NHS: University Health Centres
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Baroness Gardner of Parkes
To ask Her Majesty’s Government whether NHS university health centres are being disadvantaged by the weighting of the registered list size and the introduction of prevalence quotas for the quality and outcomes framework.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, no. Payments to practices are based on an agreed calculation of health need and on equitable funding. The funding formula recognises patient numbers, with adjustments for the characteristics of the patient population and practice circumstances. The disease prevalence formula in the quality and outcomes framework provides fair rewards to all practices, but with stronger incentives for them to identify and treat patients with the greatest health need.
Baroness Gardner of Parkes
My Lords, I thank the Minister for that Answer, but is he aware that, although some practices in university centres receive support from the university, others are linked to GP practices which run services as a separate contract? Many of those have looked into the finances and found that it is so disadvantageous to them that they are not considering renewing or extending their contracts to supply what I consider to be necessary services. What will the Minister do?
Earl Howe
My Lords, naturally, before preparing myself for this Question, I looked carefully into the way in which university practices are funded. The advice I received is that there is no reason to be concerned on that front. Many university GP practices are funded quite generously. Where they can lose out is over the quality and outcomes framework, which is targeted mainly at elderly patients with long-term chronic conditions, so it is not surprising that university campus practices do not earn the extra money that they could. Nevertheless, we believe that there is no case for making an exception for university practices in the way that they are funded.
Baroness Thornton
My Lords, I congratulate the noble Baroness on getting her head around the system of weighting for payments to GPs for their patients. It contains such gems as,
“An overall weighted listsize for the PCO is generated as the sum of Practice Weighted Listsizes for all Practices in the PCO, and this PCO Weighted Listsize is used together with the PCO Weighted Population”.
I will not go on, but I congratulate the noble Baroness. Given the mental health problems that students often face, is the Minister confident that the system of weighting takes proper account of that medical issue, which is certainly more prevalent than the chronic conditions that he mentioned in a community general practice?
Earl Howe
My Lords, the characteristics of each GP practice will naturally vary according to the patient population. Although a practice situated on a university campus may have higher numbers of patients who require mental health advice and support, there may well be fewer patients in need of other services. I am not aware that there is a particular issue of underfunding of university practices in relation to the mental health burden. As the noble Baroness will know, the QOF was adjusted in 2008 with a two-year time delay, so university practices have had a chance to adjust and prepare for the change.
Lord Foulkes of Cumnock
Are university health centres gearing up to deal with cases of anxiety and depression among students at English universities who wish to go to Scottish universities for a further degree and who find that they will have to pay the full fees, unlike students from other countries in Europe? Is that not a disgraceful, discriminatory proposal by the Scottish Government? Can this Parliament not find a way of outlawing such discrimination?
Lord Patel
Can the Minister say what assessment has been made of the impact of the QOF on the outcomes for patients, whether university patients or otherwise?
Earl Howe
My Lords, there is no doubt that the QOF had many beneficial effects when it first began, and we recognise those. However, there is a general feeling that it needs to evolve and refocus itself more on those things for which it was originally intended, which were to promote quality and better outcomes in patient care.
Baroness Jolly
My Lords, student health does not quite fit the national pattern. Who is currently responsible for public health campaigns within the student body and, with the advent of clinical commissioning groups, is their future assured?
Earl Howe
My Lords, my noble friend will know that public health campaigns and health improvement efforts are currently being commissioned and directed by primary care trusts. That will continue until such time as local authorities take responsibility locally for the public health endeavour.
Lord Richard
My Lords, is the noble Earl aware that very few people in the House understood the Question and, with great respect, even fewer people understood the Answer? Does he not think that his department has an obligation to put out policies that are at least comprehensible to the people whom they are meant to affect?
Earl Howe
I can only apologise to the noble Lord, but he is right that it is a very complex topic. The simplest way in which I can explain the issue around the QOF, which is an element of the way in which GP practices are remunerated, is to say that before we had a situation where practices with large lists but little recordings of those conditions which QOF is aiming at, such as university practices, were receiving relatively higher reward than practices with smaller lists but higher levels of chronic disease and, as a result of the changes, the true prevalence is being used to weight the payments for all practices. The overall effect is to redistribute the total resource for the QOF among GP practices in a much fairer way.
Health: Stroke Care
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Baroness Wheeler
To ask Her Majesty’s Government what actions they will take to address geographic variations in stroke care identified by the Royal College of Physicians and detailed in the National Stroke Audit Report 2010.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the 2010 audit shows ongoing improvements in stroke care in England. To achieve the high-quality care described in the national stroke strategy and the NICE quality standard, the NHS is continuing to implement the accelerating stroke improvement programme. This aims to go further and faster in delivering improvements in stroke care across England.
Baroness Wheeler
I thank the Minister for his response and his recognition of the tremendous progress that has been made in the past three years with the national stroke strategy. I am sure that he agrees that progress has been most marked where strategic health authorities have provided strong leadership to drive forward strategy. With their abolition, how will the new system, through the subnational elements of the NHS commissioning board—the clinical senates—help facilitate the necessary improvements, and where will accountability lie? Also, I am concerned that the future of the stroke strategy team at the Department of Health seems to be uncertain. I have heard that the national clinical director for strokes will shortly stand down. Will the Minister confirm this and explain, if that is so, who will be responsible for providing strong leadership on stroke improvements at national level both in the short term and under the proposed new system?
Earl Howe
My Lords, clinical leadership is at the heart of our reform plans for the NHS, both at local and national levels. As regards the national director, our officials are currently considering how best to reflect that leadership at national level as part of the work being done to develop the new NHS commissioning board. I say to the noble Baroness that I see the NHS reforms as presenting an opportunity for much stronger partnership working between primary care commissioners and secondary care specialists. The NHS outcomes framework will enable us to track the overall progress of the NHS in delivering improved outcomes, and commissioners and providers will be supported by advice from the stroke networks under the auspices of the board. Therefore, we will have the opportunity in future to drive consistency and quality throughout stroke care in England.
