 1, Clauses 7 to 22, Schedule 2, Clauses 23 to 48, Schedule 3, Clauses 49 to 52, Schedules 4 to 6, Clause 53, Schedule 7, Clauses 54 to 58, Schedule 8, Clauses 59 to 73, Schedule 9, Clauses 74 to 99, Schedule 10 , Clauses 100 to 105, Schedule 11, Clauses 106 to 118, Schedule 12, Clauses 119 to 147, Schedule 13, Clauses 148 to 176, Schedule 14, Clauses 177 to 179, Schedule 15, Clauses 180 to 228, Schedule 16, Clause 229, Schedule 17, Clauses 230 to 246, Schedule 18, Clauses 247 to 249, Schedule 19, Clauses 250 to 271, Schedule 20, Clauses 272 to 274, Schedule 21, Clauses 275 to 291, Schedule 22, Clauses 292 to 294, Schedules 23 and 24, Clauses 295 to 303.
Medicines Act 1968 (Pharmacy) Order 2011
Earl Howe Excerpts(12 years, 6 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Medicines Act 1968 (Pharmacy) Order, being debated today, will remove the restriction placed upon pharmacists registered in Britain by virtue of a pharmacy qualification awarded by a relevant European state that prevents them being in charge of a newly established pharmacy. This refers to any pharmacy that has been registered for less than three years and is commonly known as “the three-year rule”.
The relevant European states referred to are Iceland, Norway, Liechtenstein, Switzerland and the European Union (EU) member states. It is not relevant to pharmacists who qualified in the United Kingdom.
I should first give the Grand Committee some background. All pharmacists practising in Britain must be registered by the General Pharmaceutical Council, as must all pharmacy premises. Some pharmacists are registered to practise in Britain under arrangements for the mutual recognition of pharmacist qualifications awarded by EU member states or other relevant European states.
EU Directive 85/433—now 2005/36/EC—includes provision for member states to place restrictions on the recognition of the qualifications of such pharmacists in the case of pharmacy premises registered for a period of less than three years. In Britain, the restriction applies to the pharmacist in charge of such pharmacies, known as the “responsible pharmacist”. In other words, while all pharmacists registered in Britain under the mutual recognition arrangements may work in any British pharmacy, however long it has been registered, such pharmacists cannot hold the position of responsible pharmacist in a pharmacy that has been registered for less than three years. The current restrictions on visiting pharmacists owning pharmacy businesses or acting as superintendents are not affected by this order.
The derogation in the directive was originally put in place in the mid-1980s for economic reasons, following concerns by UK MEPs. They believed that, given the UK’s comparatively open arrangements in relation to pharmacy ownership, there was a risk that the mutual recognition arrangements would put existing UK pharmacies at a disadvantage. Since then, however, much has changed both in terms of pharmacy arrangements in other EU member states and the evolution of domestic policy in Britain.
We have conducted a full public consultation on removing the restriction, both for established pharmacists—those fully registered with the General Pharmaceutical Council in part 1 of the register—and for visiting pharmacists—those temporarily practising in the UK and registered in part 4 of the register. However, the restriction has not affected any visiting pharmacists as, to date, none has been registered.
The response to the public consultation has been very much in favour of removing the restriction. The proposal has support from the General Pharmaceutical Council, the pharmacy regulator, the Royal Pharmaceutical Society, the professional body for pharmacists, as well as all the main pharmacy representative organisations, including the Pharmaceutical Services Negotiating Committee, Community Pharmacy Scotland, the Company Chemists Association and the devolved Administrations.
The proposal will encourage flexibility, efficiency and continuity of care within pharmacy. It will end the situation where a responsible pharmacist, registered here by virtue of the mutual recognition arrangements, can no longer continue in that role if their pharmacy relocates, even if it only moves next door, and therefore becomes a newly registered pharmacy. Removing this restriction will mean that patients can enjoy greater continuity of care in such circumstances; that all registered pharmacists will be placed on a level footing in terms of their employment prospects; and that employers will have a deeper pool of potential employees to draw upon and less bureaucracy to deal with when filling vacancies.
I should now explain the revision of the draft Explanatory Memorandum laid before your Lordships today and the change required to the final version of the Explanatory Note on the order. In undertaking preparatory work for this debate on the draft order, officials in the Department of Health realised that, contrary to previous understanding, “visiting pharmacists”, a sub-category of registrants from relevant European states who do not go through the full registration procedure, are covered by the removal of restrictions that the draft order would achieve. It will not, therefore, require a separate legal instrument to remove the restriction upon their acting as “responsible pharmacist” at new pharmacies. Up to this point, it had been thought that a separate legislative instrument would be required to achieve this. The confusion appears to have arisen in the understanding of the differences between the restrictions applying to those who either may own, or carry on, a pharmacy business or act as superintendent, on the one hand, and the provisions relating to the responsible pharmacist on the other. A superintendent manages a pharmacy on behalf of a company. A responsible pharmacist is in charge of a pharmacy at a given time, and takes on responsibility for the effective management of pharmacy law and practice within a single branch at a particular time. If the draft order is approved, it will still not be possible for a visiting pharmacist to carry on—that is, to own a new pharmacy—or act as a superintendent in relation to a new pharmacy.
However, a visiting pharmacist, and any other pharmacist registered by virtue of the mutual recognition arrangements, would, upon the coming into force of the order, be entitled to be the responsible pharmacist in charge of a newly registered pharmacy in Britain. It is the similarity between the different concepts of control that appears to have led to the confusion. The intention has always been to remove the restriction on responsible pharmacists for all those registered to practise in Great Britain under the EU mutual recognition arrangements, whether visiting or not. The consultation reflected this and the order as currently drafted would achieve this.
Because of the misunderstanding, the earlier version of the accompanying draft Explanatory Memorandum, and the Explanatory Note on the order itself, suggested that the order did not remove the restriction in relation to visiting pharmacists. In fact, the substantive provisions of the order achieve the intention and a further instrument is not, therefore, required. However, the text in the Explanatory Note that refers to the register was incorrect, and the reference to part 1 of the register will not appear in the final version. I apologise for any confusion caused by this late change. I commend this order to the Committee.
Lord Collins of Highbury
As the noble Earl stated, a lot has changed since the derogation in the directive was put in place. Much has changed in pharmacy arrangements in other EU member states and in the evolution of domestic policy. The reasons, as the Minister stated, were commercial.
In England, for example, there has been a welcome change over the past few years making it easier for people to get to a chemist, given that there are new pharmacies with longer opening hours. Clearly, such market restrictions are not appropriate today, and their removal will assist by increasing the pool of available pharmacists and ensure improved continuity of service delivery. I note that the change has also been welcomed by the key representative bodies of pharmacies.
I of course recognise that the restriction affects a relatively small number of pharmacies—just over 10 per cent, and just over 5 per cent of all pharmacists registered to practise in Great Britain. I also understand and accept the reasons for the change in the Explanatory Memorandum. However, these changes in the legislation raise broader issues relating to the competencies of the pharmacist and the person’s ability to manage a pharmacy. For example, the report on the consultation noted that concerns were expressed by respondents on competency in English. The Department of Health in its response stated that in the UK a check on the language knowledge of a pharmacist from outside the UK who is seeking work within the NHS is applied by the prospective employer, but that there is no check made at the point of registration.
This leads to three specific questions to the Minister. First, are there plans to introduce a standardised competency test to ensure that any pharmacists from the countries mentioned in the order who are in charge of a new pharmacy have all the required skills and competences? Secondly, are there plans to ensure that those in charge of a pharmacy will have a sufficiently high standard of English to avoid all risk of a patient misunderstanding any advice given? Thirdly, how can an employer determine whether the pharmacist in question is qualified in their own country and has no pending fitness-to-practise cases to answer?
Lord Clement-Jones
My Lords, I declare an interest as chairman of the council of the School of Pharmacy of the University of London. I thank the noble Earl, Lord Howe, for a crystal clear explanation. I suppose, perforce, it had to be crystal clear to clear up some confusion arising from the Explanatory Memorandum. This is precisely the kind of uncontroversial deregulation that is important in the context. From both professional and consumer perspectives one could say that it is a perfectly formed small regulation. It affects a limited number of people who could not be responsible pharmacists in certain circumstances, but will now be able to be so where there are no significant safety implications from deregulating in the way that this order does.
I want to raise the issue of reciprocity. The noble Earl mentioned that the reason for deregulation is that circumstances have changed. The noble Lord, Lord Collins, also referred to that. I am sure that in broad terms that is the case, but I should be extremely grateful to hear what the noble Earl believes the level of that deregulation would be. I remember doing a study of several EU countries, looking into what was permissible in pharmacy ownership and the level of regulation. That was about five years ago, when the level of regulation was extremely high—not just pharmacy regulation but the kind of licensing required to run a retail outlet, and so on. We have some extremely well run chains in this country, which would like to expand their offer in the EU more broadly. They have been largely frustrated from doing so by some of the regulation that applies. Therefore, reciprocity in these circumstances is extremely important. I am interested to hear just what the Minister believes to be the level of significant deregulation that has taken place.
