Health: Breast Cancer
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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?
NHS Future Forum
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I agree with the noble Baroness, Lady Thornton, that this has been a timely debate. I thank the noble Baroness, Lady Wheeler, for calling it and all noble Lords who have spoken and contributed so eloquently. To pick up the baton handed to me by the noble Baroness, Lady Donaghy, who remarked what big plans my colleagues and I have in the Government's programme of modernisation of the NHS, the debate has indeed covered a great deal of ground. I will do my best to cover most of the key issues in my speech. To the extent that I do not, I will of course follow up those points in writing.
The noble Baroness, Lady Wheeler, asked why we needed to legislate at all. The Health and Social Care Bill seeks to create a stronger, more responsive and more innovative NHS—an NHS led by clinicians, with patients in control of their own care and with a resolute and unflinching focus on results. We must streamline the architecture of the health service to improve its efficiency.
My noble friend Lord Ribeiro directed us towards exactly the right starting point by referring to the core principles underpinning the Bill. Despite widespread support for these principles—and there has been such support—some thought that the detail of the Bill could be improved to better support those principles. So we took the unprecedented step of asking a group of independent health experts, the Future Forum, to recommend changes to the Bill. I would like once again to thank Professor Steve Field, the members of the NHS Future Forum, the hundreds of organisations and thousands of people who contributed to the listening exercise. We accepted all of the forum’s core recommendations and we have since made significant changes during the Bill’s Second Committee stage. I cannot accept the criticism of the noble Baroness, Lady Thornton, of the process. Stakeholders have in fact welcomed how the forum conducted itself—for example, Mike Farrar of the NHS Confederation and Hamish Meldrum of the BMA. I believe that the process has been hugely positive and has helped us to improve a number of our plans in different ways.
First, I would like to run briefly through some of the key changes that the Government are making. My noble friend Lord Ribeiro, as might have been expected of him, referred to clinical leadership. Some were concerned that too narrow a group of clinicians would be charged with designing services, so we have amended the Bill to place stronger duties on commissioners to ensure that all relevant health professionals are involved in the design and commissioning of services at every level—including clinical networks in relation to specific conditions and new clinical senates for broader areas. The governing bodies of clinical commissioning groups will need to appoint at least one registered nurse and one secondary care specialist.
The noble Lord, Lord Rea, questioned whether there would be public health input into the commissioning process. The Bill should require commissioning consortia or groups to obtain all relevant multiprofessional advice to inform their commissioning decisions, including public health but also other types of advice. The authorisation and annual assessment process should be used to assure this. We will make sure that a range of professionals plays an integral part in clinical commissioning of patient care and we have amended the Bill to place stronger duties on commissioners to obtain that advice.
We are committed to harnessing the benefits that competition and choice bring for patient care but let me make it clear, particularly to the noble Lords, Lord Rea and Lord Sawyer, that competition will never be about serving the interests of corporations. It will be about serving only the interests of patients and we have made changes to the Bill to reflect this. We have removed Monitor’s duty to promote competition as though it were an end in itself. Instead, it will be under a duty to support services integrated around the needs of patients and the continuous improvement of quality. The choice of “any qualified provider” will be limited to those areas where there is a national or local tariff, ensuring that competition is only ever based on quality, not price. That will also ensure that there can be no cherry picking. I will come back to that point in a moment. There will be and can be no privatisation of the NHS. In fact, it will be illegal for current or future Ministers, the NHS Commissioning Board or Monitor to favour the private sector over the public sector, or indeed vice versa. While some will undoubtedly disagree, what matters is the outcome of care provided and the end results for patients, not the nature of the provider—public, private or otherwise.
The noble Baroness, Lady Wheeler, suggested that we had not implemented the Future Forum’s recommendations on board meetings being held in public. It is not correct to say that we have not amended the Bill in regard to that, as we have made it a requirement for every clinical commissioning group to have a governing body with decision-making powers. To enhance transparency and accountability, governing bodies will be required to meet in public and publish their minutes, while clinical commissioning groups will have to publish details of contracts with health services. Openness and transparency will be the bedrock of a new, more patient-centred, outcome-focused and accountable NHS. We have amended the Bill in the way that I have described but, in addition, we have said that the governing bodies of commissioning groups must have at least two lay members: one to champion patient and public involvement, the other focused on overseeing key elements of governance such as audit, remuneration and managing conflicts of interest. Foundation trust governing boards will also need to meet in public.
The theme of integration loomed quite large in a number of noble Lords’ contributions. Excellent care often means integrated care. We have strengthened the NHS Commissioning Board’s duty to integrate services and introduced an equivalent duty for clinical commissioning groups. Health and well-being boards will be required to involve the public when identifying local needs and developing the joint health and well-being strategy. In future, I think there will be far more effective arrangements than exist currently for ensuring joined-up working across the NHS, public health and social care—a theme picked up by the noble Baroness, Lady Pitkeathley. We will have an NHS Commissioning Board setting common frameworks in which clinical commissioning groups commission services, a regulator to ensure that standards in care are met and greater transparency of outcomes, which will drive up efficiency and quality. I add that we have asked the NHS Future Forum to look at integration as part of its continued conversations with patients, service users and professionals. The forum will report back to Ministers later this year on what it has heard.
The pace of change has also caused concern for some people, so in a number of areas we have made the timetable for change more flexible. No one will be forced to take on new responsibilities before they are ready to do so. However, those who wish to progress more quickly will not be prevented from doing so.
Let me now turn to some of the specific concerns which have been raised during the debate. The noble Baroness, Lady Wheeler, and my noble friend Lady Jolly referred to the Secretary of State’s duties—concerns that were echoed by the noble Baroness, Lady Donaghy, and the noble Lord, Lord Sawyer. At present, the Secretary of State has a duty to provide or secure services himself but delegates that responsibility to strategic health authorities or primary care trusts by directions. Generally, he delegates nearly all his commissioning responsibilities to SHAs or PCTs, but he has the powers to alter that and vary the extent of delegations. Under the new system, the function of arranging the provision of services—that is to say, commissioning—will be conferred directly on the board and clinical commissioning groups by Parliament, providing stability for the system and removing the Secretary of State’s ability to intervene arbitrarily in the day-to-day management of the commissioning process. That will free up those with the relevant expertise to focus on commissioning the best possible services for patients, free from political micromanagement.
Ministers are accountable for the NHS and will remain so. The Bill does not change the Secretary of State's overarching duty to promote a comprehensive health service, which has underpinned the NHS since it was founded. The Bill simply makes it clear that it should not be the responsibility of Ministers to provide or commission services directly. That should be the job of front-line organisations, free from interference. We are putting patients and professionals in the driving seat in order to create better quality care and better value for taxpayers.
The noble Lord, Lord Sawyer, said that there was not enough in the Bill to provide clarity. I understand why he makes that point. Every Bill that we scrutinise in this House needs to get the balance right between what is on its face and what is in regulations. We have republished our delegated powers memorandum, which sets out our justification for taking the delegated powers that the Bill proposes, and I hope that memorandum is well read and scrutinised.
The noble Baroness, Lady Wheeler, and others including the noble Lords, Lord Warner and Lord Sawyer, suggested that we were adding layers of bureaucracy. I think the noble Baroness said that the number of bodies would be increasing from 163 to 521, if I did not mishear her. I simply cannot accept that; it is not true that we are creating additional bureaucracy. The changes we made to the Bill as a result of the listening exercise do not create any extra statutory organisations at all and I do not recognise the figure that she cited. We remain absolutely committed to our promise to cut bureaucracy. We are removing layers of management by abolishing 151 PCTs, 10 strategic health authorities and half of the national health quangos. Administration costs across the health system will be cut by a third in real terms by 2014-15.
The noble Baroness, Lady Wheeler, spoke generally about the Future Forum recommendations, particularly about some that in her eyes the Government did not accept. We accept all the core recommendations of the Future Forum report but there are some areas that need further work before the final decision is taken. Those include further work on the feasibility of a citizens’ right to challenge poor quality services and lack of choice, and work to improve how continuing professional development is provided.
Some but not all of the forum’s core recommendations to the Bill require amendments to the Bill. For example, clinical networks and clinical senates will be hosted by the commissioning board, and will not need to be provided for by amendments to the Bill.