Lord Wigley
My Lords, does the Minister accept that, in addition to the availability of facilities in all geographical areas, the other essential ingredient in getting a successful outcome is the level of knowledge that individuals have of the symptoms that might indicate that a stroke is about to happen? What initiatives have the Government in mind to improve public understanding and education in that matter?
Earl Howe
The noble Lord is absolutely right. I am sure that he will know of the FAST campaign, which stands for face, arm, speech and time to call 999, as the noble Baroness, Lady Thornton, used to tell us. We conducted a renewal of that campaign in March. We believe that it is an extremely important way of raising public awareness of the urgency of the situation. We will keep that programme firmly under our eye and renew it as we feel necessary.
The Lord Bishop of Blackburn
My Lords, it is well reported that the incidence of stroke and TIA in the north-west is higher than the national average. It is sad to note that, in my diocese of Blackburn, none of the hospitals in Lancashire manages to come into the best 25 per cent. I am very satisfied with the noble Earl’s Answer about the improvement that has taken place, but can he ensure that there are suitable specialists in place to provide a comprehensive stroke service throughout the country?
Earl Howe
The right reverend Prelate is quite correct to point out that there is variation in the country, as one would expect, not least in the area of rehabilitation after a stroke. The most encouraging progress we have seen throughout the country has been on acute stroke care, but we now have work to do on the rehabilitation side. As it happens, I was in the north-west some weeks ago and saw some encouraging work going on in the area of telecare, whereby stroke physicians can assess and diagnose a patient remotely, sometimes from their own living room. This will make an enormous difference, particularly where there are distances to travel for stroke specialists. I believe we should encourage those initiatives where we can.
Lord Smith of Clifton
My Lords, with regard to stroke in young people, what specific policies is the Minister’s department pursuing, particularly bearing in mind that most strokes in young people are caused by sickle cell disease?
Earl Howe
My noble friend makes an extremely important point about strokes in young people. It is of course true that, thankfully, fewer young people suffer these strokes, but he is right that sickle cell presents a warning sign. There are clear guidelines for ambulance crews and doctors more generally relating to those who have sickle cell disease. We had a debate a while ago on this topic in which the noble Baroness, Lady Benjamin, made some extremely important points which we continue to bear in mind.
Lord Winston
My Lords, various reports show that the mortality for stroke can be as high as 30 per cent. Sadly, in the United Kingdom mortality is higher than almost anywhere else in Europe, although there is great geographical variation all over the world. One of the issues that Professor Peter Rothwell, of the University of Oxford, has pointed out is that speed is the essence of success. Therefore, it is not merely a question of informing patients, but of making certain that the right availability is present in our hospitals. If we do that we can reduce the risk of a further stroke by 80 per cent and probably, as he says, reduce the cost to the National Health Service in primary care by somewhere between £100 million and £200 million annually. Would the Minister be kind enough to explain how that will work in the future of the health service?
Earl Howe
My Lords, the noble Lord is quite right in all that he says. I would just point out that the official statistics are rather historic and it is important that we take stock when the revised figures are before us in some months’ time. As regards how best practice will be driven when the health service reforms are in place, I would repeat my earlier comments about the ability of the NHS commissioning board to drive forward higher quality, informed by the new quality standard produced by NICE. More particularly I think we can do a lot through the tariff. At the moment, best practice tariffs are starting to play a role in encouraging and driving best practice at hospital level.
Baroness Thornton
My Lords, tomorrow is the 63rd birthday of the NHS. Would the Government give the NHS the birthday present of eliminating local differences in stroke services by implementing the recommendations in the stroke strategy? In that way, when we all break into song next year when the NHS is 64 years old, we will actually have achieved something very important.
Earl Howe
It is very appropriate that the noble Baroness should remind the House of the NHS’s 63rd birthday. I can think of few better presents than that which the noble Baroness has outlined. I can say only that the efforts within my department, and indeed throughout the NHS, continue unabated to ensure that stroke patients are treated to the highest possible standards and that unacceptable variations are eliminated.
Reform of Social Care
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House, I shall now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:
“Mr Speaker, with permission, I wish to make a Statement on the reform of social care. This coalition Government have from the outset recognised that reform of the care and support system is needed to provide people with more choice and control, and to reduce the insecurity faced by individuals, carers and their families. By 2026, the number of people over 85 years old is projected to double. Age is the principal determinant of need for health and for care services. It is estimated that in 20 years’ time, 1.7 million more people will have a potential care need than do today.
People often do not think about how they might meet those costs in later life. They assume that social care will be provided free for all at the point of need, but since the establishment of the welfare state this has never been the case. Currently people with more than £23,250 in assets, often including their home, face meeting the whole cost of care themselves. The cost of care can vary considerably and it is hard for people to predict what costs they may face. The average 65 year-old today will face lifetime care costs of £35,000. However, as the Commission on the Funding of Care and Support notes, costs are widely distributed: one in four will have no care costs, but one in four will face care costs over £50,000 and one in 10 over £100,000.
The lack of understanding of how the system works and the uncertainty about costs means that it is difficult for people to prepare to meet potential care costs and there are currently few financial products available to help them. This means that paying for care can come as a shock to many families and can have a severe impact on their financial security.
Change is essential. That is why we took immediate action by establishing the Commission on the Funding of Care and Support last July. It was tasked with making recommendations on how to achieve an affordable and sustainable funding system for care and support for all adults in England. In response to its initial advice, we allocated an additional £2 billion a year by 2014-15 in the spending review to support the delivery of social care as a bridge to reform. This represents a total of £7.2 billion extra support for social care over the next four years, including an unprecedented transfer of funds from the NHS to support social care services that will also benefit health.