Earl Howe
My Lords, I am grateful to both noble Lords for their support for the order. The noble Lord, Lord Collins, asked me three questions. The first was about whether there are any plans to introduce a standardised competency test to make sure that pharmacists from the various countries mentioned have all the required skills to do their job. Under directive 2005/36/EC on the recognition of professional qualifications, which I mentioned, a pharmacist who holds a recognised qualification issued by one member state is entitled to recognition of that qualification in another member state, and would therefore be entitled to registration with a competent authority, such as the General Pharmaceutical Council.
However, employers of pharmacists should ensure that anybody they employ has the skills required to undertake the specific post. The General Pharmaceutical Council’s standards of conduct, ethics and performance, among other things, require the pharmacist to recognise the limits of their professional competence and practise in only those areas in which they are competent. Their continued registration is subject to adherence to the council’s requirement for continuing professional development—CPD—and standards of conduct, ethics and performance.
Secondly, the noble Lord asked whether there are plans to make sure that those in charge of a pharmacy have a high enough standard of English. The UK Government’s response to the European Commission’s consultation on the review of the directive on the recognition of professional qualifications clearly sets out the view that in the healthcare professions the ability to communicate with patients and service users is vital.
Multiple Sclerosis
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Lord Walton of Detchant
To ask Her Majesty’s Government what action they are taking to improve the United Kingdom’s international standing in relation to patient access to new treatments for multiple sclerosis.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, a number of treatments for multiple sclerosis are available to UK patients, supported by the multiple sclerosis risk sharing scheme, National Institute for Health and Clinical Excellence guidance and Scottish Medicines Consortium advice. Our priority is to ensure that patients have access to new and effective treatments. NICE’s forthcoming review of its clinical guideline on MS will bring together up-to-date advice on the best treatments for patients, as part of the overall package of care.
Lord Walton of Detchant
My Lords, I thank the noble Earl the Minister for that reply. It is true that the prognosis for many patients with multiple sclerosis has been transformed by the use of these immunosuppressive agents since interferons were introduced. Is he aware that recently a new and effective remedy called fingolimod, which is available by oral administration instead of injection, has been introduced? It has been licensed but has been rejected by NICE for the moment purely on cost grounds. At the moment, evidence suggests that about 60 per cent of patients with this condition in the United States, 30 per cent in most of Europe and only 17 per cent in the UK are receiving this type of medication. Is it therefore not likely that this is the result of restraints on prescribing largely on financial grounds?
Earl Howe
The noble Lord is quite right about fingolimod. Since the publication of NICE’s draft guidance, the manufacturer has proposed a patient access scheme for the drug, and the department has agreed that this can be considered as part of NICE’s appraisal. The noble Lord raises a very interesting point about cost. Professor Mike Richards’s report, which came out last year and looked at the extent and causes of international variations in drug usage, outlined a number of potential explanations for the relatively low uptake of some treatments. In the case of MS, one of the reasons identified was caution among some neurologists about the benefits of particular treatments, but also tighter clinical guidelines on the use of MS treatments in the UK compared with some other countries. It is important to stress that in treating MS, medicines form only part of an overall package of care, which of course can consist of access to neurology services and specialist MS nurses.
Lord Monks
My Lords, referring to what the noble Earl just said about the Richards report, that report ranked the UK 23rd out of 25 EU countries, with only Slovenia and Lithuania more restrictive on access to new treatments than the UK. The NICE guidelines will not be revised until 2014, having last been done in 2003. For sufferers of MS, a horrible disease, that seems a very long time to wait. I hope that in the reviews that are taking place, the Government will do everything possible to accelerate this work and ensure that NICE gets on with it, and that the Government give priority to MS research in future.
Earl Howe
My Lords, I take the noble Lord’s point. NICE is reviewing its clinical guideline. That is not due to be published until 2014. Although we strive to ensure that there is national guidance on the most commonly used medicines and treatments, there will always be instances where decisions have to be made locally. Under the NHS constitution, patients have the right to expect local decisions about the funding of medicines and treatments to be made rationally, following proper consideration of the evidence. We are emphasising to PCTs that they should do just that.
Baroness Gardner of Parkes
My Lords, I declare an interest in that I have a daughter who has had MS for 30 years. Recent research announced in Russia indicated that they believe they are developing an answer to rebuilding the myelin sheath, which would be great progress in multiple sclerosis treatment. Can the Minister assure us that when that research is available we will follow it here and introduce it at the earliest possible time?
Earl Howe
My Lords, new and innovative treatments for MS are being developed in a number of countries. It is quite clear that any new treatment of this kind should be subject to the rigours of the regulatory system before it is made available to NHS patients. Many of them will not have been fully tested to ensure efficacy and safety, but we will of course examine every novel and innovative treatment that has the potential to benefit patients.
Earl Howe
The noble Lord makes a very good point. Commissioning by clinical commissioning groups does not mean that individual groups will have to commission every service. They can commission collaboratively across larger populations if that makes sense for them. Additionally, some services for less common conditions, including some neurological conditions, fall within the scope of specialised commissions and will be commissioned subject to the passage of the Health and Social Care Bill by the NHS Commissioning Board.
I understand that in Europe the neurological commissioning support, which was developed with the support of a number of neurological charities, including the MS Society, has been well received by commissioners and is doing very good work.
Health and Social Care Bill
Earl Howe Excerpts(12 years, 7 months ago)
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Earl Howe
I rise to conclude an excellent and constructive debate. It has been long, and the task that rests with me in summing it up in the space of 20 minutes is clearly an impossible one, if I am to do justice to every speaker. Therefore, I hope that the House will find it acceptable if I aim in my response to capture the main themes of this debate and to write to noble Lords whose specific and detailed questions I do not have time to answer. In addition, I am happy to offer any the noble Lord a meeting with me or with officials from the Department of Health to discuss any of the issues that they have raised.
To begin with what might seem an emotional and emotive point, it was said by more than one speaker, including the noble Lord, Lord Hennessy, this morning, that the NHS is the nearest thing that this country has to institutionalised altruism. That is surely right. It is equally right that the NHS is a part of our national life, of which we can be deeply proud. At its best, which is often, it delivers high-quality excellent care. The investment made by the previous Government has contributed significantly to that.
A number of noble Lords asked why, therefore, the Government’s reforms are needed at all. Part of the answer to that is about the clear imperative around the quality of care, about which the noble Lord, Lord Darzi, and my noble friend Lord Black spoke so powerfully. Indeed, we have excellent care in the NHS, but sadly this is not universal. The variations in quality and outcomes and longevity around the country are too great for us to sit back and do very little. But there is another less visible reason. In a sense, the need for reform is not about how excellent the NHS may be today; it is about our making sure that in five, 10 and 20 years’ time the NHS is still there as a sustainable public service, free at the point of use, delivering the care that we all want it to.
The financial challenge facing the NHS is acute. We have protected its budget in real terms, but that is not going to be enough to meet demand from an ageing and growing population unless we take some radical steps to simplify and streamline the NHS architecture and to free up the service from central control in a way that will drive innovation and productivity as never before. That is the purpose of these reforms and this Bill. It is not just about today; it is about safeguarding the future. If I had one criticism of some of the contributions from the Benches opposite it was of their failure to acknowledge the scale of the financial and quality challenge that now faces us. Money will no longer grow on trees in the NHS; we have to think out of the box. So we are seizing on the evidence of what works in order to drive quality—namely, empowering commissioners. We are cutting the cost of NHS administration by one third, and we are trusting the men and women of the health service—including, incidentally, our many excellent managers—to deliver what we know they can, which is an even better service for their patients. And make no mistake—there are doctors and nurses and managers out there who are keen to get to grips with this. Yes, of course, there are many who have no appetite for change, and there are many critics and doubters. But I have met so many clinicians that I cannot count them, who believe that what we are doing is right, and who are being inspired by these reforms to lead the way in the local pathfinder groups and in local authorities.
The NHS needs continual renewal. It has never stood still, and it cannot do so now. The noble Lord, Lord Darzi, put it perfectly when he said:
“To believe in the NHS is to believe in its reform”.
Many speakers, most prominently my noble friend Lady Williams and the noble Baroness, Lady Jay, have spoken about accountability in the role of the Secretary of State. For me, the debate on this topic crystallised into two issues. A number of speakers aligned themselves with the Select Committee on the Constitution in questioning why we have removed the Secretary of State’s duty to provide. There has been concern that this means that the Minister’s ultimate accountability for the NHS is in some way diluted. I can reassure the House that this is not so. A change as pointed out by several noble Lords, including the noble Lord, Lord Warner, and my noble friend Lady Bottomley, as well as the noble Baroness, Lady Murphy, is to reflect a fact which has been the case for many years; namely, that the Secretary of State does not directly provide services himself.