The noble Lord, Lord Warner, asked about phase 2 of the Future Forum’s activities. We announced in August that the forum will provide further independent advice on four themes: information, education and training, integrated care and public health. While the first phase of the forum’s work focused largely on the Bill, the second is focusing on non-legislative aspects of the reforms. It will report back to the Government later this year and publish its advice, as I indicated earlier, and we will draw on that advice as we work to implement the reforms across the piece.
My noble friend Lady Jolly took up the subject of education and training, which was also the theme of a number of other noble Lords’ contributions. It is vital that any changes to the funding of education and training have to be introduced in a careful phased way that does not create instability. We are therefore going to take our time to develop the proposals, working with our health and social care partners, and through further consultation. We will be publishing more details about that in the autumn and will bring forward an amendment in due course.
We think that individual employers with appropriate professional input and leadership are best placed to plan and develop their own workforce and assess what workforce and skills are needed on the front line to provide affordable, safe and high-quality care. Health Education England is being established to support healthcare providers and provide national oversight of workforce planning, education and training. It will be a lean and expert organisation and will provide leadership for effective workforce planning and the provision of high-quality education and training that supports innovation, value for money and better skills. We have also been working closely with strategic health authorities, which are managing the transition to the new system.
I turn to specific questions about the subject of competition, an issue raised by the noble Baronesses, Lady Wheeler and Lady Donaghy, and the noble Lord, Lord Rea, among others. “Promoting competition”, which was the original wording in the Bill, could have been interpreted in a number of ways. It could have been interpreted as proactively encouraging new providers of NHS-funded services to come forward or existing suppliers to compete for more services, irrespective of what was in the best interests of patients. Addressing anti-competitive behaviour is about preventing potential abuses by providers and commissioners to ensure that the system works in the best interests of patients. “Promoting competition” might also have been interpreted as requiring action where Monitor felt that there was insufficient competition in place, such as where there was a single dominant supplier of a particular service. The Bill now provides that Monitor should consider acting in such cases only if the provision of services is not economic, efficient or effective, or if a provider is abusing its market position to the detriment of patients.
A number of noble Lords were worried about cherry picking, especially the noble Lord, Lord Rea, and the noble Baroness, Lady Thornton. Those two noble Lords in particular were mistaken in their analysis of the position. We have consistently said that we would prevent private companies from cherry picking easy, profitable NHS services. We fully agree with the Future Forum’s call for additional safeguards against private providers being able to cherry pick profitable NHS business. We have made changes to the Bill to ensure that competition is about quality, not price; for example, there will now be a specific duty on Monitor to ensure that providers are paid in line with the complexity of the cases that they treat. Providers will have to set and apply transparent eligibility and selection criteria.
In her wide-ranging speech, the noble Baroness, Lady Wheeler, also covered the subject of the private patient income cap. Professor Field told the Commons committee in June that the Future Forum heard a wide range of views on that subject. He expressed the personal view that, because of the mixed views on this area, the forum could not make a strong recommendation as a body. In the eyes of many, the current cap is arbitrary and unfair. Foundation trusts tell us that the private income cap is unnecessary and restricts their ability to innovate and maximise income to deliver improved NHS services. We are confident that, as and when the cap is lifted, private income will benefit NHS patients. We are determined that that should be seen to happen. However, we will explore whether and how to amend the Bill to ensure that foundation trusts explain how their non-NHS income is benefiting NHS patients.
My noble friends Lady Jolly and Lord Ribeiro and the noble Lord, Lord Warner, spoke about reconfiguration. Although I have extensive notes on that important subject, I suspect that there is not time to cover it now. However, we will no doubt return to it, as we will to the many questions asked of me by the noble Baroness, Lady Pitkeathley.
I shall cover a couple of smaller issues. My noble friend Lady Jolly asked whether directors of public health would report directly to the chief executive of a local authority. We expect directors of public health to be of chief officer status and to report directly to the chief executives of local authorities. We are engaging with local government and public health stakeholders about how best to ensure that they have appropriate status.
Now that the Bill has passed to this House, I look forward to the debates that we will have in the weeks and months ahead. In preparation for those, my office will be in touch with interested Peers to arrange briefings with the Bill team and Library officials about any of the issues that we have been debating today and indeed any others that are troubling noble Lords. Those are likely to take place between Second Reading and Committee.
On the question of organigrams, I refer the noble Baroness to the original White Paper that we published, which contains a rather good one. We will also shortly be publishing a statement of accountabilities in the NHS, which will set out the roles and responsibilities of each organisation in the system.
Thanks to the excellent work of members of the Future Forum, the Bill has the potential to free clinicians to lead, to enable patients to take control and to focus the NHS on improving the quality of outcomes—principles that I hope we can all agree upon as we move forward to the next very interesting stage of the parliamentary process.
NHS: Cost-effectiveness
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Baroness Thornton
To ask Her Majesty’s Government whether the Department of Health will draw attention to the recent report in the Journal of the Royal Society of Medicine on the cost-effectiveness of the National Health Service.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the department welcomes the report to which the noble Baroness refers, and recognises the significant gains in health achieved by the National Health Service since 1979. However, its evidence is limited and does not support broad generalisations on NHS cost-effectiveness. The NHS can still make major improvements to the health of the nation and must continue to respond to pressures from an ageing population, new technology and rising patient expectations.
Baroness Thornton
My Lords, I thank the Minister for that Answer. The Government seek to justify the hugely risky reforms of the NHS by saying that our NHS is not fit for purpose in a variety of ways, including not being cost-effective. We all know that improvements can be made—there is no doubt about that at all—but how does the Minister reconcile that with yet another authoritative report in the Royal Society of Medicine journal which says, among other things, that in terms of cost-effectiveness—that is, economic input versus clinical output—the UK NHS is one of the most cost-effective in the world, particularly in reducing mortality rates, and that among other systems, the US healthcare system is one of the least cost-effective?
Earl Howe
My Lords, I must point out one thing about this report: it does not make any claims for how cost-effective our health system was at any given point in time. What it does is measure the improvement in mortality over a period and then assess the cost-effectiveness of that improvement, which is a very different thing. Yes, the NHS has made great strides in improving mortality rates, but that is the only metric that the report deals with. It completely ignores other measures of quality. It is also completely silent about anything that happened after 2005, so recent years are not covered.
Lord Clement-Jones
Is not the really difficult and vital context in which we find ourselves at the moment the fact that we need significantly to improve productivity in the NHS in line with the so-called Nicholson challenge, which was endorsed by both this Government and the previous one? Can the Minister remind us of the record under the previous Government and tell us what he expects to be the outcome of the current health reforms?
Earl Howe
I am grateful to my noble friend. A Written Answer was published in Hansard recently that tracked the changes in productivity of the NHS between 1996 and 2008. He will know if he read it that there was a decrease in productivity over that period of around 3.1 per cent. The pressures on the NHS are increasing. In order for it to respond to the needs of the future, including an ageing population and the cost of new technologies, it needs to adapt to new ways of working that reduce cost pressures while delivering improved outcomes. The measures that are before Parliament seek to do just that.
Baroness Farrington of Ribbleton
My Lords, can the Minister give an example of any major reorganisation and restructuring that has not cost more money and put the brakes on improvements in the service that were being made, particularly when the Government bringing in to the system such major changes comprise two parties that said that there would be no major reorganisation of the National Health Service were they to be in government?
Lord Patel
Does the Minister agree that improving the quality of healthcare will lead to higher costs?
Earl Howe
No, I do not. There are plenty of examples of quality costing less because the system gets it right first time. We see this time and again, for example in the Quit programme. The simplest example is that if we can treat patients correctly in hospital and keep them in for the shortest amount of time, we save a great deal of money.
Lord McColl of Dulwich
My Lords, on the subject of cost-effectiveness, does my noble friend agree that we are in the middle of the most serious epidemic to afflict this country for 100 years—namely the obesity epidemic? The cure is free: you just have to eat less. Why does the Department of Health insist that exercise is important in this equation?
Earl Howe
My Lords, the department takes its cue from NICE. I am sure that my noble friend will agree that exercise is never irrelevant to the question of obesity. I think that my noble friend's difficulty centres on how relevant it is in relation to reducing calorie intake. No doubt the debate on that will continue.