Since then we have taken forward wider reform. In November last year, we published our vision for adult social care setting out our commitment to a more responsive and personalised care and support system that empowers individuals and communities, including the objective that all those who wish it should have access to a personal social care budget by 2013, and in May, the Law Commission published its report, after three years of work, on how to deliver a modernised statute for adult social care. Making sense of the current confused tangle of legislation to deliver a social care statute will allow individuals, carers, families and local authorities more clearly to understand when care and support will be provided.
Andrew Dilnot’s report comes at the same time as the final report from the palliative care funding review, which I received last week. Tom Hughes-Hallett and Sir Alan Craft have made an excellent start in looking at this complex and challenging issue. We want to see integrated, responsive, high-quality health and care services for those at the end of life. We will now consider the review team's proposals in detail before consulting stakeholders on the way forward later this summer. We will also consider how best to undertake substantial piloting, as recommended in the report, in order to gather information on how best to deliver palliative services.
We are also responding to events at Southern Cross, which have caused concern to residents in Southern Cross care homes and their relatives and families. We welcome the fact that Southern Cross, the landlords and the lenders are working hard to come up with a plan to stabilise the ownership and operation of the care homes. We have also been clear that we would take action to make sure there was proper oversight of the market in social care. That is why, through the Health and Social Care Bill, we are seeking powers to extend to social care the financial regulatory regime we are putting in place in the NHS, if we decide it is needed, as part of wider reform.
A central component of those reforms will be the long-term funding of care and support. Over the past 12 months, Andrew Dilnot, the chair of the Commission on the Funding of Care and Support, together with the noble Lord, Lord Warner, and Dame Jo Williams have engaged extensively with many different stakeholders. They brought fresh insight and impetus to this most challenging area of public policy. We welcome the excellent work of the commission and its final report. I would like to thank Andrew Dilnot, the noble Lord, Lord Warner, and Dame Jo Williams for the work they have undertaken. It is an immensely valuable contribution to meeting the long-term challenge of an ageing population.
The report argues that people are unable to protect themselves against the risk of high care costs, leaving people fearful and uncertain about the future. The commission’s central proposal is therefore a cap on the care costs that people face over their lifetime of between £25,000 and £50,000; it recommends £35,000. Under the commission’s proposals, people who cannot afford to make their personal contribution would continue to receive means-tested support, but it proposes that the threshold for getting state help with residential care costs would rise from £23,250 to £100,000. People would make some contribution to their general living costs in residential care, but this should be limited to between £7,000 and £10,000.
The commission also proposes: standardised national eligibility for care, increasing consistency across the country; universal access to a deferred payments scheme for means-tested contributions; improvements in information and advice; improved assessments for carers and better alignment between social care and the wider care and support system; and to consider changing the means test in domiciliary care to include housing assets. It makes recommendations about how, as a society, we will organise and fund social care. We will now take forward consideration of the commission’s recommendations as a priority.
The commission recognises that implementing its reforms would have significant costs that the Government will need to consider against other funding priorities and calls on constrained resources. In the current public spending environment, we have to consider carefully the additional costs to the taxpayer of the commission’s proposals against other funding priorities. Within the commission’s recommendations, it presents a range of options, including on the level of a cap and the contribution people make to living costs in residential care, which could help us to manage the system and its costs. That is why we intend to engage with stakeholders on these issues, including on the trade-offs involved.
Reform in this area will need to meet a number of tests, including: whether proposals would promote closer integration of health and social care; whether proposals would promote increased personalisation, choice and quality; whether proposals would support greater prevention and early intervention; whether a viable insurance market and a more diverse and responsive care market would be established as a result of the proposals; the level of consensus that additional resources should be targeted on a capped costs scheme for social care; and what a fair and appropriate method of financing the additional costs would be.
The Government have set out a broad agenda for reform in social care. We want to see care that is personalised, that offers people choice in how their care needs are met, that supports carers, that is supported by a diverse and flourishing market of providers and a skilled workforce who can provide care and support with compassion and imagination, and that offers people the assurances they expect of high-quality care and protection against poor standards and abuse. Andrew Dilnot’s report was never intended to address all these questions, but it forms a vital part of that wider agenda.
To take it forward, we will work with stakeholders in the autumn, using Andrew Dilnot’s report as the basis for engagement as a key part of a broader picture. This engagement will look at the fundamental questions for reform in social care: improving quality, developing and assuring the care market, integration with the NHS and wider services, and personalisation. As part of that we want to hear stakeholders’ views on the priorities for action from the commission’s report and how we should assess these proposals, including in relation to other priorities for improvement in the system. As the right honourable Member the Shadow Health Secretary and I have discussed, we will also engage directly with the Official Opposition in order to seek consensus on the future of long-term care funding.
We will then set out our response to the Law Commission and to the Dilnot Commission in the spring, with full proposals for reform of adult social care in a White Paper and a progress report on funding reform. It remains our intention to legislate to this effect at the earliest opportunity. The care of the elderly and vulnerable adults is a key priority for reform under this Government, and I commend this Statement to the House”.
My Lords, that concludes the Statement.
Baroness Thornton
First, my Lords, I thank the Minister for repeating the Statement today. It is difficult to imagine a more important issue for us to consider. Care of the elderly and vulnerable is probably the most difficult and intractable problem facing our society. It is one that we have to resolve; we cannot afford to let it go on and on unresolved. We can all agree about this.