Under the Bill, the Secretary of State will continue to have a statutory duty to promote a comprehensive health service, and a duty to use his powers to secure the provision of the service. As has been the case for decades, it does not extend to the Secretary of State directly providing services. So rather than pretend that somehow the Secretary of State is responsible for all clinical decision making in the NHS, the Bill recognises that expertise for such decisions must sit with those health professionals closest to patients. Indeed, my noble friend Lord Marks put it well when he pointed to the means by which Secretaries of State will be able to do this; namely, the mandate to the NHS Commissioning Board, the standing rules, and the failure intervention powers. I may say that the improvements that my noble friend suggested to these powers sounded interesting to me, and I look forward to discussing these with him in greater detail at a later date.
The noble Lord, Lord Owen, asked what would happen in the event of a pandemic. If I could direct the noble Lord to Clause 44 of the Bill, he will read of the extensive powers the Secretary of State has to take control in an emergency—and this even extends to foundation trusts, which is a power not available to Ministers today.
The second issue raised with regard to the Secretary of State turns us to Clause 4, the duty of autonomy, and I am sorry that what I have said on this has been the subject of concern. My noble friends Lady Williams and Lord Marks highlighted this clause as raising the possibility that it will lead to an unacceptably hands-off approach on the part of the Secretary of State. We do not think that that is the case. However, I would like to repeat the commitment made by my honourable friend the Minister for Care Services at Report stage in the other place, about Clause 4, namely that,
“we are willing to listen to and consider the concerns that have been raised and make any necessary amendment to put it beyond doubt that the Secretary of State remains responsible and accountable for a comprehensive health service, which we all want to see.”—[Official Report, 7/9/11; col. 454.]
If there is an amendment which will improve the Bill, we will make it. This offer stands, irrespective of how the House votes on the amendment tabled by the noble Lord, Lord Owen, and I hope that this gives reassurance to those who have been concerned on this point. I also today commit to host a meeting with all interested Peers—including the noble and learned Baroness, Lady Scotland, if she wishes—to discuss any matters around accountability further so that we can all better understand each other’s positions and concerns, but also inform Committee discussions on these vital issues.
The second concern I would like to turn to is that of competition. Many speakers, such as the noble Baronesses, Lady Kennedy and Lady Billingham, fear that the Bill could lead to an American-style market free-for-all, with competition harming patients’ interests. Others, such as the noble Baroness, Lady Murphy, have claimed that we are actually doing too much to shackle the benefits of competition, and that we should look at removing some of the safeguards that we have put in place.
Let me be clear about what the Bill does and does not do. The Bill does not introduce a free market for all. It does not change competition law, or widen the scope of competition law. It does introduce a framework in which competition can be effectively managed as a means to benefit patients. That competition can work in the interests of patients is well backed up by academic research, such as the studies quoted by the noble Lord, Lord Warner, on mortality rates, and by noble friend Lady Cumberlege on inequalities. The Bill does not do anything which might or could lead to the privatisation of the NHS. What it does do is create a level playing field between different providers, putting an end to the subsidies and guarantees given to the private sector under the last Government.
The Bill will not mean that competition will trump integration. The safeguards and duties that it places on Monitor, in particular its core duty towards the interests of patients, will ensure that Monitor supports integration. The balance that we have struck in this Bill, once more returns to the North Star—that graphic metaphor from the noble Lord, Lord Kakkar—namely, patients. We believe that competition has a place, but only as a means to an end, the end being to improve quality and efficiency.
The noble Lord, Lord Darzi, made the case, as usual, very strongly, by talking of competition as a means to spark creativity and light innovation. However, it does require safeguards to ensure that other factors such as integration, service continuity and the prevention of cherry-picking are given due weight—and those safeguards are there.
I turn next to concerns raised that the Bill creates too much complexity, meaning that care will be fragmented, and decision-making harder to achieve, and we heard that concern expressed this morning by the noble Baroness, Lady Pitkeathley. Let me first be clear about the different organisations abolished and created by this Bill. The Bill abolishes the 151 primary care trusts, half of the national arm’s-length bodies, and the 10 strategic health authorities. It establishes clinical commissioning groups which are currently growing out of existing practice-based commissioning groups. Likewise, local HealthWatch will build on existing local involvement networks, and HealthWatch England will be situated within the Care Quality Commission. I can reassure the noble Lords that the Bill contains a number of mechanisms to ensure independence of HealthWatch both locally and nationally. Monitor will be expanded to become a provider regulator, and the NHS Commissioning Board, led by Sir David Nicholson, will be a new body, but it will draw on the best aspects of a range of departing organisations. We envisage that it will host the existing clinical networks and the new advisory clinical senates.
Concerns were raised that the board could have too much power over commissioning groups. I genuinely agree that the Bill contains sufficient safeguards against this, but I do of course look forward to discussing this issue further. Overall, administration costs across the health system will be cut by one-third in real terms by 2014-15—this will save £4.5 billion by the end of the Parliament alone—all to be reinvested in front-line patient care.
A number of noble Lords have asked who takes the decisions. This Bill represents a significant step forward by directly conferring responsibilities in statute, rather than having them all delegated in an opaque way through the Secretary of State. This clarity extends to how different organisations should work together and the Bill contains significant new provisions regarding collaborative working. In her opening remarks, the noble Baroness, Lady Thornton, expressed her support for health and well-being boards, which will be hosted by local authorities. Other speakers have endorsed the plans for joint strategies to be determined and agreed by all relevant local services. Many speakers have raised service configuration, which we can happily debate. However, I believe that the Bill supports effective, clinically led reconfigurations led locally but with the NHS Commissioning Board playing an important leadership role.
A number of speakers spoke about particular service areas within the NHS and how the reforms would impact on them. Let me start by reassuring noble Lords that those working in general practice will not be commissioning in isolation. Clinical commissioning groups must obtain appropriate advice from a broad range of professionals. This would, for example, include experts in mental health, children’s health, learning disabilities or other areas as appropriate. Given this duty to obtain advice, we do not think that it is necessary to expand the membership of clinical commissioning groups’ governing bodies further than is currently set out in the Bill, which was a suggestion made by a number of speakers, including the right reverend Prelate the Bishop of Bristol. Indeed, if all the additional representatives suggested in this debate alone were to join the governing body it would quickly become unwieldy and unworkable. Clinical advice would also come through other forms, such as clinical networks, which I can confirm to my noble friend Lord Clement-Jones will continue, and new clinical senates. These mechanisms should ensure that specialist advice at all levels of the NHS is there. They are not extra layers of bureaucracy.
Many speakers have stressed the importance of public health and health inequalities and the changes proposed by this Bill. I completely agree that these are fundamental issues. Our plans seek to create a new focused approach for public health, protected by a ring-fenced budget. The noble Baroness, Lady Gould, asked a range of questions about the detail behind our arrangements and I will respond to her in writing. But in terms of inequalities, this Bill, for the first time, puts in place specific duties on key relevant bodies to act with a view to reducing health inequalities. That should surely be seen as welcome.
One or two noble Lords, including the noble Baroness, Lady Royall, raised the removal of a foundation trust private income cap and feared that it could lead to longer waiting lists for NHS patients. I am confident that it would not have this effect. My right honourable friend the Minister for Health said on Report in the other place that,
“we are proposing to explore whether and how to amend the Bill to ensure that FTs explain how their non-NHS income is benefiting NHS patients. We will also ensure that governors of FTs can hold boards to account for how they meet their purpose and use that income”.—[Official Report, Commons, 6/9/11; col. 289.]
I hope that provides some reassurance. I look forward however to further debates on that issue.
The future of both education and training, and research, were raised by a number of speakers. The noble Lord, Lord Walton, and my noble friend Lord Willis spoke passionately about the benefits of research. The noble Baroness, Lady Masham, and my noble friend Lord Ribeiro spoke equally passionately about innovation. As Minister responsible for research and innovation, I fully share this passion and I hope that I can reassure noble Lords that we are taking all necessary steps to ensure that we act quickly on taking forward the report of the Academy of Medical Royal Colleges, including future legislation.
Such legislation will also take forward the future arrangements for education and training but I can confirm to the House that we will table a new duty for the Secretary of State with regard to education and training in time for Committee. In addition, as both issues have attracted so much interest, I will ensure that new fact sheets on both topics are produced by officials in the Department of Health and made available prior to Committee. Again, my door is open to noble Lords to discuss any or all those issues.