Baroness Pitkeathley
My Lords, does the noble Earl agree that no system of health, particularly with an ageing population, can be effective and efficient unless we also provide the best possible social care to link with it?
Earl Howe
I agree with the noble Baroness. One of the aims of our reforms is to integrate health and social care in a much more seamless way. There is another element to our reforms, which may have escaped noble Lords' notice. It is our wish to bear down on health inequalities in a much more systematic way than we have done hitherto. Both health and social care have a part to play in that.
Lord Tugendhat
My Lords, I declare an interest as chairman of the Imperial College Healthcare NHS Trust. Does my noble friend not agree that whenever an international organisation such as the OECD or the IMF has good words to say about the conduct of the British economy, the Chancellor of the Exchequer always welcomes them and uses them as an argument to support the Government’s economic policy? Would it not be helpful, when other organisations have good words to say about the NHS, for the Government to welcome them with equal fervour? Of course the NHS can improve and must modernise and move with the times; but when significant institutions such as the Commonwealth Fund in America, and the one that has just been quoted, have good words to say about the NHS, surely the Minister should be less carping.
Earl Howe
My Lords, in my opening words I said that we welcomed the report. I stressed that we fully acknowledge the improvements that have been made by the NHS over the past few years, which the report highlights. However, it is limited in its scope. The difficulty with all these reports is comparing like with like, particularly with different health systems. I am not decrying the work that went into the report, but I will say that perhaps some OECD reports take us closer to how well the UK's health system is performing in relation to those of other countries.
Baroness Williams of Crosby
My Lords, will the Government take a larger look at the scope and permanence of the NHS’s success in recent years? Does the Minister agree that a key factor is the share of GDP devoted to the NHS and the results that it produces? The NHS has consistently produced better results with a much lower share of GDP than some comparative health services, including that of the United States.
Earl Howe
My noble friend is right. There is also another measure that counts—not just the percentage share of GDP, but the absolute amount of money in the health budget that goes into our NHS. As she will know, the amounts of money have increased substantially over recent years. That produces a rather different ratio from the one in the report referred to in the Question.
Smoking
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Lord Ribeiro
To ask Her Majesty’s Government whether they will introduce legislation to stop adults smoking in cars when children are present.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, exposure to second-hand smoke is hazardous, especially to children’s health. Since smoke-free legislation was introduced in England in 2007, evidence shows that the number of children being exposed to second-hand smoke has continued to fall. However, some children are still exposed in the home and in family cars. We want to encourage people to create family environments free from second-hand smoke. The Government are proposing a range of voluntary measures that we believe can achieve more, more quickly, than legislation.
Lord Ribeiro
My Lords, I thank the Minister for his considered response. The evidence of damage to children from passive smoking is well documented. Thirty jurisdictions in Canada, Australia and the United States have banned smoking in cars when children are present. In Canada, exposure to smoking in cars fell by one-third to one-half in some provinces over a six-year period. Is my noble friend aware that the concentration of smoke in the back of a car is considerably greater than that in the front, even if the driver’s window is open? Is he prepared to follow the example of the Welsh Assembly and introduce legislation if efforts to change behaviour fail?
Earl Howe
My noble friend speaks with great authority on this subject, and I find little to disagree with in anything that he has said. He is absolutely right that children are particularly vulnerable to the harms of second-hand smoke: more than 300,000 children in the UK present passive smoking-related illnesses to their GP every year. We have to take this matter seriously, and we are. However, despite the evidence my noble friend cites from Canada, it is still early days to judge how effective that legislation has been, over and above voluntary measures. The second issue that poses problems is enforcement. However, we continue to look at these questions very closely.
Lord Hughes of Woodside
My Lords, as a former heavy smoker, I still have a guilty conscience over what I must have done to my own children. I fully support every effort to attack passive smoking. But did the Minister see in a report in today’s press that a council somewhere in England has refused to allow an adoption because the male of the family had once smoked a cigar at a wedding and had once smoked a cigar at a party? Is this not taking things to a totally ridiculous level?
Lord Foulkes of Cumnock
My Lords, I moved Private Member’s legislation in the other place in the early 1980s and got nowhere on it. Only when legislation was moved was there a real reduction—a complete ban—on smoking in public places and only through legislation can effective action be achieved. Is it not also the case that smokers lighting up cigarettes in cars are dangerous in terms of road safety? That is an extra reason for doing it. Will the Minister therefore stop pussy-footing around and saying that this can be achieved voluntarily, when we all know that it can only really, successfully and effectively, be achieved through legislation?
Earl Howe
My Lords, I do not agree with the noble Lord’s analysis. It is true that, on current evidence, the legislation is having a beneficial effect; I would not dissent from that. However, we know that voluntary behaviour change is eminently possible. It would explain why, between 1996 and 2007 when the legislation came in, secondhand smoking exposure in children in England declined by 70 per cent. That was driven by not only the evidence but also awareness campaigns and increased awareness in the lead-up to the legislation. Therefore, voluntary action can have a beneficial and marked effect.
Baroness McIntosh of Hudnall
My Lords, since the Minister mentioned enforcement, I wonder whether he would like to comment on the issue more generally. I take the point of my noble friend Lord Foulkes about road safety issues that arise from smoking in cars, as well as health issues. Is the Minister content that enough is being done to enforce restrictions that are already in place, for example on the use of mobile phones in cars? Is it not the case that the burden of enforcement always will fall mostly on the police, and that they are unlikely to be able to carry out those duties very effectively when they are under such pressure to cut their numbers?
Earl Howe
The noble Baroness makes a very good point. Currently, enforcement in the hands of the police centres mainly on dangerous driving. That may take the form of people illegally using mobile phones while driving or perhaps smoking in a dangerous way. However, I take her point that there is a limit on the extent to which the police can be expected to extend their remit. There is also a sensitivity in this area. The idea of police stopping a car in which somebody in the front seat is smoking on suspicion that there might be a child inside may stray over the boundary of what society would consider an acceptable use of police time.
Baroness Howarth of Breckland
My Lords, I know that the Minister is very concerned about the effects on children. Could he remind me of the timetable to remove displays from tobacconists’ stores so that children do not see them and are not encouraged to smoke, because that legislation can already be put in place and carried through?
Earl Howe
The noble Baroness is right. We believe that the Government’s commitment around the introduction of tobacco display legislation strikes the right balance. We have amended the implementation dates. Displays will come to an end in large shops on 6 April next year, and in small shops on 6 April 2015.
Baroness Thornton
My Lords, my Government and this Government should be proud that today there are more than 2.5 million fewer smokers in England than there were in 1998. The noble Lord, Lord Ribeiro, points to the challenge of how to make certain behaviours unacceptable. Does the Minister believe that the Government’s nudge policy will work here? Will the Government invest in a public information campaign aimed at substantially and permanently changing public behaviour in this respect?
Earl Howe
My Lords, we are going to publish a tobacco marketing plan later this year which will lay out precisely what we propose to do at a local level. It is our intention to support local efforts to raise awareness and use the insights that we know about from behavioural science to influence positive changes in behaviour, including around the social norms of not smoking when children are present. Voluntary local initiatives are already working. There is a very good example of that in Lincolnshire at the moment. We want to roll out more programmes like that.
Viscount Simon
My Lords, legislation already exists to ban smoking in commercial vehicles and in company cars because of the road safety aspects and also, presumably, because of health. Would it not be easy to ban smoking in all vehicles?
Earl Howe
My Lords, as I indicated earlier, we certainly have not ruled out the possibility of legislation, but we need to be sure about the evidence that legislation will have a greater beneficial effect than voluntary action on its own. It is a case of balancing the pros and cons. We have touched upon the enforcement issue and I do not think that that will go away, but on the other hand, the benefits of legislation in other jurisdictions may turn out to be compelling.
NHS: Hospitals
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Lord Clinton-Davis
To ask Her Majesty’s Government what meetings they have held with private companies concerning the management of NHS hospitals; and what was the outcome of any such meetings.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, as part of standard policy development, officials in the Department of Health met UK-based companies and one international health expert to hear their experiences of intervening to improve underperforming organisations. These were background sessions to inform policy development. Any decisions to involve organisations such as the independent sector or foundation trusts in running NHS hospitals would be locally led. In all cases, staff will remain within the NHS and assets owned by the NHS.