It should be a cause for celebration and pride that one in five of us alive in Britain today will now live to be 100, and that our children can expect to spend one-third of their lives in retirement. Instead, thousands and thousands of us approach old age in fear—fear that we will need care that will not be there or will not be good enough, fear that our savings will be wiped out by an open-ended cost, fear that we cannot protect our families from this cost, and fear of becoming a burden or being left alone. That is why we on these Benches welcome the Dilnot report and the Statement.
These proposals contain many important elements that were in the plans that we set out when we were in government in our care White Paper prior to the general election. I join the Minister in congratulating Mr Andrew Dilnot and his colleagues, my noble friend Lord Warner and Dame Jo Williams on the excellent job that they have done. I know that many of the organisations concerned with this issue—Age UK, the Alzheimer’s Society, Care UK and others—have been very impressed by the way in which the commission has carried out its tasks, but they are now, quite rightly, very keen to ensure that the momentum created by this excellent report is not lost. Many noble Lords will have seen the letter, signed by 32 of these organisations, pleading with us not to pass up this opportunity. I welcome the Minister’s confirmation that detailed and important involvement of stakeholders will continue.
I am very impressed with the way in which all the members of the commission have seen it as their mission to explain to the widest possible audience what lies behind their recommendations and why they have reached the conclusions that they have. I know that my noble friend Lord Warner has been in major media contact since the early hours of this morning; many of us will have been treated to the masterclass from Andrew Dilnot on the “Today” programme.
In response to the report my right honourable friend Ed Miliband, the leader of the Labour Party, has said on behalf of the Labour Party that we would be willing to put aside our party’s pre-election proposals in order to try to find a solution. I invite the Minister to agree with me that it is just as well that politicians sometimes ignore the cynicism and negativity of commentators, such as Mr Nick Robinson of the BBC, who I heard recently, and show an understanding of the importance of reaching a national consensus on these matters. We will all need to show the kind of determination that my right honourable friend the leader of the Labour Party is showing. Will the Minister comment on suggestions in the media, including from members of the Conservative Party, that suggest that the Treasury is already lining up to kill these proposals? I hope that this is not the case and that the tweet today quoting Stephen Dorrell as saying that the Government must show willingness to find the money for Dilnot’s long-term care overhaul is more accurate.
The last thing Britain needs is for Andrew Dilnot’s proposals to be put into the long grass, or even the medium-cut grass. This is a once-in-a-lifetime opportunity that we must address. It is what the Government do with it now that counts. My right honourable friend the leader of the Labour Party has made a big offer to the Prime Minister to put politics aside and to work to see a better long-term system of social care put in place for elderly and disabled people in our country. We on this side are willing to talk to and work with the Government and all other parties to do so, because we know that any system of care must give all of us the long-term confidence to know what will be on offer for us and our families. It requires the Prime Minister to give a lead, because agreeing an affordable and sustainable system involves important parts of government beyond the reach of the Health Secretary. It requires the Prime Minister to give a guarantee that the Government will not kick Mr Dilnot’s recommendations into the long grass, because the system needs urgent and lasting reform. Will the Minister give us that guarantee today? If the Government are serious, we in the Labour Party are serious. If the Government are serious, we need to hear what the plan is going to be as we move forward.
Mr Dilnot recommends a White Paper by December this year, but this already seems to have slipped to the spring. Will the Minister say which is it? Will he also tell the House when we can expect a draft Bill—are the Government aiming for this to be in the next Queen’s Speech? In the absence of the noble Baroness, Lady Campbell of Surbiton, will the Minister confirm that the Government welcome and will take forward recommendation 6 on the portability of care assessments? Will the Government be supporting her Private Member’s Bill on this? Does he agree that cross-party talks are required and that the Prime Minister should give this lead? How and when will this start?
Finally, I know the Minister agrees that there is a need for the House to have an opportunity to have a more thoroughgoing debate about this matter, the report and its recommendations. I hope that we can also join forces in trying to secure that opportunity.
Earl Howe
My Lords, I am most grateful to the noble Baroness for her welcome of both the commission’s report and the Statement that I repeated. I believe that the commission has not only provided us with an excellent report but has instilled a sense of impetus in this agenda. We must not lose that momentum now. She referred to the prospect of cross-party talks, and I can only repeat that the engagement that we seek in the coming weeks and months will fully extend to the Official Opposition. We recognise the value of building a broad coalition of support on an issue as important as this. As she rightly said, there has to be security for the longer term so that we can provide citizens with the understanding and predictability that they rightfully expect of the system.
Reforming adult social care remains a top priority for us, but it is complex. As the Statement indicated, a number of related questions need to be addressed. Andrew Dilnot’s report provides recommendations on only one of these questions: how we pay for care as a country. It is our intention to set out our plans for wider social care reform in a White Paper in the spring. The noble Baroness is right that the timetable has slipped from that which we originally indicated, but that is not for sinister reasons. We think it is important to engage as widely as possible on these recommendations. There are many different views and we need to understand them.
Last week, the Alzheimer’s Society called for an open debate on the Dilnot proposals, with which we agree. As I have said, we are committed to a White Paper in the spring of 2012, which will include our response to the Law Commission’s report on the legal framework for social care, and we will publish a progress report on the funding. We remain committed to legislating at the earliest opportunity to take forward the proposals in the White Paper, although naturally I cannot give the noble Baroness a specific indication on the timing of that. That, however, is our ambition.
The noble Baroness referred to portability. In November, in our vision for adult social care, we made clear that we want the greater portability of assessments, which could help people who use social care to move without unnecessary multiple assessments and uncertainty. We also said that we would consider how to pursue this in the light of the work of the Law Commission and the Commission on Funding of Care and Support. We are considering both reports carefully. It is too early for me to say precisely what reaction we will give to the Bill sponsored by the noble Baroness, Lady Campbell, but we look forward to debating it. I am sure that that Bill will enable us to drill down to some of the more difficult aspects of portability, with which I know that the noble Baroness is all too familiar.