Several noble Lords called for healthcare assistance to be given full statutory regulation. While I accept the need for action in this area, I cannot agree that statutory regulation is the best way to proceed. Our view is that employers of such workers have to take responsibility for the quality of services provided, including the use of existing systems. In addition, when tasks are delegated by qualified professionals, this has to be done with appropriate and effective supervision. I am of course more than willing to discuss this issue further as the Bill proceeds.
I turn now to the procedural concerns raised during the debate and to the Motions tabled by the noble Lords, Lord Owen and Lord Rea. First, a number of speakers questioned what they call the democratic mandate for this Bill claiming that the Bill’s proposals were not in manifestos or the coalition agreement. Both these claims are untrue, as any quick read of these documents will show.
What is true, as my noble friend Lord Rodgers pointed out, is that sheaves of documents covering every detail of policy were set out in July last year when we published the White Paper and associated consultation documents. This was followed up by a period of public engagement, a lengthy Government response, the listening exercise in the spring of this year and 40 sittings in Committee in the other place. At all stages, we have been open and transparent about our plans. This approach will of course continue and I welcome the proposal of the noble Lord, Lord Kakkar, in terms of ensuring effective post-legislative scrutiny. I can confirm today that while five years would normally elapse prior to post-legislative scrutiny of a Bill, we will bring that forward for this Bill to three years. As a result, I simply cannot accept the amendment in the name of the noble Lord, Lord Rea. I respectfully suggest to your Lordships that to vote for that amendment would run directly counter to the proper role and functions of this House.
Secondly, concerns have been raised about what has been seen as implementation of the Bill’s proposals prior to Royal Assent. I suggest that this fear is unfounded. Preparatory work is ongoing to implement the Government’s plans, such as the creation of clinical commissioning group pathfinders. This is all within the current legal framework. However, such powers can get the reform only so far; hence the need for this Bill. For example, while early implementers of health and well-being boards are emerging all over the country, until this Bill is passed they lack all the statutory powers that we think are essential for them to operate.
Finally, I turn to the Motion in the name of the noble Lord, Lord Owen. I do not feel that a further Select Committee would add significant value to our normal processes. A Committee of the Whole House with all interested Peers, including constitutional experts in attendance, would in my view be the best forum to ensure effective and thorough scrutiny. Perhaps I may say that this Second Reading debate has amply proved that. My noble friend Lord Rodgers put it well in saying:
“The House is now able to make fully informed decisions … we should not duck … them further”.—[Official Report, 11/10/11; col. 1543.]
Furthermore, I agree with my noble and learned friend Lord Mackay of Clashfern that the early clauses of this Bill, which cover the Secretary of State’s duties and powers overarch the rest of the Bill. It is right for a Committee of the Whole House to consider them at the outset of the deliberations.
I engaged in discussions with the noble Lords, Lord Owen and Lord Hennessy, to see if there was a way to accommodate their proposals for a special Select Committee. The only way, I feel, that such a novel procedure could work would be to put a clear end point on both the Select Committee and the Committee of the Whole House. It is not sufficient to put a time limit solely on the Select Committee. This Session, all pre-legislative scrutiny committees set up in this House have required time extensions.
While the noble Lord, Lord Owen, says in perfectly good faith that the committee will report before Christmas, there is no way in which this House can make that truly binding without an end date on both committees. The key point is that if the Select Committee needed more time or if it recommended amendments affecting parts of the Bill—
Lord Peston
Is the Minister certain that there is no way that the amendment to which he refers can be made to work so that the job gets done in time? That bears no resemblance to my knowledge of how this House works. The House can end things at any time it wants to.
Lord Hunt of Kings Heath
My Lords, in my experience, if this House wants something to happen it finds a way for it to happen. Even at this late stage, I ask the noble Earl to give careful consideration to this. I have already said from this Bench that we are happy to meet through the usual channels to agree a date by which the Committee stage will be finished on the Floor of the House. I am sure that the noble Lord, Lord Owen, as far as he is able, will wish to say that he is happy for the special committee to finish by a certain date. I do not believe that it is impossible for agreement to be reached on this.
Earl Howe
My Lords, I very much welcome that offer, which has come rather late in the day. My understanding is that discussions over the timetabling of the Bill have taken place over the past week. However, we are faced with the amendment that is on the Order Paper and must vote on it as it stands.
Baroness Royall of Blaisdon
I beg your Lordships’ pardon but I have to say that we are and have been entirely open to this suggestion. I was not aware of it until yesterday. I give the House my pledge that the Bill will come out of Committee by mid-January, which is, I think, when the noble Earl was thinking of. We should be delighted to give our firm assurance that the Bill will come out in mid-January.
Earl Howe
My Lords, that is an extremely welcome offer, which we accept. I am grateful to the noble Baroness.
It is right for me to conclude, with your Lordships’ agreement. I bring this extended debate to an end by returning to the point of the Bill, which is to improve the quality of care for patients. For all the generosity of the noble Baroness’s offer, the amendment of the noble Lord, Lord Owen, would not help patients. It would insert additional uncertainty into the parliamentary passage of the Bill. As my noble friend Lord Fowler rightly emphasised, the amendment of the noble Lord, Lord Rea, would leave the NHS in far greater uncertainty. It would also leave it unprotected from both the present and future challenges that it faces.
Baroness Royall of Blaisdon
My Lords, I crave the indulgence of the House to confirm one point that was clarified by the noble Lord. I do not advocate any timetabling Motion: that would not be appropriate for the House. I give the assurance that, were the noble Lord’s amendment to be agreed, my Benches would wish the Bill to be out of Committee by mid-January. However, if the amendment is not accepted, it will be right and proper for the usual channels to discuss the appropriate number of days needed in the light of this excellent Second Reading debate. I cite the excellent speeches made by many noble Lords, including the wise words of the noble Lord, Lord Walton of Detchant, who spoke before me last night and who said that enough time must be given. He is absolutely right. I have no intention of delaying the Bill. My intention is to ensure that there is proper agreement between the usual channels on the appropriate amount of time that the Bill needs in Committee.
Earl Howe
My Lords, I will make three very brief points. The provisions that the noble Lord, Lord Owen, asks us to send to a special Select Committee affect the entire Bill. The twin-track approach that he advocates carries a major risk: the potential disconnect between the special Select Committee and the Committee of the whole House. The Select Committee might recommend amendments to parts of the Bill that have already been debated by the Committee of the whole House. The result could be that, notwithstanding the offer made in good faith by the noble Baroness, Lady Royall, we could see a slippage of the timetable of the Bill that would be most unwelcome.
I repeat my assurance that I am entirely open to considering the concerns that have been raised about the issue and to make any necessary amendment to put it beyond doubt that the Secretary of State will remain responsible and accountable for a comprehensive health service.
Health: Charities
Earl Howe Excerpts(12 years, 7 months ago)
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Lord James of Blackheath
To ask Her Majesty’s Government what consideration they have given to extending the cost-saving work of health charities by providing them with NHS premises free of charge.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, health charities make a significant contribution to the NHS and are valuable partners. We are keen to support initiatives that will help them make cost savings and to support them through this challenging financial period. It is for local NHS organisations to decide to whom, and in what circumstances, they can offer NHS premises at concessionary rates.
Lord James of Blackheath
My Lords, I thank my noble friend for that Answer, which is encouraging in the context of local interests. But does he agree that some charities carry a case for a nationwide intervention due to the huge savings that they can produce, such as the Connect aphasia/stroke charity of which I am myself a rescued case? I was rescued so well that I married my therapist; I understand that that is an option, not an obligation. In this case, will my noble friend consider whether the huge savings that can come by removing aphasia cases from a dependence on welfare handouts and enormously expensive treatment could be alleviated by support being provided from the social care allocations fund on a completely cost-effective basis? The money could be replaced afterwards by giving some nominal recognition back to the fund as a consequence of the huge number of cases that would be saved by the charity.
Earl Howe
My Lords, we greatly value the work that Connect and other charities carry out, working alongside people with aphasia and their families to develop communication and rebuild confidence. I can tell my noble friend that we understand that the current fiscal position is presenting voluntary organisations and charities such as Connect with challenging funding issues. But, in the end, we are looking at local services. Where local services are concerned, it is the responsibility of commissioners—currently primary care trusts and local authorities—to commission services based on their local population needs. They must ensure that the services that they secure for local people provide the best value for money and quality for patients. I am afraid that we cannot get away from the value-for-money question. It is important to emphasise that we are sending the message to local authorities and PCTs that the voluntary sector should not shoulder a disproportionate share of funding cuts.
Baroness Finlay of Llandaff
Will the Minister ensure that healthcare charities that provide clinical services have the same VAT exemption as NHS providers, to establish the level playing field at this time of financial stringency that the Minister spoke about in the preceding debate?