Lord Clinton-Davis
Is there any suggestion by the Government of cutting staff or wage levels, thus putting greater emphasis on raising revenue rather than patient care, which we regard as highly important? This policy represents, does it not, the decline of the NHS rather than its reform?
Earl Howe
I am not sure what policy the noble Lord is referring to. There is certainly no concerted policy to decrease the pay levels of NHS staff. That is something we take very seriously. The proper remuneration of NHS staff, and their motivation, is of central importance to the well-being of patients. No, we are not diluting the NHS; the whole point of the Government’s programme is to bolster and boost the sustainability of the NHS for the long term.
Lord Hamilton of Epsom
Does my noble friend accept that productivity in the NHS has been absolutely abysmal over recent years and that the private sector, if it comes in to run hospitals better, may be able to raise it?
Earl Howe
My noble friend is right. The statistics for the productivity of the NHS over the past 10 or 12 years show that it has actually gone down by about 3 per cent in total. We certainly think that the private sector has a role to play in places where it can introduce the higher quality of service that patients actually want. There is no question, however, of the Government forcing private enterprise into health services where it is not wanted and not in the interest of patients.
Baroness Jolly
My Lords, within England there are already several NHS-badged private hospitals. Can my noble friend tell the House how many of these establishments were set up by the previous Government and how many of their employees are non-UK nationals?
Earl Howe
My Lords, I am grateful to my noble friend for that question. I am sorry to say that I do not have those figures in front of me, but she is absolutely right to make the point that the independent sector treatment centres introduced by the previous Government were a perfectly proper move to increase choice for patients, and in many cases we have seen the quality of care in those hospitals encourage the NHS to raise its own game. Competition on that basis is highly beneficial.
Lord Patel
Will the Minister say what assessment has been made of the causes of low productivity in the NHS?
Earl Howe
My Lords, it is clear that one of the causes was that the previous Government—for all the right reasons, I have to say—injected very large sums of additional money into the health service, but alongside that there was no commensurate increase in activity. A lot of the additional money went into settling pay claims. That is not to decry the many benefits that arose from the additional money, but the net effect was a decline in productivity.
Baroness Wall of New Barnet
Does the Minister agree that there are dangers in sweeping statements on how NHS hospitals perform and that they perform badly, because that is not the case? In many instances, not just in my own hospital—Barnet and Chase Farm—the improvement in hospital services over the past years has been incredible. Does he also agree that there are already strong and widespread relationships with the private sector in NHS hospitals and that the challenge is for NHS hospitals to be better than private hospitals so that people will choose to go to their local hospital?
Earl Howe
The noble Baroness is right to pull me up. If I implied that the NHS was across the board providing a lower standard of care than the private sector, I apologise because that is certainly not the case. There are some shining examples of care delivered by the NHS. However, as she will know, not all hospital trusts are as good as hers. Some give us cause for concern in a clinical sense, and they need to be challenged sometimes on the way they look at quality. That is going on at the moment with the quality, innovation, productivity and prevention programme that she will know very well.
Baroness Thornton
My Lords, let us get this Question back to transparency. Over a year ago, David Cameron, the Prime Minister, said:
“Greater transparency across Government is at the heart of our shared commitment to enable the public to hold politicians and public bodies to account”.
That is the point of my noble friend’s Question. I would like an assurance from the Minister that minutes and discussions are available at local and national level on the public record of meetings with private and independent healthcare providers.
Earl Howe
My Lords, the origin of this Question was, I believe, a freedom of information request that was replied to by my department. The background is that we have a small handful of hospitals that will struggle to achieve foundation trust status in their own right. I suggest that civil servants have to be allowed to have potentially helpful conversations with those who have experience of turning around financially challenged organisations. That is the background. We are perfectly transparent about that situation, as were the Government of which the noble Baroness was a member.
NHS: Medical Records
Earl Howe Excerpts(13 years, 2 months ago)
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Lord Naseby
To ask Her Majesty’s Government whether they intend to continue to computerise all NHS medical records.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government aim to continue to computerise NHS medical records so that patient experience is enhanced, patient care is made more efficient, and patient safety is improved. However, we recognise the weakness of top-down, centrally imposed IT systems. Although elements of the programme have been successful, the policy approach taken has failed to engage the NHS sufficiently. The findings of recent reviews will contribute to planning currently under way for future informatics support to the modernised NHS.
Lord Naseby
Is my noble friend aware that the current programme for the NHS database has cost over £6.2 billion, has taken 10 years and is currently totally unworkable? Is he aware of any other country in the world that has attempted such a project and succeeded? As far as I can see, no other country has even attempted it. Would it not be far better if Her Majesty’s Government bit the bullet and scrapped the whole scheme, as they did with the RAF’s Nimrod programme, which was itself a brave decision?
Earl Howe
My Lords, I can well understand my noble friend’s acute disquiet over this matter, particularly in light of the recent report from the Public Accounts Committee. The view we have taken is that some very good things have been achieved so far, particularly from the national elements of the programme, but it is equally clear that the top-down policy approach taken to the computerisation of the NHS has not delivered the benefits at local level that everybody was hoping for and has failed to engage the NHS sufficiently. Those are the things we are now concentrating on: making sure that the governance of the programme is sound; learning lessons from what has happened; and achieving value for money.
Lord Warner
My Lords, I declare an interest as the former Minister responsible for this programme—one does have to own up to one’s past from time to time. Could the Minister assure the House that the Government are fully committed to the idea of an electronic patient record system as the way forward for the NHS, given its benefits for patient care, research and NHS efficiency? Could he tell the House what proportion of the population has now been able to avail itself of an electronic summary record?
Earl Howe
I pay tribute to the work that the noble Lord did when he was a Minister. Yes, the Government are committed to a summary care record, which, for the benefit of noble Lords, is a record that includes a defined set of key patient data, other than for patients who choose to opt out—that is an important rider. Clinicians can then access essential medical information that they need to support safe treatment and to reduce the risk of inadvertent harm, especially during emergency care. To answer the second question that the noble Lord asked, over six million patients now have a summary care record, which is a considerable increase over a few months ago.
Lord Patel
My Lords, would the Minister agree that to improve the quality of healthcare we would need comparable indicators of health outcomes? In the absence of nationally collected computerised data, how would we achieve this?
Earl Howe
My Lords, the noble Lord is absolutely right. We have to measure performance in order to improve upon it. That is why we are focused on producing an information strategy, which we hope to publish later this year. A lot of work has already gone on and the NHS Future Forum, as he may know, is looking at this area. He is absolutely right that this will be central to the performance management of the NHS.
Baroness Jolly
My Lords, we are now well into the 21st century. Can the Minister give us some indication as to when patients might be able to access their own records online?
Earl Howe
This is a commitment that we have made. We fully support the concept of patients having full access to their medical records online. A great deal of work is going on at the moment to make sure that the protocols are sound, because clearly the one thing one does not want is for the wrong people to access the wrong patient data. If we can achieve that and do it in a simple way, we shall roll the programme out as soon as we can.
Baroness Pitkeathley
I take on board what the noble Earl says about engaging local commitment and the failure that there has been in that so far, but does he agree that one of the most important things about local commitment is that different localities may have different systems? As far as the patient is concerned, it is absolutely essential that the systems can talk to each other. How will that be ensured if we go down the local route?
Earl Howe
The noble Baroness makes a very good point. I said that the top-down approach to local service provision has not worked when it has come to local service provider systems. We think that local requirements are best judged and best met by decisions being taken locally but that does not mean that they will be left on their own. There will be the necessary support from the centre wherever needed. She is again right that the key will be that these local systems must be interoperable.
The Countess of Mar
My Lords, does the Minister agree that while technology is incredibly beneficial to the National Health Service, we must be wary of people working within the health service depending too much upon technology and ignoring the human aspects of care for people who are in hospital—talking to patients, touching them and holding their hands when they have problems? My recent experiences in hospital have been very unpleasant because people have relied entirely on technology and not listened to what I have had to say.
Earl Howe
The noble Countess is of course correct that good patient care is about humane and sensitive treatment by the staff who serve in the National Health Service. At the same time, I think we are all clear that technology has a role to play in enhancing patient safety and improving the quality of care that the good staff of the NHS can deliver.