As for a more general debate on these important issues, I well understand the noble Baroness’s wish to have such an opportunity. I will of course relay that desire to my noble friend the Leader of the House. It is not in my hands, and as she knows the available time for general debates of that kind is rather limited at this time of year, but we will see what can be done.
Baroness Oppenheim-Barnes
My Lords, I was extremely pleased to hear this Statement and to hear it in the form that it has come. It must be well over 20 years since I first started writing to various Prime Ministers about the dreadful case of a constituent who had to sell his house—his life savings went into the house—to go into a care home, who said, “This cannot be fair. People who never bothered to save or to put money aside are getting the same treatment I am being charged for”.
On the other hand, and this illustrates the difficulty of the problem, the view of the taxpayers, also expressed to me, was, “Why should we have to support the inheritance of the sons and daughters of these people?”. There were two completely separate points of view that were very difficult to reconcile. As the problem becomes bigger and more urgent all the time, it is extremely brave of the Government to embark at this stage on a Statement that refers to the priority that will be given to this problem, and I welcome that very greatly.
Earl Howe
I thank my noble friend Lady Oppenheim-Barnes for those remarks. The House will know that her experience of these matters goes back many years. She is right; these thorny issues have been with us for a very long time and we have to get a grip on them. There is, as I made clear earlier, a clear imperative to inject certainty and predictability into the system, but there is also a need to strike a balance between the state and the individual. That principle was one that the Dilnot commission articulated—overreliance on the state would be unsustainable and arguably unfair, and overreliance on the individual presents obvious problems of a different sort. It is that balance that we need to identify.
Lord Lipsey
My Lords, as a member of the Royal Commission on the funding of Long-Term Care for the Elderly, which so singularly failed to find any consensus—my fault, no doubt, as I signed the minority report—I welcome the Dilnot report very much as bringing us nearer to the kind of political consensus on this issue that is intrinsic to its final solution.
However, we should not take the proposals in Dilnot as written in stone. There are severe problems of cost and the fact that they do so much more for the very rich members of society and so much less for the middle. Will the Minister—who has rather wisely stretched out the consultation period on this—assure the House now that although Dilnot’s fundamental architecture has a great deal to be said for it, the Government will keep a very open mind on the details throughout the process ahead?
Earl Howe
I am grateful to the noble Lord, Lord Lipsey, and broadly my answer to him is yes. They are clearly a set of well considered recommendations which we think are eminently worthy of serious study as a basis for cross-party consensus. However, I will not be tempted to pin my colours to any mast that the Dilnot commission has erected because it is important that we have this consensus as far as we can generate it, and that will mean looking at the detail and at individual recommendations on their own merits, maybe taking forward some but not others, and maybe looking at a staggered timetable. These are all questions that we have to resolve between us.
Baroness Barker
My Lords, I am in danger of agreeing with the noble Lord, Lord Lipsey, which is something that always worries me, as he knows. I, too, welcome this. After 13 years of the Labour Government trying in various ways to approach this problem we have, with this report, an architecture that is very important, although I agree with the noble Lord, Lord Lipsey, that there a great many technical matters within it that should be open for negotiation.
The report and the extent to which its objectives are achieved rely on two areas: first, a broad political consensus that it is a fair approach to take to the problem; and secondly, as the Minister said, a number of specific technical issues, the main one being that there should be a consistency in the criteria between eligibility for state provision and any insurance-based cover. That is perhaps the biggest single factor in determining whether the entire system will work. What work will be done with stakeholder groups, including carers and older people, and the private insurance business on that specific point? Only by resolving that can we enable individuals to have the security of knowing when the state will pay for their provision and when they as individuals will be expected to contribute.
Earl Howe
My noble friend has highlighted a key issue. We know that it is important to people that access to care services is fair and that resources are used wisely. However, the commission is clear that it believes that local authorities should continue to play a key role in the funding and delivery of social care, so we need to consider carefully how to achieve the right balance between national consistency and local flexibility. That is a very difficult question.
During the coming period of engagement in the autumn, we will want to take views on that matter. I remind my noble friend that in the light of recommendations made in CSCI’s review, called Cutting the Cake Fairly, which I am sure she will remember, the department issued guidance to local authorities on eligibility to support fairer and more transparent and consistent implementation of the criteria. We fully appreciate, however, that the concerns on that front continue; the current eligibility framework is subjective and it is difficult for individuals to understand what they might be entitled to in advance of an assessment. We will consider whether to take forward work on a new assessment framework following discussions with stakeholders.
Lord Myners
My Lords, the Government deserve credit for establishing the commission and choosing Mr Andrew Dilnot to chair it. I welcome the constructive way in which the Minister has summarised how the Government intend to take this forward.
I have two questions arising from the Statement. I shall ask them in the sequence in which they arose from the Minister’s announcement. First, he observed that financial markets have no answer to this problem. That is quite extraordinary. Our colleague, the noble Lord, Lord Turner, in his capacity as chairman of the Financial Services Authority, told us that much of what goes on in the City is socially useless. Here is an area where the financial community in the City could be socially useful, yet it seems to be turning its back on the opportunities to create long-term annuity products appropriate to meeting people’s expenditure requirements in the later period of their life. Will the Minister raise this with the Treasury and the FSA and consider establishing a working group to investigate particularly whether EU legislation on capital requirements for variable annuities is frustrating a market response?
Secondly, the Minister mentioned Southern Cross. There is much concern in the country about Southern Cross and I am grateful for the Minister’s Statement. Will he confirm that no resident of a Southern Cross home will be required to move against their wishes from the home in which they are currently being cared for?