Baroness Thornton
Will the Minister confirm that the Department of Health has a strategy for encouraging and supporting charities, social enterprises and mutuals, both as patient and carer advocates and as providers of healthcare? In addition, would the Minister care to say how that policy might be enacted by the proposed commissioning structures in light of, for example, the failure of Surrey Community Health—a local and qualified social enterprise—to win a very large contract, losing it to Richard Branson’s Virgin Healthcare?
Earl Howe
I agree with the noble Baroness that it is important we do not lose vital local services that achieve high-quality outcomes. We shall be working with PCTs, therefore, in the transition to the new arrangements between the NHS Commissioning Board and clinical commissioning groups as they develop, to ensure that the sector’s contribution to improved public health and social care is fully recognised. In the end, however, she will appreciate from our preceding debate that these matters will continue to be determined at a local rather than a national level—and it is quite right that they should be—because centrally we are not aware of local circumstances in the detail that we should be.
Lord Phillips of Sudbury
My noble friend the Minister will be well aware that there is a chapter in the health Bill on public involvement. Will he accept that there is a general perception that at present there is extraordinarily little attempt made by the health bureaucracies to engage particularly small local charities, which often have more to give in terms of public involvement than the very large ones?
Earl Howe
It varies. I am well aware of some PCTs that are engaging very creditably with voluntary organisations, but I am sure my noble friend can give examples of where that is not happening. I can only say to him that the policy of any qualified provider should mean that local voluntary organisations that can provide services to the quality and terms that the NHS requires should be in with an equal chance of providing services. We will ensure that proper guidance is issued to make sure that happens.
Health and Social Care Bill
Earl Howe Excerpts(12 years, 7 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this is a Bill of profound importance for the quality and delivery of health and care in England, for patients and for all those who care for them. As such it has been, quite rightly, the subject of intense scrutiny, not only in another place, but also more widely. Indeed, the intensity of the spotlight directed at its content over the last few months is borne out by the number of your Lordships who wish to speak today and tomorrow. I look forward to the debate ahead of us.
In approaching this Bill, I believe it is instructive to look backwards to its roots as well as forward to what it seeks to achieve. In opposition, the two coalition parties asked themselves the same simple question: “How can we make the NHS better?”. In asking that question we were clear about several things. We were clear that the founding principles of the NHS—that it should be a comprehensive service, free at the point of use, regardless of ability to pay, and funded from general taxation—should remain sacrosanct. We were also clear that we should reject any system that discriminated between rich and poor. The NHS should aspire to the highest standards of service for all our citizens, but in seeking ways to make the health service better, it was necessary to identify the challenges that it faces. What are they?
The first, and most obvious, is rising demand for healthcare from a growing and ageing population and the increase in long-term conditions. The second is the rising expectations of patients about what should be on offer to them from a health service in the 21st century, including new drugs and technologies. The third is the financial challenge—the inexorably rising costs of providing services against an increasingly constrained budget.
Two key principles emerge from this analysis: the need for maximum efficiency in the way the health budget is spent; and the need to make the service patient-centred. For many years, politicians have spoken of the NHS as a patient-centred service, but how can a service be truly patient-centred if decisions about the treatments and pathways of care that are available to patients are taken at several removes from those who know best what the needs of patients are—namely, the patients themselves and the healthcare professionals who look after them?
How can a health service be patient-centred if the measures of its performance overlook what for patients matters most, namely the outcomes that it achieves and the quality of care that patients receive? What of NHS efficiency, when so much of its budget is consumed by layers of administration, when its productivity over the last few years has fallen, and when patients experience poor handovers between different parts of the NHS and between the NHS and social care?
There is a fundamental problem, too, in NHS accountability. The original National Health Service Act 1946 provided for a comprehensive health service, but it did so by employing a simple legal precept—that responsibility for everything that happened in the NHS should lie with the Secretary of State. That may have held good in the 1940s, when the challenges facing the NHS were largely the management of acute short-term conditions, but it does not hold good now. The Secretary of State has for decades delegated his functions for the commissioning and provision of healthcare services to other bodies. The reason for that is simple: managing the range of healthcare needs for our diverse population is now so complex that no one would argue that it is a task best carried out from Whitehall. This has resulted in a vacuum in NHS accountability, with no measures or mechanisms whereby PCTs and trusts can be held locally to account. We in Parliament can only turn to the Secretary of State: he in turn can only give one answer—PCTs and trusts are autonomous organisations, their decisions are taken independently, in accordance with local priorities, and it is not appropriate for these decisions to be subject to interference from the centre. So the fact that the Secretary of State is responsible for making sure that there is an NHS available to all clashes with the fiction—for that is what it is—that he is somehow responsible for all clinical decision-making in the NHS. This results in a poor deal for the person at the centre of things—the patient.
During the last few years, it became clear to politicians of all persuasions that there was another nettle that the NHS had to grasp: the need to improve quality. We know that, measured against accepted benchmarks, the outcomes experienced in the NHS sometimes fail to match up to those achieved in comparable countries. The OECD has reported that if the NHS were to perform as well as the best performing health systems, we could increase life expectancy in the UK by three years.
Towards the end of the previous Government, the noble Lord, Lord Darzi, sounded a clarion call to managers and clinicians around the quality imperative. The focus of the noble Lord’s work—to define what quality means and to drive forward that agenda by fostering innovation, transparency, and choice, by strengthening regulation and by encapsulating the rights and legitimate expectations of patients and staff in an NHS constitution—was unarguably right. But his time in office was short. There was much more that still needed doing.
Our plans for the NHS therefore focused on three main themes: accountability, efficiency and quality—keeping at the centre the most important theme of all, the interests of patients. Modernisation of the health service, we were clear, had to involve a fundamental shift in the balance of power, away from politicians and on to patients themselves through increased choice and information, and on to doctors and health professionals, giving them real budgets and empowering them to use those resources in a cost-effective way to drive up quality. That shift would have two advantages: it would serve to depoliticise the NHS; and it would promote efficiency and quality by making those who take clinical decisions on behalf of their patients responsible for the financial consequences of those decisions. Both GP fundholding in the 1990s and, more recently, practice-based commissioning showed that empowering clinicians directly could improve the quality of care that patients experience. The potential is truly enormous: allowing doctors, nurses, hospital specialists, social services and other professionals the freedom to design care pathways that are integrated, and to commission them on behalf of their patients, will, we firmly believe, transform the quality of care and treatment that the service delivers.
At the same time, the clinicians on whom this greater autonomy is bestowed should be held accountable as never before—not only for their use of public money but also for the outcomes they achieve for patients. Unlike the largely illusory accountability of the present system, we were clear that doctors should be held to account in a transparent way by the patients and the communities whom they serve. Success and failure have to be measured in better and more meaningful ways, by reference to outcomes, not processes. For their part, elected politicians should be held accountable in a dual fashion: first, to Parliament, for the performance of the health service as a whole, defined principally in terms of outcomes; and, in parallel, for directly overseeing and delivering the public health agenda so critical for the long-term health of the nation—an agenda which, too often, has tended to assume a lower priority for government at times when the NHS budget has come under strain.
The fruits of this deliberation were laid out in various Conservative and Liberal Democrat publications from 2006 onwards, including a White Paper, in our manifestos at the last election, the coalition agreement and, finally, a government White Paper from which this Bill directly stems. The democratic mandate for our proposals is absolutely clear.
This brings me to the amendment tabled by the noble Lord, Lord Rea. It is important that we remember what the Labour Party manifesto said on health at the last election:
“We will continue to press ahead with bold NHS reforms. All hospitals will become Foundation Trusts … Failing hospitals will have their management replaced. We will support an active role for the independent sector working alongside the NHS in the provision of care … Patient power will be increased”.
Even Labour accepted at the last election that doing nothing is not an option for the NHS. Many of the principles in this Bill were ones that they wholeheartedly embraced. But the nature of the change must be different. Instead of putting in tiers of management and controlling everything from the centre, we are removing bureaucratic structures so that the front line is empowered as never before to deliver better patient care. This Bill achieves that by means of a better framework which allows power to be devolved from the centre so that innovation is unleashed—
Lord Clinton-Davis
Why was none of this mentioned in the Conservative manifesto at the election?
Earl Howe
I commend the manifesto to the noble Lord because our plans were very clearly set out in it. It allows power to be devolved from the centre so that innovation is unleashed from the bottom up, supported by clear lines of accountability. It is, in fact, the inverse of a topdown reorganisation.
The Bill is long and complex because for the first time in statute it seeks to define the functions and duties of every element in the chain of accountability within a reformed healthcare system, and to join up those functions and duties into a coherent whole. Whereas in the past it has been possible for a Government to change the NHS simply by direction, in the future it will be impossible to do so without recourse to Parliament. Much that was defined in regulations and directions is now to be covered clearly in statute. Daunting as it may seem to some of your Lordships, we were clear that this was an ambition whose realisation was well worth the effort. At the same time as introducing change, it is a Bill which seeks to build on much of the existing and therefore familiar features of the NHS architecture put in place by the previous Administration. Noble lords will know of the Nicholson challenge: to deliver up to £20 billion of savings in the NHS over the next four years, all of which money will be ploughed back into patient care. Savings on this scale are not possible to achieve without system-wide change, and the measures in this Bill are inseparable from that process.