Baroness Thornton
My Lords, can I entice the Minister into being slightly more definite about when the House might see the new IT strategy which the Government keep telling us that they are about to publish? As a former Minister, I know that the answer “soon” is one that the House always looks at with some wry smiles. If we could have a more definite date, that might be helpful.
Earl Howe
My Lords, we plan to make an announcement towards the latter part of the autumn about the way forward for informatics, which will mean—we are clear about this—that we continue to gain more value for money from taxpayers’ investment and ensure that informatics support is fit for purpose in the modern NHS.
Health: HIV/AIDS
Earl Howe Excerpts(13 years, 2 months ago)
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Lord Fowler
To ask Her Majesty’s Government what steps they are taking to prevent the spread of HIV and AIDS in the United Kingdom.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government fund national HIV health promotion programmes for men who have sex with men and for African communities, the groups most affected by HIV in the UK. This is in addition to harm minimisation programmes for injecting drug users, NHS HIV prevention programmes and open-access testing and treatment services. The White Paper, Healthy Lives, Healthy People, sets out the Government’s strategy for reform of public health in England. This includes sexual health and HIV.
Lord Fowler
My Lords, I thank my noble friend for that reply, but does he really think that we are getting the message over on the dangers of HIV? Is it not a fact that the number of people accessing care for HIV has trebled in the past 10 years, that we now have almost 100,000 people with HIV in the United Kingdom and that the cost of treatment and care has now risen to almost £1 billion a year? Given that this is an entirely preventable disease, does not my noble friend agree that we have devoted disgracefully little to HIV prevention programmes over the past decade and that our efforts here should now be urgently increased?
Earl Howe
My Lords, may I begin by paying tribute to my noble friend Lord Fowler in his continuing interest in HIV and AIDS, here and internationally? He has done a huge amount to raise the issue’s profile in Parliament and more widely. I agree with much of the thrust of what he said; there is no doubt that over the past 10 or 12 years great progress has been made in a number of areas, but we are still concerned about the increasing incidence of HIV among men who have sex with men and sub-Saharan African communities, which are the groups most affected and vulnerable to HIV in the UK. That is why our prevention campaigns have been targeted primarily at those communities. There is much more work to do. The sexual health framework report that we are publishing later this year will have a separate section on HIV, and I hope that in that document my noble friend will be reassured that our efforts in this area will not let up.
Lord May of Oxford
Would the Minister agree that while HIV is of special importance it is also a fact that all other sexually transmitted infections are showing similar marked patterns of increase? Should not the Department of Health be showing more concern about this than it currently seems to?
Earl Howe
The noble Lord is right to draw attention to the rising incidence of other sexually transmitted diseases. I draw the House’s attention in particular to the large numbers of cases of chlamydia and herpes, where he is perfectly correct in saying that the statistics are rising. In other areas, the statistics are stabilising—but he is generally right in the point that he makes. The data show that in 2010 there was a 1 per cent decrease in all diagnoses, but within that there are areas on which we undoubtedly have to concentrate.
Baroness Gould of Potternewton
My Lords, I am sure that the Minister appreciates how important it is to have early testing. What efforts will the Government make to ensure that GPs and other primary care professionals routinely offer HIV testing to all new patients, particularly in high prevalence areas? More than that, is any action being taken to give the new GPs and other new professionals the confidence, skills and ability to be able to offer that test?
Earl Howe
The noble Baroness with her experience makes a central point here. We absolutely agree that increasing the offer and uptake of HIV testing in a variety of healthcare settings is important to reduce undiagnosed HIV. We welcome the BHIVA professional guidelines in this area, which have been extremely helpful. The sooner a person with HIV is diagnosed, the sooner they can benefit from treatment and also make any behavioural changes to prevent transmission. It is those behavioural changes that count most strongly.
The department funded pilots to support the implementation of recommendations from the BHIVA, and those were extremely successful. In the coming days, we will consider carefully the report that is due to be published by the Health Protection Agency to see how we can take forward its findings in this area.
Baroness Masham of Ilton
My Lords, as a member of the House of Lords committee that produced the report, I pay tribute to our chairman, the noble Lord, Lord Fowler, for his excellent work. Is the Minister aware that one-quarter of the people with HIV do not know that they have it? That is extremely dangerous; late diagnosis costs a lot and many of those people die early. Will he do more to promote prevention?
Baroness Trumpington
My Lords, following on from the previous speaker, perhaps my question is appropriate. The Minister knows my interest in this subject but would not the legitimisation of brothels be a great help, with regular health checks therein?
Baroness McIntosh of Hudnall
My Lords, as a member of the committee of the noble Lord, Lord Fowler, I ask the Minister if he agrees that the contribution made by the voluntary sector to the effort both to prevent and to inform about AIDS is very significant. It is particularly important in the combating of stigma, which, as he will be aware, is a tremendous impediment to the good take-up of treatment and testing. Will he reassure the House that funding to the voluntary organisations that are most involved in HIV/AIDS will not be affected by the cuts that are currently being undertaken?
Earl Howe
My Lords, I readily join the noble Baroness in paying tribute to those voluntary organisations, not least the Terrence Higgins Trust, which over the past 10 years has done a great job in leading the department’s national programme of work—we believe that that has contributed in a major way to the increased uptake of testing in clinics—while for African communities the African Health Policy Network has managed the department’s national programme, working with community-based groups in a very positive way. Those two groups in particular are being funded this year. No decisions have been made about next year because a tendering process will apply, but this work needs to continue in some form.
Health: Diabetes
Earl Howe Excerpts(13 years, 4 months ago)
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Lord Morris of Manchester
To ask Her Majesty’s Government what further action they are taking to help patients with diabetes.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
To support the NHS in improving outcomes, NICE has published a quality standard for diabetes, providing an authoritative definition of good-quality care and building on the existing national service framework. This year, the NHS operating framework specifically highlights the need to do more to improve in-patient care for people with diabetes, the availability of structured education and retinopathy screening for everyone with diabetes, and access to therapies, including insulin pumps.
Lord Morris of Manchester
My Lords, I am grateful to the noble Earl for that Answer. Is he aware that 1.4 million people with diabetes are now at risk of preventable blindness, over a million of kidney disease, and up to 8,600 a year of having a foot amputated due to delayed diagnosis and treatment; and that doctors of distinction in this specialty insist that, with adequate resources, they could do much more to maximise prevention and treatment? Knowing as I do the depth of the Minister’s own concern for this policy area, when does he expect to be able to announce specific new measures to help the rapidly increasing number of children afflicted?
Earl Howe
My Lords, Ministers often express thanks to those noble Lords who table Questions but I owe a particular debt to the noble Lord, Lord Morris, for highlighting one of the greatest public health challenges of our time. He is absolutely right in all that he has said. I alight particularly on his point about prevention. We are committed to preventing type 2 diabetes. All our work on promoting an active lifestyle and tackling obesity will support that aim. The NHS Health Check programme has the potential to prevent many cases of type 2 diabetes and, as the noble Lord said, to identify thousands more cases earlier in their development. The Change4Life programme—the campaign that started under the previous Government, which we are continuing —raises awareness of maintaining a healthy weight and being physically active. A great deal of work is going on in this area, which is one of the major focuses of our public health programme.
Lord Walton of Detchant
My Lords, the Minister has indicated that there is a clear positive correlation between the rising incidence of type 2 diabetes on the one hand and the rising incidence of obesity on the other. What action are the Government taking to advise the population at large of the dangers of overeating?
Earl Howe
I have already mentioned the Change4Life programme, which is designed to raise awareness across a number of public health areas, including obesity and overeating. I think also of the Healthy Schools programme, which instils the need to eat healthily and take exercise in youngsters at an early age. As the noble Lord will know, there is no magic bullet for the problem of obesity. It is something that must be addressed in a variety of ways through public health programmes and general practice.
Baroness Gardner of Parkes
My Lords, does the Minister agree that foot ulceration precedes 85 per cent of amputations? A study in Southampton showed that, by keeping people in hospital and treating them well through preventing foot ulcers, over 36 months not only did patient outcomes improve but the National Health Service saved £1.2 million in in-patient time.