Earl Howe
I am grateful to the noble Lord, Lord Myners. I shall address his questions in the opposite order. We have been clear about the situation at Southern Cross: we hope that a resolution will emerge as a result of the current discussions between Southern Cross, its lenders and its landlords. However, we have been equally clear that the residents of the care homes are our prime concern. It is not possible for me to give an absolute assurance that no resident will be required to move, but I can say that we will ensure that if a resident is required to move, there will, in accordance with best practice, be plenty of time to ensure that suitable alternative accommodation is available. It is a fact of life that care home residents sometimes do have to move, but it is our ambition that no care home resident of Southern Cross should move. I do not intend to sound in the least complacent about this because we have set a clear sense of direction to the parties involved that we hope to see this settlement reached.
The noble Lord, Lord Myners, is right about financial products. I have noted over the past 10 years with some disappointment the dearth of suitable financial products to enable people to save for long-term care. The commission has analysed extremely ably the barriers that currently prevent the establishment of an effective market for financial products and we want to consider how best to promote a more effective market for such products. We will consider the commission’s recommendations carefully, of course. An effective market in this area would be extremely helpful. It may help people to become more aware of the costs that they may face in later life, which in itself would be useful, and to take steps to prepare for these. I will bring the noble Lord’s remarks to the attention of my colleagues in the Treasury in the sense that he indicated.
Lord Newton of Braintree
My Lords, I declare an interest as chairman of the Suffolk Mental Health Partnership NHS Trust and the immediate past chairman of Help the Hospices. I agree with my noble friend Lady Oppenheim-Barnes. Indeed, this has been a running sore throughout my entire political lifetime since I was first elected as an MP in 1974. The right metaphor now might be a ticking time bomb in one of those James Bond films getting quite close to where it actually goes off, or does not quite. This is potentially seriously, socially divisive and difficult, so I hugely welcome both the report and the tone that has been adopted by those on the two Front Benches. It is essential that we should seek political consensus, otherwise there will be big trouble for all of us.
Lastly, and more specifically, I come to my question: does my noble friend accept that there are also health implications in the demographics as well as social care implications? A growing number of people are presenting with mental illness problems—dementia, in particular—at mental health trusts, and indeed in acute trusts in the A&E departments, with a knock-on effect on requests for assistance from mental health trusts and their clinicians. There is a serious need for health resources to be directed towards some aspects of this problem as well as to a solution to social care problems. I hope that my noble friend will take that on board.
Earl Howe
I am grateful to my noble friend and agree with all that he said. The early part of the Statement demonstrates very graphically the demographic aspects of this matter. He is of course right that there are clear health implications in all of this, which is precisely why the work that we are doing in the department lays such emphasis on the need to integrate health and social care commissioning and provision and on the need to place a greater emphasis on prevention both in health and social care. That is also why we have channelled substantial additional funds from the health budget to support social care over the next four years. There is a clear interest for the health service in wishing to see a stable and fair system of social care provision, so I identify absolutely with everything that my noble friend has said.
Lord Lloyd of Berwick
My Lords, the emphasis in the Statement is very much on the care of the elderly, some of whom will be disabled. What I am not clear about is whether the report also covers care of the disabled who are still young, who are currently covered by the Chronically Sick and Disabled Persons Act, which was sponsored by the noble Lord, Lord Morris of Manchester, 40 years ago. Is that also up for grabs, as it were, among the tangle of legislation which is being considered?
Earl Howe
My Lords, this area was not overlooked by the commission. Indeed, the commission has made a specific recommendation as regards the cap on costs, which it believes should be, as a generality, somewhere between £25,000 and £50,000, although it has come down in favour of a £35,000 figure. That figure is lower for those who require long-term care at a much earlier age. The noble and learned Lord is right that this area should not be neglected, and I am sure will not be neglected.
Baroness Pitkeathley
My Lords, does the Minister agree that although the sum of £2 billion mentioned by Andrew Dilnot may strike fear into the heart of the Treasury at a time of financial constraints, it is a puny sum when you compare it with the £119 billion contributed by the main providers of care—the family carers? Therefore, I am sure he agrees that the support offered to family carers in the report is extremely welcome. Will he reconfirm the Government’s commitment to continuing to work with the stakeholder groups, as the Dilnot commission has so admirably done, particularly as the advice and information service for families is developed as we go forward?
Earl Howe
My Lords, I cannot stand here and claim that an additional £2 billion is a trivial amount of money; it clearly is not. That is why it was made clear in the Statement that we need to make some difficult decisions over priorities in public spending. As regards carers, for whom the noble Baroness has done so much in her career, I am sure she will accept from me that we recognise the value and contribution that carers make. We recently published Recognised, Valued and Supported: Next Steps for the Carers Strategy, which announced an additional £400 million over four years for PCTs to pool with local authorities to provide carers’ breaks. In our carers strategy we indicated that assumptions should not be made about who will provide care and to what extent. There has been a 21 per cent increase in the number of carers receiving information. We want to see greater flexibility and portability of assessments for carers. The agenda in this area is proceeding and we shall not forget it amidst the concerns over funding. It is every bit as important as getting the funding system for paid residential long-term care right.
Baroness Shephard of Northwold
My Lords, I, too, welcome the political consensus that is bathing us in its glow this afternoon. Several noble Lords have spoken, and so has my noble friend, of the importance of engaging individuals in taking responsibility for their own care. I am sure that he is very aware of this, but does he realise how important it is for there to be a clear financial framework so that individuals and their families can take decisions concerning their own care? That is the important starting point given in the Dilnot report. It is an indicator—I do not know how the Government will treat it—which provides admirable clarity. Wrestling with the complexities of the different organisations involved will come later. However, I remind my noble friend that those complexities are already struggled with by individuals and their families when making these plans. An espousing of the financial certainties of the report would be a great move towards enabling individuals to take charge of their own futures.