Let me now focus on its content. This Bill is about several things. It is about liberating the NHS and those within it to enable them to work better and more accountably in the interests of patients. It is about streamlining the architecture of the NHS to make it more efficient and transparent. And it is about creating a public health service that is configured to tackle the major challenges to the nation’s health and well-being that face us over the years ahead. The key to achieving this, we believe, is a strengthened and more logical spread of accountabilities. Put simply, the Bill provides that the Secretary of State should remain accountable to Parliament, as he has been since 1948, for promoting a comprehensive health service and for the funds voted each year by Parliament for the health budget.
Let me be clear—the Bill does not undermine the Secretary of State’s ultimate accountability for the NHS or the responsibility that he carries for a comprehensive service. I am fully aware of concerns raised on this point, and I respectfully refer your Lordships to the response we published yesterday to the Lords Select Committee on the Constitution on this very matter. We are unequivocally clear that the Bill safeguards the Secretary of State’s accountability. However, we are willing to listen to and consider the concerns that have been raised and make any necessary amendment to put the matter beyond doubt.
The duty to commission and provide healthcare day to day, which hitherto the Secretary of State has delegated to the NHS, will instead be conferred on NHS bodies directly. Clause 6 proposes that below the Secretary of State there should be a new body, the NHS Commissioning Board, directly responsible for holding and distributing the NHS commissioning budget and for assuming many of the functions now performed by strategic health authorities and patient care trusts, which will be abolished. But the board will not operate without political oversight. The Secretary of State will issue a mandate detailing the outcomes for which the board will be held accountable. The mandate will be subject to public consultation and laid before Parliament, creating a clear line of political accountability. Unlike the current operating framework, the Bill gives the Secretary of State an explicit duty to report on how the board has performed against the mandate. But, as an independent body, the board will be a buffer against the short-term, politically motivated whims of government.
Clause 7 creates clinical commissioning groups as statutory bodies authorised by the board which will commission local healthcare services. CCGs, consisting of groups of GP practices and with doctors in control, will be stewards of the bulk of the NHS commissioning budget and will be held transparently and rigorously to account for the use of those funds against a set of quality and outcome measures. The defining characteristic of CCGs as compared to PCTs will be their clinical ethos. It is doctors and their fellow clinicians, not managers, who know the needs of patients best. By making clinicians financially responsible for the clinical decisions that they take, we will not only drive efficiency but also achieve a step change towards a genuinely patient-centred service.
Real accountability to the patient will be achieved in a number of ways. It will be achieved by empowering patients with information and involving them in decisions around their care. But it will also be achieved by empowering local groups of patient representatives to be involved in how services are commissioned, provided and scrutinised. Clauses 178 to 186 propose the creation of HealthWatch. Local HealthWatch will be based on the existing local involvement networks, or LINks, but with added clout. Funded through local authorities, they will act as the independent eyes, ears and voice of patients and service users in a local area. At the national level, a new body, HealthWatch England, will be established to support local HealthWatch and to act as the national care watchdog wherever quality of care is called into serious question. By making HealthWatch England a committee of the Care Quality Commission, as is proposed in the Bill, we will enable the voice of patients and the public to be heard at the very heart of health and social care regulation.
But liberating the NHS goes further. It means enabling the governors of foundation trusts, who represent the public, patients and staff, to exercise more meaningful influence over strategic decisions made by their trust boards. It means freeing foundation trusts from the private income cap; a constraint which they repeatedly tell us is arbitrary and unnecessary, and whose removal will enable them—without jeopardising their NHS focus—to generate income which can be deployed for the benefit of NHS patients. Clauses 148 to 177 cover these proposals. Noble lords will recall the debate we had on this subject two years ago.
In developing healthcare provision, the previous Government began to champion the cause of patient choice as a driver of quality, and in doing so moved us in the direction of a more plural service with the introduction of independent sector treatment centres, social enterprises and charities operating alongside mainstream NHS providers. We have long agreed that this was the right direction of travel. Competition and choice will no doubt prove a major theme in some of our later debates on the Bill, but let me say for now that we are absolutely clear from past evidence that where competition can operate to improve the service on offer to patients, or to address a need that the NHS fails to meet, we should let the system facilitate it. However, competition only has a place when it is clearly and unequivocally in the interests of patients.
This is where we were critical of one aspect of the previous Government’s policies. The playing field was levelled against the NHS. ISTCs were given guarantees and price subsidies that were not available to public sector providers. That is why we want to ensure that all providers of healthcare operate to the same clear rules. This, in turn, necessitates an independent body capable of holding the ring. That body, we propose, should be Monitor in its new guise as a sector-specific regulator for the health service, with functions and duties framed to enable it to bear down on unfair competition, conflicts of interest and unsustainable pricing. It will operate in accordance with the principles and rules for co-operation and competition, which were introduced by the previous Administration.
For a long time now, the idea of a local democratic mandate for healthcare provision has been a pipedream of many. For the first time, this Bill imposes duties on local authorities that will see the creation of health and well-being boards, bodies charged with assessing and addressing the health and social care needs of a local area. This represents a huge opportunity for improving the commissioning of health and social care. Health and well-being boards will consist of, as a minimum, representatives from clinical commissioning groups, social care, public health and patient groups including local healthwatch, plus elected representatives. They will provide a forum for joined-up decision-making on service configuration and local priorities. Joint health and well-being strategies will not simply inform clinical commissioning in a local area, CCGs will also be required to have regard to them when preparing their commissioning plans, with safeguards in place should they fail to do so. The democratic underpinning this gives to service provision is a major and exciting change.
At the same time, the Government’s clear focus on public health will usher in a new public health architecture. At a local level, for the first time since 1974, local authorities will become the hubs for commissioning and delivering public health services, led by directors of public health and supported by a ring-fenced budget. At the centre, under the direct auspices of the Secretary of State, a new executive agency, Public Health England, will bring together health protection functions currently distributed between a number of different organisations. In driving forward public health strategies at a national level, it will inform and support local authorities in their work, thus ensuring a joined-up system. We believe it is of vital importance that public health should receive the emphasis due to it, if we are to tackle the long-term challenges to the nation’s health and well-being that currently face us.
Alongside this, we will modernise and streamline the Department of Health’s arm’s-length bodies. The Bill abolishes bodies that are no longer required, thus releasing more money to the front line. At the same time, NICE and the NHS Information Centre will have their future secured by being established in primary legislation for the first time.
The changes we have set out will be introduced in measured stages over a period of years, and our plans for transition will ensure that the health service is well prepared; for example, no clinical commissioning group will be authorised to take on any part of the commissioning budget until it is ready and willing to so; Monitor will continue to have transitional intervention powers over all foundation trusts until 2016 to maintain high standards of governance during the transition; and to avoid instability, there will be a careful transition process on education and training.
In framing the provisions of this Bill, Ministers have talked and listened to a great many people; not only before the election but since, with a public engagement on our White Paper in 2010 and, in the spring of this year, the very productive two-month listening exercise. Throughout this time we have encountered consistent and widespread agreement for the key principles underpinning our policies; in particular, since the listening exercise, a shared view among professionals about the way those principles should be put into practice. At the same time, reform of the NHS is seen not just as an option but as absolutely essential for its future.
In addition to this consultation and engagement, this Bill has also undergone significant scrutiny in the other place. The Bill’s first Committee stage lasted 28 sittings—longer than any Bill in nine years. Following the Future Forum’s report, the Bill was recommitted for a further 12 sittings. The Bill was therefore scrutinised over more sittings in the other place—40 in total—than any other Public Bill in the whole period from 1997 to 2010. I direct that point in particular to the noble Lord, Lord Rea.
I conclude with a brief word about the Motion tabled by the noble Lord, Lord Owen, which I shall speak to in detail when I wind up the debate. Suffice it to say for now that while I fully recognise the strength of his concerns, I regard the proposal he has made as posing an unacceptable risk to the passage of this Bill and hence to the Government’s programme for the health service. He is proposing an unusual process. The only basis on which such a process might be workable would be with the prior reassurance, for the Government, of a strict time limit on the Bill’s Committee stage as a whole. Regrettably, I was unable to reach agreement with the noble Lord that this was a reasonable basis on which to proceed. I therefore do not think that his Motion should be supported.
The case for change is clear and compelling, and I am personally in no doubt that the changes set out in this Bill are right for our NHS and—more importantly—right for patients. I hope very much that your Lordships, in reserving your powers to scrutinise the detail of the Bill with your usual care, will wish to endorse the ideas and the vision that it presents. This is a Bill with but a single purpose: to deliver, for the long term, a sustainable NHS, true to its founding principles. It is on that basis that I am proud to commend the Bill to the House, and I beg to move.