Earl Howe
My Lords, I am grateful to my noble friend. I have an astonishing figure in my brief. On average, 73 amputations of lower limbs occur every week in England because of complications to do with diabetes. It is estimated that, with the right care, 80 per cent of amputations carried out on patients suffering from diabetes would be preventable. That is the scale of the challenge. We are clear that this is a major issue for diabetes. NICE has published guidelines on in-patient management of people with diabetic foot ulcers and infection. That is vital because amputations are often preceded by ulceration. That is also why the national clinical director for diabetes considers diabetic foot care and prevention to be a major priority.
Lord Harrison
My Lords, will the Minister give an assurance that the retinopathy screening that was introduced by the previous Labour Government, and which has been so successful, will continue apace to match his own ambition of ensuring prevention by identifying diabetic disease of the eye at an early stage?
Earl Howe
The noble Lord, Lord Harrison, is quite right. England, along with the devolved Administrations, leads the world in this area. It is the first time that a population-based screening programme has been introduced on such a large scale. We are committed to continuing it. More people with diabetes are now being offered retinopathy screening than ever before and to higher standards, despite the increasing number of people with diabetes. The latest data that I have show that 98 per cent of people with diabetes have been offered screening for diabetic retinopathy during the past 12 months.
Lord Rennard
My Lords, is the Minister aware that people with diabetes are twice as likely to be admitted to hospital as people without diabetes? Will he undertake to look at best-practice models, such as that of the University Hospitals of Leicester, where diabetes specialist nurses have been stationed in the accident and emergency department and are able, in many cases, to advise against admission to hospital and provide more appropriate treatment and support? This is believed to have saved the University Hospitals of Leicester around £100,000. Diabetes UK estimates that, if rolled out nationally, such good practice might save the NHS up to £100 million a year.
Earl Howe
My Lords, I am aware of that excellent beacon of good practice in Leicester, which is an example that we welcome. It is an approach that is already being taken in other parts of the country. The NICE quality standard for diabetes states that people who have the condition, and who have experienced hypoglycaemia that requires medical attention, should be referred to a specialist diabetes team for advice and support to reduce admissions in exactly the way that my noble friend described.
Southern Cross Care Homes
Earl Howe Excerpts(13 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall now repeat as a Statement the response given earlier today by my honourable friend the Minister for Care Services to an Urgent Question tabled in another place on Southern Cross Healthcare. The response was as follows.
“As the House will be aware, Southern Cross has been working with its landlords and lenders to agree a restructuring process to secure a viable way forward for the future. The Government have made clear, as I set out to the House on 16 June, that our overriding concern is the welfare and safety of the 31,000 residents in Southern Cross’s care, and we expect all parties to work together to secure a consensual, solvent restructuring of the business that meets their collective responsibility to secure the welfare and care of those residents.
When I last updated the House on 16 June, Southern Cross, its landlords and its lenders had announced the previous day an agreement to work through, over a period of four months, arrangements for a consensual, solvent restructuring. Yesterday’s announcement was one step in that ongoing process, and discussions continue to resolve the remaining steps.
I know that there has been some concern about what yesterday’s statement may mean, and that residents and their families—as well as staff—are anxious to know what will happen. Let me repeat the assurance I have given to this House before: whatever the outcome, no one will find themselves homeless or without care. We will not stand by and let that happen. We have worked and will continue to work with the Association of Directors of Adult Social Services, the Local Government Association, the Care Quality Commission and others to ensure that there is an effective response to any potential disruption to the continuity of care, and that all residents are protected. A consensual restructuring that assures a smooth transition to new arrangements will mean that those contingency arrangements will not be needed, and that is what we want to see.
Let me reassure the House on some of the questions that I know honourable Members may have. First, yesterday’s announcement—which stated that at the end of the restructuring process the Southern Cross corporate entity would cease to exist—has no effect on the provision of care or the operation of care homes. Southern Cross remains in operation, and will continue to operate all its care homes until any transfer to new operators takes place.
Secondly, the transfer of care homes to alternative operators will be a managed process that ensures the continuity of services. Yesterday’s statement makes clear that care home staff will transfer on their current terms, and the service that residents receive should be unaffected by the transfer. All parties involved in the negotiations have given a clear commitment that continuity of care will be paramount in this process. Local authorities are already working to ensure that they can assist in the smooth transfer of arrangements of homes in their area, and the department has been working with ADASS and the LGA to support that.
Thirdly, no transfer will take place without the new operator being approved and registered by the Care Quality Commission. There has been speculation that companies with no experience in the care sector will take over the running of homes. That will not happen. Alternative operators will need to be reputable and experienced companies which are able to satisfy the CQC that they are capable of delivering high quality care and meeting all regulatory standards. The CQC will not drop its standards in ensuring that requirements are met. I understand that each of Southern Cross’s landlords are settling their arrangements as to which care home operator to work with, and that is an essential part of the discussions that are ongoing. That will cover all landlords, so that there is a clear way forward for all homes.
Finally, I can assure the House that the Care Quality Commission has been working with Southern Cross, landlords and other stakeholders for several months to ensure the smooth transition of services and has processes to deal with re-registration and undertake the essential checks needed as a priority. It is having ongoing conversations with Southern Cross, landlords and other providers on the timing of applications.
Our priority as a Government is to ensure that the current problems with Southern Cross are resolved and that a sustainable way forward can be secured. But as the Prime Minister has previously stated to the House, we are also clear that we will take action for the future to ensure there is proper oversight of the social care market. The Health and Social Care Bill allows us to extend to social care—if we decide that it is needed—the financial regulatory regime we are putting in place in the NHS. However, regulation is not the only solution. We will approach this in a measured way and as part of wider reform in the social care market to ensure that we do not face a similar problem in future.
I said that yesterday’s statement from Southern Cross was one step in an ongoing process over the coming weeks and months. Until all future arrangements are settled, Southern Cross will continue to operate and provide care in all its care homes. It is only at the end of the process, when all transfer arrangements have been completed, that Southern Cross as an entity will cease to exist. By then, all homes will have a clear plan for future operation and for the continuity of services into the future.
What we now want to see is a swift conclusion to these important discussions, to offer reassurance and certainty to residents and their families. I want to reassure the House that the Department of Health has been and remains fully engaged, and senior officials are in daily contact with all the parties to ensure that the interests of residents are at the forefront of all discussions. The Government will continue to keep close contact with all involved in the process, and I will continue to keep the House informed”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Baroness for her comments and questions. She asked a number of the latter. I hope I can answer most of them. It is important to appreciate that this is a managed process. The announcement that the Government made last month of a four-month restructuring window still applies, and we are at the first major stage of that process. Therefore, anxieties about the welfare of residents are misplaced because this is not a case of the collapse of Southern Cross. It is still very much a managed and solvent restructuring that is going on.
The noble Baroness asked me about the landlords. It is not for the Government to liaise with all the landlords directly but they are all represented on the restructuring committee, working to develop a plan for the future. Local authorities and the CQC will link as necessary with all the landlords as they take through their plans for the future management of homes. I am advised that the CQC understands that the Southern Cross landlords’ committee wants the handover of care home properties to take place at the end of September. The CQC is co-ordinating its activities to ensure that regulation does not prevent the handover across England. I hope that reassures the noble Baroness that nothing is going to happen tomorrow. It is very much part of a planned and structured process.
The noble Baroness asked about care homes that were in debt. Many companies, in all sectors, may have some degree of debt, quite obviously—this is a normal part of business, not necessarily a concern. We are clear that Southern Cross’s particular business model—not owning but leasing nearly all its properties—is a unique model and that is what has given rise to its particular problems.
The noble Baroness asked about the consequences of the landlords taking back their properties. The department is very clear that it expects all parties to maintain service continuity and quality of care while the restructuring process is ongoing. Our principal concern, as I have said, is for the safety and well-being of the residents. CQC will pay particular attention to any care homes where there is a concern that quality may be at risk or inadequate. It does have the resources to do this. It has indicated that there is not a problem in that sense. CQC has regular dialogue with Southern Cross at corporate level in addition to the attention it gives to individual services. We have emphasised to CQC the importance of ensuring that Southern Cross homes continue to comply with regulations and safety and quality requirements. Of course, we expect CQC to take the necessary action if it finds, for example, that staff reductions are affecting safety and quality of services.