Earl Howe
I am grateful to my noble friend, who has put her finger on an extremely important aspect of the debate. Much of the thrust of our proposals on the NHS revolves around the personalisation agenda, which applies in equal measure to social care. This is about the call to arms that Derek Wanless sounded a few years ago about the need for people to take ownership of their own healthcare if we are to have an affordable and sustainable system over the longer term. That process can be aided and boosted in a number of ways, not only by the rollout of a greater range of financial products but also through mechanisms such as personal budgets, which empower patients inherently, and through telecare, on which this country leads the world in the advances we have made and in the potential that exists for those in receipt of health and social care in their own homes to take ownership of their condition.
NHS: Health Improvements
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Baroness Thornton
To ask Her Majesty’s Government how they will ensure that the NHS delivers strategic health improvements requiring levels of technology and expertise appropriate to regions or cities with large populations.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, our commissioning proposals will establish a national NHS commissioning board providing oversight of commissioning in the NHS and directly commissioning some services, including specialised services, where it makes sense to commission for larger populations. The NHS commissioning board will have a sub-national presence and local commissioning will be undertaken by clinical commissioning groups. The NHS commissioning board will have a duty to promote integrated services for patients, both within the NHS and between other local services.
Baroness Thornton
I thank the Minister for that Answer, as far as it goes. The successful reorganisation of stroke services in London, which has saved many lives, was led by clinicians, as it should have been, but the commissioning and its delivery were in fact only brought about by NHS London, the ability of the strategic health authority to manage the PCTs and through great collaboration with the providers. Apart from the providers, all of these bodies are being dismantled and abolished as we speak. In the new system, how precisely would similar improvements be brought about? Who would take the lead and who would ensure their delivery?
Earl Howe
My Lords, where it is deemed appropriate to commission a service at scale but below the level of the NHS commissioning board, as I described in my original Answer, it will be open to clinical commissioning groups either to establish a lead group to take control of the commissioning and to agree budgets and pathways or for clinical commissioning groups to collaborate jointly. The advantage of the system that we are proposing is its flexibility. Depending on population size and the needs of an area, commissioning can be done at several levels.
Baroness Gardner of Parkes
My Lords, the Question was so difficult to understand that I thought it was about telemedicine. Does it cover the issue of reducing the number of accident and emergency services in London so that they are more equivalent to the stroke units, which, as the noble Baroness said, have worked so well? Many people say that fewer but more effective accident and emergency services would be better. On the other hand, is the Minister aware of the concern over the closure of the Royal Brompton’s heart section for children, which is essential to the future of that hospital?
Earl Howe
My Lords, my noble friend will know that an independent inquiry into children’s heart services is under way at the moment. It would be inappropriate for me to comment. I have not been involved at all but it would be inappropriate for Ministers to become involved. As regards ambulance and A&E services, we envisage that clinical commissioning groups will commission the great majority of NHS services for their patients, including urgent and emergency care and ambulance services. Prior to that, PCT clusters, which are being formed from the primary care trusts, will be responsible for commissioning ambulance services until 1 April 2013.
Lord Winston
My Lords, does the Minister agree that we are facing one of the greatest revolutions in medicine—that is, genomic medicine? It will make medical treatment more effective and efficient and will reduce the national drug bill. Therefore, does he not agree that one of the most urgent needs of a large population is for increased computing power and proper information technology?
Earl Howe
I absolutely agree with the noble Lord. The information agenda, which should run in parallel with our plans, is essential for delivering the improvement in outcomes that we all want to see. Part of that will involve new technology. As the noble Lord knows, work is under way on genomic medicine, which is extremely exciting. We have included in the amendments tabled to the Health and Social Care Bill in another place a duty on both the Secretary of State and clinical commissioning groups to promote research in the health service.
Baroness Finlay of Llandaff
My Lords, who will be the final arbiter in a decision if a commissioning board commissions a highly specialised treatment that may require patient testing locally and an infrastructure of local services, but the local commissioning group does not recognise the importance and potential good patient outcomes of this, and therefore does not adequately provide the infrastructure needed for the more highly specialised service?
Earl Howe
My Lords, the system ought to respond to the kind of situation that the noble Baroness has posited. If a service is specially commissioned by a board, that board and local commissioners will be required to work in concert. If they do not, there will be mechanisms to ensure that the healthcare needs of an area are aired at the local authority level—that is, through the joint health and well-being boards, whose job it will be to prioritise the commissioning of services in that area.
NHS: Clinical Excellence Awards
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Lord Walton of Detchant
To ask Her Majesty’s Government why they have decided not to recommend any Clinical Excellence awards for NHS consultants this year.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the 2011 round for clinical excellence awards is currently proceeding, with the rules unchanged. No decisions have been taken about the 2012 round. The Doctors’ and Dentists’ Review Body is taking views on the matter from other parties and in due course will make a recommendation, which the Government will consider.
Lord Walton of Detchant
My Lords, I thank the Minister for that Answer. Is he aware that there has been some ill informed comment in the public press suggesting that these awards are bonuses? They are not. They are a fundamental part of the salary structure of senior clinical academics and consultants. They were introduced as distinction awards by Aneurin Bevan at the inception of the National Health Service in order to persuade distinguished consultants and academics to give their services to it. If it were to be suggested that these awards would be abandoned, as has been thought in certain quarters, would the Minister agree that that would sound the death-knell for clinical academic medicine and high-quality clinical practice teaching and research in the NHS?
Earl Howe
My Lords, in building the NHS that we all want for the future, we need to continue to recognise and reward those individuals who give outstanding patient care and who contribute in a notable way to clinical academic excellence. At the same time, we need to ensure that the system in place to do that is effective, affordable and in line with other public sector reform. It is those questions that the Doctors’ and Dentists’ Review Body is considering at the moment.