Amendment to the Motion
Health: Non-communicable Diseases
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank the noble Lord, Lord Crisp, for introducing a debate on an issue of such global importance. Indeed, I am grateful to all noble Lords who have spoken so powerfully and I welcome in particular the noble Lord, Lord Collins of Highbury, to his Front-Bench responsibilities. Non-communicable diseases, or NCDs, kill millions of people across the world every year. Indeed, they are responsible for three in five of all deaths and bring illness and disability to countless more. People with NCDs are high users of health services worldwide. In England alone, around 70p in every £1 spent on health and care is spent caring for people with a long-term condition, the majority of which are as a consequence of the so-called four big killers: cancer, cardiovascular disease, chronic lung diseases and diabetes.
I listened with huge interest to the noble Baroness, Lady Hayman, and I am so glad that she gave way to temptation by joining our debate today. To pick up on what she said, non-communicable and communicable diseases combined can both devastate the lives of individuals and hinder the growth of whole countries. This is particularly the case in developing nations, which face the double burden of communicable and non-communicable diseases. The true prevalence of non-communicable diseases is often hidden in a number of countries, simply due to the lack of data. I shall come on to that in a moment.
The noble Baroness, Lady Masham, is right: the scale of the challenge is huge but it is not insurmountable. We start from a position of collective international commitment to act. The UK, along with other Commonwealth countries, has called for global action. The recent UN high-level meeting about NCDs, which a number of noble Lords referred to, raised awareness of the issue and culminated in a unanimous declaration by all member states stating their commitment to taking concerted action to prevent, manage and treat NCDs. There is a helpful practical focus on tackling the common risk factors and the WHO has introduced the idea of “best buys” that can be introduced by all countries at little cost.
My right honourable friend the Secretary of State for Health participated fully in that meeting. I take note of the disappointment expressed by the noble Lord, Lord May, but at the same time the meeting was an important first step and a sound basis for sustained action in the years and decades to come.
In reply to the noble Baroness, Lady Murphy, I say that mental health is referred to in the political declaration and the UK supported this inclusion, but we wanted to ensure support for the primary focus to be on tackling the common underlying risk factors and wider social and environmental determinants for the four big killers. We do not in the least underestimate the burden of mental ill health. I hope that the mental health strategy is evidence of that, but we believe that, once we see benefits from this initial focus, there will be positive impacts on health and well-being far beyond these four disease groups, including mental health. The linkages in risk factors were highlighted in the UN declaration.
Global health has long been a priority for the UK Government. I can tell the noble Baronesses, Lady Masham and Lady Hayman, that we are trying, working through both the Department of Health and the Department for International Development, to help developing countries to build health systems that can meet today’s challenges, including the problem of NCDs but also all causes of ill health, especially for the poorest in society.
The UK also supports multilateral organisations. We are the third largest donor to the World Health Organization and we support initiatives such as the Global Alliance for Vaccines and Immunisations, GAVI, to which the UK is the largest contributor. Indeed, GAVI has immunised over 250 million children against hepatitis B and saved over 3 million lives as a result. I was interested in the work of the noble Baroness, Lady Hayman, in promoting vaccine uptake in the third world.
Whatever we do, though, I fear that we need to face one unpalatable fact: we will not be able to eradicate NCDs, unlike smallpox. There is no obesity inoculation. Prevention alone, important though it is, cannot be the sole answer either at home or abroad. Globally, we continue to work to strengthen health systems so that they can provide early, cost-effective care to all who need it, including the poor and vulnerable.
I mentioned that we are strengthening the capacity of countries to deliver improved health services. This is a key area of DfID’s work. So, too, is the health partnership scheme, which facilitates links between UK health institutions and professionals from developing countries to improve health outcomes by sharing skills and capacity building. We are also supporting the medical training initiative, designed for doctors from developing countries to benefit from training in the NHS and foster exchange programmes. I pick up the point made by the noble Baroness, Lady Hayman, that we can learn from others overseas.
I can tell the noble Lord, Lord Crisp, that we also support research on global health. For example, DfID has recently launched PRIME, which stands for “programme for improving mental health care”. That is a new multinational research programme that will focus on the development, acceptability and impact of mental health care packages for priority mental disorders. We have also supported research on tobacco, and I can let the noble Lord have further details on those programmes if he is interested.
The noble Lord asked me about access to essential medicines. This is a priority for us. We are supporting countries to develop domestic health financing mechanisms to ensure sustainable and long-term funding for cost-effective interventions to tackle NCDs, not just drugs but diagnostics and vaccines as well.
Health services have a key part to play in reducing health inequalities in terms of access and quality and working with others to improve health outcomes. We need health systems not simply to treat disease but to be reoriented towards preventative action. As ever, as the noble Lords, Lord Crisp and Lord Kennedy, reminded us, prevention is better than cure—preventing the onset of disease rather than merely treating the symptoms.
Our health reforms in the UK are designed to strengthen our approach to improving public health. On the Health and Social Care Bill we will debate how there is a new health improvement duty for local authorities, supported by a ring-fenced public health budget. This will allow local decisions on health improvement to be taken about the interventions that are most suited to local needs. We think that that will represent a very responsive system, more so than we have at the moment. We are committed to reducing health inequalities, which is why for the first time, subject to parliamentary approval, we are putting into legislation a duty on the Secretary of State for Health focused on the need to reduce inequalities. That makes this the strongest health inequalities duty we have ever had.
First and foremost in the UK, we focus on prevention through an integrated approach as the major non-communicable diseases share a number of common risk factors. We address the causes of the causes, the underlying wider social and environmental determinants. The conditions in which people are born, grow, work and age, their education, employment and housing—all these shape the health of individuals and communities. The Public Health Cabinet Sub-Committee, which we established, allows a wide range of Cabinet Ministers to agree how best to respond to the public health challenges. The importance of taking a whole-of-government approach is emphasised in the UN political declaration.
We are a world leader on collecting data on public health, and other countries draw on our approach to surveillance. WHO is looking now to strengthen global monitoring of the prevalence of NCDs and the common risk factors, which is essential if we are to establish the kind of meaningful targets referred to by the noble Lord, Lord Rea. In England we are putting in place a new strategic outcomes framework for public health at national and local levels—again, in an effort to benchmark these matters—which will be based on the evidence of where the biggest challenges are for health and well-being.
On the domestic front, we are making progress on some of the key areas of action highlighted by the UN and we stand ready to share those experiences with others. NCDs share common risk factors—tobacco use, unhealthy diets, physical inactivity and alcohol misuse. Our actions, particularly on tobacco control and reducing salt intake, have been highlighted by WHO as international best practice.
The noble Lords, Lord Rea, Lord May and Lord Collins, rightly lay particular emphasis on tobacco policy. The UK strongly supports the WHO Framework Convention on Tobacco Control, and we take it very seriously. Tobacco use is by far the biggest risk factor for NCDs, so effective policies to reduce smoking rates are essential. We urge all countries that are not yet parties to the treaty to sign up to it as quickly as possible, and equally we urge all those who are signatories to implement the treaty fully, as we have done in this country. The convention encourages parties to take comprehensive action on tobacco control. The Tobacco Control Plan for England, published in March, sets out a range of actions that will bear down on tobacco use.
The noble Lord, Lord Collins, mentioned salt. As he knows, we have made considerable progress in recent years by working in partnership with industry and others to reduce salt intake. It has gone down by about 10 per cent in the past few years, which has served to prevent over 4,000 deaths a year and saved the NHS a great deal of money. We are taking that work forward as one of the pledges contained within the Public Health Responsibility Deal.
As well as these initiatives, which aim to tackle population health here in England, we are working to strengthen our primary care system, putting the patient and their GP at the heart of service delivery. This will reduce the impact of non-communicable diseases through programmes such as the NHS Health Check, which I hope is of particular interest to the noble Lords, Lord Kennedy and Lord Collins. Our NHS Health Check programme assesses people's risk of heart disease, stroke, diabetes and kidney disease. It has the potential to prevent 1,600 heart attacks and strokes a year—so I am told—to prevent over 4,000 people a year from developing diabetes and to detect at least 20,000 cases of diabetes or kidney disease earlier. It is an important programme.
The noble Lord, Lord Crisp, asked me about the training and the DfID programme. He suggested that DfID was too rigid on this, and too focused on NGOs. Health system strengthening includes training as a key part of DfID’s work. Globally, we provide training through a number of different organisations, including government organisations, NGOs and our contributions to multilateral organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. DfID estimates that 25 per cent of its aid to health supports human resources, including training.