The noble Baroness asked about government money for Southern Cross. Southern Cross is not asking for a bailout. It is looking to resolve its problems and it is for the company, its landlords and those with an interest in the business to put in place a plan that stabilises ownership and operation of the care homes. That process is happening and we must let it continue.
A number of providers that will acquire Southern Cross homes are already registered with the CQC as care providers in their own right, such as Four Seasons. There are established processes in place to allow these providers to extend their current registration to take on additional care homes. That process, assuming that it occurs, is relatively straightforward. Providers who are not known to or registered with the CQC will require a full application that will be subject to full scrutiny and a determination of fitness to provide the service. This cannot be a case of companies registered overseas suddenly becoming care home operators—that will not happen. Any new operator must demonstrate that they are fit and proper people to conduct this type of business and prove that to the CQC. Each landlord will be required to ensure that it has arrangements with a reputable and capable operator which can meet the CQC’s requirements. This is what the companies are now resolving as restructuring discussions continue.
It is also important to emphasise that while the CQC is committed to ensuring continuity of care, it will not lower the regulatory bar or reduce the rigour of registration. CQC’s principal concern is the safety of service users and it will not compromise on the standards that are required. At the same time, we expect that local authorities will ensure that any transfer or new arrangement to provide care for residents takes place smoothly and with continuity of care for service users assured. We are talking to the Association of Directors of Adult Social Services, the Local Government Association and, of course, the CQC, as I have mentioned, to ensure that robust local arrangements are in place.
Finally, the noble Baroness asked about the staff and their legal position. This is not a matter that the department can comment on directly, but staff are protected by the relevant employment law. I understand that Southern Cross has undertaken in a letter to care staff that they will be transferred under their existing terms to new operators under TUPE. That is our understanding of the position.
Earl Attlee
My Lords, perhaps I may remind the House of the benefits of short questions which will enable my noble friend the Minister to answer as many questions as possible.
Earl Howe
My clear understanding is that many homes will continue in operation with the same staff, and that the residents of those homes will therefore not be required to move. We hope most earnestly that no resident of any Southern Cross care home will be required to move. I am not aware of the precise situation in the north-east of England, but my noble friend’s comments suggest to me that there is no undue cause for concern in that part of the country. The plan certainly would be, as far as possible, to maintain the residents in their current homes, and they should notice no difference in the quality of care that they are receiving.
To the extent that residents are required to move—and as I have said, we hope that that will not be necessary—yes, of course there will have to be a process of monitoring the welfare of those people in those circumstances. The duty to do that falls primarily on local authorities, where they are the commissioner of the care, but I have absolutely no doubt that the CQC will wish to add to that oversight. I believe that it is too soon to speculate—because we are not sufficiently far down the restructuring process—on the extent to which residents will be disrupted, but the number of homes that do not in the end prove viable as businesses will emerge in due course.
Lord Campbell-Savours
My Lords, first, I noticed that the noble Earl did not respond to the question asked by my noble friend on the publication of the names of the property companies that stand behind many of these homes. Will a special regime be introduced by the CQC of random unannounced visits for homes managed by property companies? It is important that we get an assurance that it will carry out random unannounced visits as against other forms of visits which are possible. Secondly, given that Regulation 13 of the CQC registration regulations 2009 requires a service provider to,
“take all reasonable steps to carry on the regulated activity in such a manner as to ensure the financial viability”,
of the operation, who then is going to monitor compliance with Regulation 13? Should we not now have—set and enshrined in some regulatory arrangement —some authority given the power to seek to secure compliance, or are we simply going to leave it to an offence, as the noble Earl has referred to in an Answer he has given to me, whereby no one is actually monitoring these matters?
Earl Howe
First of all, the CQC is an independent body; it is not under the jurisdiction of Ministers, and it must be free to organise itself as it sees fit. I cannot undertake on its behalf that it will perform random unannounced visits. It does, however, do that as a matter of course, and it generally does so on a risk-based basis so it would surprise me if, where the CQC saw that there was an enhanced risk to residents, it did not make it its business to perform inspections. Looking ahead into the medium term, should the Health and Social Care Bill pass through Parliament, as the Government propose, local HealthWatch will be in a position to enter and view care homes, as LINks are at the moment, but I believe that HealthWatch will be, in most areas at least, in a better position to undertake such inspections on a random basis.
The financial liability will of course not be the province of HealthWatch, but any concerns about the welfare of residents would be subject to the powers of HealthWatch to refer up to HealthWatch England, and in so doing, through HealthWatch England to the CQC. The financial viability of care homes is of course a live issue. I have commented on this in the past, and we are certainly considering whether Clause 57 of the Health and Social Care Bill could be used to extend the regulatory regime that we are proposing for the NHS to care homes. That is something that we will need to discuss because it would amount to a regulatory burden on care homes. Nevertheless, I do not belittle the issue. My ministerial colleagues in the Department for Business, Innovation and Skills are looking at the issue of private bodies that provide publicly funded services and whether there are implications in the sense that the noble Lord has indicated.
Lord Elystan-Morgan
My Lords, has the Minister considered the legal question of fraudulent trading, which seems to be apposite not only to the case of Southern Cross, but indeed—according to the comments made by the noble Baroness, Lady Thornton—to other care companies as well? Does the Minister recollect that exactly 50 years ago, in a case called Wellfield, this House, sitting in its judicial capacity, defined fraudulent trading as a situation where the directors of a company continue trading, knowing that there is a risk that debts will not be able to be cleared as they arise? Bearing in mind that as far as Southern Cross is concerned, many months ago, it announced that it would not be able to pay its tax liabilities, nor indeed to pay more than 70 per cent of the rents due to lessors, would it not seem that there was a clear breach of what is now Section 993 of the Companies Act 2006?
Earl Howe
My Lords, my advice is that Southern Cross is not insolvent in either sense of the word. Its assets, I am told, exceed its liabilities, and it is able to meet its commitments as they fall due, thanks to the agreement reached between the company, its landlords and its bankers. The process announced on 15 June is the key to this: the company’s restructuring committee is developing a plan to stabilise the ownership and operation of Southern Cross care homes. We expect, as I have said, that there will be an orderly process of reassigning homes to landlords and new operators. That process will take place between now and October, during which time continuity of care will be maintained. Nothing that I have said changes the outlook for the medium term, and I believe that we can say, and that the company can say, that insolvency is not an issue at present.
The Lord Bishop of Manchester
My Lords, for all the assurances that the Minister has given, and for all his obvious sensitivity to the issues that many residents face, the truth remains that a lot of people in these care homes feel themselves at present to be in an extremely vulnerable position. In these circumstances, does he feel that the level of salary and bonuses that some directors have is appropriate, and would he like to comment, in the light of what he said earlier about financial implications, on whether or not that is an area that in future he would feel needs to be examined more carefully?
Earl Howe
I am grateful to the right reverend Prelate. I do not think any of us feels comfortable if the directors of struggling companies take substantial bonuses. I have to say that I do not have a briefing on whether the directors of Southern Cross have taken substantial bonuses in recent months, but I shall make it my business to try to ascertain that. But of course the right reverend Prelate is right to say that we must be clear that the stability of care homes, looking after frail, vulnerable, elderly people, should not be put at risk by mismanagement. I am afraid that Southern Cross has been a story of mismanagement since it was established in its present form.
Lord Beecham
My Lords, my noble friend Lady Thornton referred to the fact that the owners of many of these properties are offshore companies. Is the Minister comfortable with the fact that according to a claim by the GMB union, some 336 of these care homes—just under half the total—are owned by companies outside the UK, with 325 of them registered in tax havens? Does the Minister agree, as I asked yesterday of his ministerial colleague about the Statement on the White Paper on public service reform, that the high proportion of residential care places managed by Southern Cross—some 18 per cent of the total of places, with roughly a further 18 per cent managed by another five companies—does not represent diversity of provision and increases the risk of things going seriously wrong on a large scale, as has happened in this case? Does that not lead to the possible conclusion that to talk about diversifying without any indication of a limit on the number of places that might be operated in a field like this needs to be rethought?