The noble Baroness, Lady Hayman, spoke about neglected tropical diseases. I am pleased to tell her that, only yesterday, the UK announced that we would support the final push to eradicate guinea worm from the world. My honourable friend Stephen O’Brien yesterday issued a challenge: we will increase our support to guinea worm eradication and fill up to one-third of the financing gap, provided that others step forward and fill the other two-thirds. This funding would form a vital part of the push from former US President Jimmy Carter to ensure that guinea worm is consigned to the history books alongside smallpox. We have already committed £25 million over five years to tackle schistosomiasis, or bilharzia.
The noble Lords, Lord Crisp and Lord Rea, and my noble friend Lord McColl expressed doubts about engagement with the food industry in this country. We start with the recognition that people’s lifestyle choices are affecting their health. The Government cannot address this challenge alone through central, top-down diktat. Everyone has a part to play, not just government but also business, industry, retailers, the third sector and individuals themselves. The Responsibility Deal is not a substitute for the development of government policy on public health; it complements it. We also know that businesses can reach consumers and deliver information in ways that other organisations, including government organisations, cannot.
My noble friend Lord McColl spoke very powerfully on obesity. I would like to think that he and I are not so far apart as he perhaps indicated. We are clear that the Government cannot tackle obesity alone. It is an issue for society as a whole. We all have a role to play. We will shortly be publishing our plans for how obesity will be tackled in the new public health and NHS systems in England, and the role of key partners. I could not help feeling, listening to my noble friend, that we might be talking at cross purposes. There is surely a distinction between keeping healthy people healthy—and the advice that goes with that—and helping obese people become less unhealthy. For the latter group, my noble friend’s advice is surely spot on. The NICE advice, I suggest, is relevant and accurate for the former group. Diet has an important role, and we are indeed working to improve it, reducing the consumption of fat, sugar and excess calories. However, it is not tenable to suggest that physical activity is not important. I wonder whether my noble friend and I can agree that physical activity helps to balance the energy consumed. I look forward to a little conversation with him about that afterwards.
The noble Lord, Lord Roberts of Llandudno, spoke extremely convincingly about alcohol. Retailers, producers and pubs ought to promote, name, market and sell their products in a responsible way. We need to see leadership from them to produce a radical and better balance between business interests and social harm. I am encouraged to tell him that there has been a wide sign-up to the first set of collective pledges under the Responsibility Deal. Networks are already developing the next tranche of pledges. Again, by working closely with industry, we help it to shoulder its responsibilities and can go further and faster in developing the initiatives that we all want.
The noble Lords, Lord Kennedy and Lord Collins, referred quite rightly to diabetes. Our national diabetes service framework, begun in 2003, has been reinvigorated this year by a new NICE quality standard for diabetes against which future care will be measured. Our national diabetic retinopathy screening programme has been offered to 98 per cent of people with diabetes; that is a great record. A National Health Check programme for 40 to 74 year-olds in England includes an assessment for those at risk of developing type 2 diabetes as well as cardiovascular and kidney disease. That programme has real potential to identify people at risk of diabetes early and prevent its debilitating complications.
Now, I have a few apologies to make; first, to the noble Baroness, Lady Masham, who asked me about the training of doctors for pain control. I do not have information on that in front of me, but I will certainly write to her. I shall also write to the noble Lord, Lord Kakkar, who asked me about the proportion of NIHR funding on cardiovascular disease and any research network that there may be on that disease in the Commonwealth. He also asked me about UK funding for research on cardiovascular disease in developing countries, and I can tell him that the Indian Council for Medical Research is collaborating on several research topics related to NCDs; indeed, there is a collaborative research programme in Mumbai studying the impact of nutrition in pregnancy and early childhood on the risk of heart disease in later life, and its intergenerational effects.
I hope that what I have said will reassure the House that we are taking action on all fronts to prevent and manage NCDs both nationally and globally. However, concerted action is needed across Governments and industry to meet the challenges of NCDs. The human and economic consequences of inaction are too grave for us all to do anything else.
Health: Breast Cancer
Earl Howe Excerpts(12 years, 7 months ago)
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Baroness Morgan of Drefelin
To ask Her Majesty’s Government what assessment they have made of the impact Improving Outcomes: A Strategy for Cancer, issued by the Department of Health, has had on women with breast cancer.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, our cancer outcome strategy sets out our ambition to improve outcomes for all cancer patients and save an additional 5,000 lives every year by 2014-15. Specifically on breast cancer, the strategy outlined commitments on local awareness campaigns, expanding breast cancer screening, measuring the prevalence of metastatic breast cancer, and one-day stays for breast surgery. Good progress is being made in all these areas and the strategy’s first annual report will be published in the winter.
Baroness Morgan of Drefelin
My Lords, may I remind the House of my interest as chief executive of the research charity Breast Cancer Campaign? I thank the Minister for his response. I have two brief questions. We know that radiotherapy is a very cost-effective treatment, improving outcomes for people with cancer at 5 per cent of the NHS cancer spend. Can the Minister explain to the House what progress is being made to ensure that the additional investment set out in the outcomes strategy is actually being converted into improved outcomes rather than lost in the bottom line? Can the Minister say what steps are being taken to improve access for women to IMRT radiotherapy, which is, of course, the modern version of this treatment and which can be so beneficial for appropriate referrals?
Earl Howe
My Lords, the noble Baroness, with her expert knowledge in this area, is absolutely right that access to appropriate treatment, delivered to a high standard, is critical to improving outcomes. We have made a commitment to expanding radiotherapy capacity by investing around £150 million more over the next four years. That is intended specifically to increase the utilisation of existing equipment, establish additional services and make sure that all patients who need the therapy can get it. We are investigating a tariff for IMRT; that is part of our work towards the aspiration to ensure that IMRT is available in at least one centre per cancer network by 2012. It is a matter for local decision-making, but an IMRT development programme is now in place.
Lord Alderdice
My Lords, would my noble friend agree that progress in this important area of breast cancer is likely to be found in the identification of molecular markers and the design of appropriate targeted medications, as has been the case in breast cancer with HER2 and Herceptin, for example? Would he acknowledge that it is a very expensive treatment? Although it really improves quality of life as well as mortality and outcome, the expense of not only the medication but the tests themselves is considerable. How will the NHS cope with this important but very expensive progress?
Earl Howe
My noble friend makes an extremely important point. That is why we need a body such as NICE, the National Institute for Health and Clinical Excellence, to advise the health service on what treatments represent cost-effective value for money. The tendency of drugs to impose considerable cost on the NHS is very great, as he points out. It is important that clinicians focus on those drugs that really do the best for patients. I am aware that a number of drugs are currently being assessed by NICE with regard to breast cancer.
Baroness Thornton
My Lords, I apologise for my conference throat—it is all the cheering I did last week. The Government published a strategy for cancer in January 2011 and set a target of improving cancer survival rates, so that by 2014-15 an extra 5,000 lives will be saved each year. What progress has been made towards meeting the target that was expressed in Improving Outcomes: A Strategy for Cancer and saving those extra 5,000 lives a year?
Earl Howe
My Lords, there are broadly three ways in which we can attain that target. The main way is through early diagnosis—in particular, by making sure that women are aware of the signs and symptoms that could indicate breast cancer—but also by improving access to screening and to radiotherapy, which has already been covered in the question from the noble Baroness, Lady Morgan. To support the NHS to achieve earlier diagnosis of cancer, the strategy has been backed by over £450 million over the next four years. That is part of over £750 million additional funding for cancer over the spending review period.
Lord Patel
My Lords, we know that one of the reasons for the poor outcomes on cancers is the late referrals of patients who suffer from cancers. We are now likely to have performance management of primary care doctors being based on their referral patterns. Can the Minister confirm that there will be no financial incentive for reducing referrals of suspected cancer patients for treatment?
Earl Howe
Yes, I can, my Lords. It is very important that doctors should feel absolutely free to refer patients. I remind the noble Lord that it is a right for patients, under the NHS constitution, to expect to be referred within the laid-down waiting time maximum periods, so we are very clear that there should be nothing to interfere with doctors’ clinical judgment in this area.
Baroness Fookes
My Lords, am I right in thinking that screening comes to an end after a certain age for women? If that is correct, does it make any sense when the incidence of breast cancer increases with age?
Earl Howe
My Lords, my noble friend is right that we have historically targeted women in a certain age group for breast cancer screening. We are looking to see whether that age group should be widened but it is generally true to say that screening is more cost-effective in older women. It has certainly been the case that the breast screening programme over the past number of years has increased the detection of cancer and saved an estimated 1,400 lives a year.
Lord Hughes of Woodside
My Lords, can the Minister confirm that there is something in the NHS called the two-week procedure whereby GPs can refer patients to a hospital and they are therefore seen by that hospital within those two weeks? If I am right in that, will that be more widely used and advertised so that patients know what they can ask of their GP?