Earl Howe
I think the noble Lord and I are at one in wanting to see diversity of provision. The restructuring that I suspect we are likely to see emerge from this will result in just that, as a matter of fact. It appears that Southern Cross is to be split into a number of smaller enterprises, and that in itself should, we hope, lead not only to a more diverse arrangement but a more secure one. However, I do not take issue with the thrust of the noble Lord’s remarks at all.
On the issue of the ownership of some of these care homes, our concern as Ministers is not so much where the shareholdings lie as on whether that in itself has implications for the quality of the care that residents receive. I am not aware that that has been a factor. As long as the ownership of these care homes is legal and we are not seeing tax evasion as opposed to tax avoidance, to an extent it is not an issue for the Government. But it is something that is likely to be examined quite closely as the restructuring takes place.
Lord Sutherland of Houndwood
My Lords, I welcome the way in which the Minister’s Statement has given reassurance to those in care homes and their families. It is immensely important that we continue to do that. There is, however, a further area of reassurance that I hope the Minister will be able to say something about. We have reassured staff through TUPE that perhaps there is some protection for their terms and conditions, but speculation in the press today suggests that the cost of care in these homes might rise significantly because of a period of underinvestment. I hope that we can at least monitor any such rises to ensure that they are gradual rather than sudden and therefore financially debilitating.
Earl Howe
My Lords, the noble Lord, Lord Sutherland, makes a very good point. The advice I have been given is that during the restructuring process, the cost of care should not be a factor. While local authorities may have to revise their budgets, that should not result in disruption for residents.
Lord Popat
My Lords, does my noble friend agree that most of the landlords of these care homes were the former operators themselves, and therefore the transfer of registration by the CQC will be a very smooth process? However, we will end up with a few homes where the landlords might not want to take them back. Should we not have contingency plans for local authorities to rent such premises on a temporary basis until a permanent solution is found?
Earl Howe
My noble friend is quite right to say that it is indeed possible that landlords may not wish to take the properties back, but in that scenario it has been agreed that those landlords will look to partner with a reputable care home operator. So it might well be that a care home will join a consortium run by one of the major care home operators which is now in discussions.
Lord Bilimoria
My Lords, the Minister said that Southern Cross’s business model was unique, but surely it is not since so many care homes have been following the Opco/Propco model. Does the Minister therefore agree that it was possibly not just mismanagement that was responsible for this situation, but the fact that the business model which worked in the good times—the previous owners did very well out of it—is not working now? As the noble Baroness, Lady Thornton, said, several care homes are in difficulties. Does the noble Earl think that the cuts that are being made might have a role to play as well? Have the Government made a full analysis of the dire situation in the care home sector?
Earl Howe
Clearly, my Lords, before the Government produce a White Paper on social care a thorough analysis will be done, and we have the Law Commission report that will guide us in part. Southern Cross developed a business model that worked during times of increasing prosperity, when property values were buoyant and occupancy levels were similar, but it entered into contracts with its landlords which are proving unsustainable in the present climate. Demand for residential care is reducing generally. Not only are councils purchasing fewer care home places, but people are also opting for greater personalisation and more innovative approaches to providing care services, including being looked after at home. My advice is that the Southern Cross business model is unique. That may be—the noble Lord has considerable knowledge in this area—an overstatement and perhaps there are some care homes which are similarly structured, but it is certainly the largest and most significant model of its kind that we are aware of. From the advice I have received, I do not think we should be unduly concerned that other instances on a par with Southern Cross are likely to occur.
Lord Hollick
My Lords, I welcome the Government’s decision to prioritise sustainability because the demise of Southern Cross is a stark example of the dangers to sustainability of overly aggressive financial engineering: too much debt, too many unwise property deals and too many gullible banks; in short, too much avarice and not enough prudence. As the Government contemplate how best to regulate the financial aspects of this industry, how will they ensure that the new operators of Southern Cross care homes will be financially sustainable?
Earl Howe
My Lords, we are reverting to the question asked by the noble Lord, Lord Campbell-Savours. The CQC already has some duties to ensure that the care homes it registers are able financially to sustain their business, as well as simply providing a quality service. But this is clearly an issue that needs to be looked at. As I have mentioned, we are taking powers in the Health and Social Care Bill which potentially could see the care-home sector subject to the kind of financial regulation that we are applying to the NHS. This is a work in progress.
Abattoirs
Earl Howe Excerpts(13 years, 4 months ago)
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Baroness Byford
To ask Her Majesty’s Government what assessment they have made of the financial impact on small and medium-sized abattoirs of the proposed introduction of a full-cost recovery system.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am advised by the Food Standards Agency, which is responsible for meat hygiene controls, that following public consultation it has significantly amended its proposals for full-cost recovery. Implementation will be delayed until April 2012, staged over three years. Support will be provided for abattoirs slaughtering up to 5,000 cattle or equivalent per year. A financial impact assessment of the amended proposals is in preparation and will be published this summer.
Baroness Byford
My Lords, I thank the Minister for that response. Will the agency move much more towards a risk-based, proportionate regime than it has in the past? Secondly, will it consider outside—in other words, private—operators taking over the task that is currently done by state employees?
Earl Howe
My Lords, it is certainly the ambition of the agency to move to a more risk-based approach but, as my noble friend will know, that has considerable implications in terms of EU law and it will take some time for such an approach to be worked through. On her second question, I am aware that the agency will discuss tomorrow the findings of the Macdonald taskforce, so it is probably premature for me to say more on that point.
The Countess of Mar
My Lords, I declare my interest as a farmer. Would the noble Earl agree that small and medium-sized abattoirs are essential to our communities? There are serious animal welfare concerns in having to drive animals for miles to gets them slaughtered. The stress on the animals also causes the meat to be not so good. In Worcestershire, we have one abattoir left, and the nearest one to us is in fact in Herefordshire. Do the Government intend to encourage small abattoirs to stay open? Is there any possibility for mobile abattoirs to be developed?
Earl Howe
My Lords, smaller abattoirs are extremely important to the rural economy, as the noble Countess rightly says. They are more likely to be rural. The support to be provided to those abattoirs processing up to 5,000 cattle—a higher threshold than was previously proposed—is intended to help preserve the provision of local services to the livestock industry. That will helpfully reduce the impact on small livestock producers, the rural economy, animal welfare and indeed consumer choice. As regards mobile abattoirs, I am not aware what initiatives are being undertaken, although I believe that there are a few around, so it will be necessary for me to seek further advice on that point.
Lord Campbell-Savours
My Lords, was not this so-called risk-based approach used in the monitoring of care homes? Has that not been a disaster?
Baroness Randerson
My Lords, many of the 28 abattoirs left in Wales are the small abattoirs that the Minister described in his Answer. He referred to support. What will that amount to?
Earl Howe
My Lords, the agency has now proposed a stepped system of discounts. For the first 1,000 livestock units processed, the reduction on the full cost would be a maximum of 70 per cent. The next 1,000 livestock units would be subject to a 50 per cent reduction and the next 3,000 subject to a 25 per cent reduction. That will directly assist those smaller abattoirs, many of which are based in Wales.
Baroness Gardner of Parkes
I find it very unusual for the Minister who usually answers on health to be answering an abattoir Question, but I am very impressed by his knowledge. Can he tell us whether there is a health implication, whether the extra costs that were to be passed on were necessary for health and whether they will be continued to be carried out even if the costs are not being passed on?
Earl Howe
My Lords, there is no direct health implication. What has happened over the past few years is that the costs of regulation have progressively been borne by the Food Standards Agency, as opposed to the industry. There has been a decision taken in principle that the regulator should not subsidise the industry that it regulates. That is the reason for the review of the charging arrangements.
Lord Pearson of Rannoch
My Lords, did the noble Lord indicate in his Answer, and will he confirm, that we owe this folly more to our lords and masters in Brussels than to our very own department for the ruin of agriculture? Does he think that the British people would have voted in 1975 to stay in what they were assured was a Common Market if they had thought that this sort of folly was going to be visited upon them by Brussels?
Earl Howe
My Lords, it is quite correct that European legislation requires the national competent authority to carry out official controls in order to verify that food businesses comply with food hygiene requirements. EU law requires the competent authority to charge food businesses for meat hygiene and welfare at slaughter—the official controls—and sets minimum charging rates. Having said that, I do not think that there is any self-respecting country that would wish to neglect meat hygiene, which has a direct implication for human health.