Lord Ribeiro
Does the Minister agree with the Academy of Medical Royal Colleges, the Academy of Medical Sciences and others that clinical excellence awards make an important contribution to the quality and excellence of care in the National Health Service? How will the replacement of these awards by one-off non-pensionable awards, like the proposed surgeon of the year prize, improve standards?
Earl Howe
My Lords, as I have just said, we believe that financial rewards, in the form of clinical excellence awards, should remain. It is just a question of how that system is designed. We have not said that non-financial recognition should take the place of financial awards. They would operate alongside financial awards; they would not in any way supplant them. However, we think that there is a role for perhaps more imaginative thinking in areas like speciality-based awards or departmental or division-based awards, for example, or indeed ad hoc recognition for outstanding clinical leadership. The DDRB is looking at these questions too.
Baroness Thornton
My Lords, I commend the noble Lords, Lord Walton and Lord Ribeiro, on doing a really admirable job as the shop stewards for distinguished clinicians—and quite right, too—but I would point out that innovation and excellence cuts across all NHS staff, including nurses, midwives and therapists, who often introduce wonderful innovation at their level. Could the Minister tell us what incentives are in place in the system that recognises that excellence as well?
Earl Howe
The noble Baroness is absolutely right. We do need to incentivise all staff, both clinical and non-clinical in the NHS, to innovate. We can do that in a variety of ways. She will know that the noble Lord, Lord Darzi, proposed a number of ways of doing this, including innovation prizes and innovation funds, which are extremely popular. We also can incentivise through the tariff. As she will know, we have protected the research budget, which in the long term will serve us well in driving through innovation in the NHS.
Lord Mawhinney
My Lords, can I encourage my noble friend, when he considers the 2012 awards, to talk to his colleagues about introducing some more transparency into the awards? Part of the difficulty referred to by the noble Lord, Lord Walton, is that no one knows who, or why, or how much. Transparency would be a strengthening as well as a salutary experience for many in the health service.
Earl Howe
I agree with my noble friend. We have identified a number of anomalous features in the current scheme which need to be looked at. He is absolutely right to point out that the current scheme is far from transparent. It enables rewards to continue that are based on historic performance rather than anything more up to date.
Baroness Jolly
My Lords, clinical excellence is important at community level as well. Would the Minister tell the House whether any restrictions will be placed on the commissioning groups concerning the payment of rewards to their members?
Earl Howe
My Lords, the pay structure for clinical commissioning groups is a separate issue from clinical excellence awards, which apply only to those holding a consultant’s contract in the NHS. To the extent that anyone holds a consultant’s contract in any of the clinical commissioning groups, they will be subject to whatever new scheme the DDRB recommends and the Government accept.
Lord Willis of Knaresborough
Would my noble friend accept that one of the real challenges is to make sure that people who are working in clinical practice have the opportunity to engage in research? Research salaries are significantly lower than clinicians’ salaries. What is the Minister doing to try to ensure that there is a seamless progression between research and clinical practice and between clinical practice and research?
Earl Howe
My Lords, those who hold honorary contracts, who are in general clinical academics, are well represented among those who are awarded clinical excellence awards. We are absolutely clear that that should continue as long as possible. We must incentivise those who do not spend the bulk of their day engaged in treating patients so that we ensure that we have a bank of academic excellence driving forward innovation in the NHS.
Lord Kakkar
My Lords, what role do Her Majesty’s Government see for the academic health science centres in promoting clinical excellence? In asking the question I remind the House of my interest as a director of the UCL Partners academic health science centre at University College London.
Earl Howe
I believe that, on current showing, the academic health science centres have pointed the way to how clinical academic leadership can promote excellence both in patient care and in translational research. We are encouraged by everything that the AHSCs are doing. We will formally review them in due course, but I am absolutely onside with the noble Lord in wishing to see the progress that they have made rolled out more generally in the NHS.
Drugs: Prescribed Drug Addiction and Withdrawal
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The Earl of Sandwich
To ask Her Majesty’s Government what action they propose following the latest two reports from the National Addiction Centre and National Treatment Agency on prescribed drug addiction and withdrawal.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, my honourable friend the Minister for Public Health, Anne Milton, has discussed the findings of the reports with the All-Party Parliamentary Group on Drug Misuse and the All-Party Parliamentary Group on Involuntary Tranquiliser Addiction at a meeting chaired by my noble friend Lord Mancroft on 14 June. She wrote to my noble friend yesterday setting out the collaborative action that she will be taking in the light of that helpful discussion. She will be convening a round table meeting to discuss the key issues.
The Earl of Sandwich
My Lords, I thank the Minister for that information. Does he accept that this is an emergency for the victims of withdrawal from prescribed drugs and their families? Cannot the Government recognise the good practice that is already out there, set up withdrawal clinics and spread the word that no longer are these prescribed drugs but that they are turning into dangerous substances which can cost lives? These people cannot wait for further reports and consultation.
Baroness Finlay of Llandaff
My Lords, how much advice is now being given to GPs over the prescribing of psychoactive substances? In the revisions of the NHS as proposed by the Government, will the pricing bureau which monitors GP prescriptions still have the same levers as it currently has in providing GPs with benchmarking of their prescribing of psychoactive substances?
Earl Howe
My Lords, I am not sure that I can answer the latter part of the noble Baroness’s question but GPs are clearly in an important position in this context. They are responsible for identifying patients who need help and for supporting them. I do not think that there is any reliable evidence that doctors are failing to comply with guidelines on the prescribing of benzodiazepines but I am aware that the Royal College of General Practitioners is updating its guidance at the moment. It is working hard to produce that very shortly.
Lord Crisp
My Lords, given the importance of making visible the number of people who are addicted in this way, when will the Government calculate the true number of people addicted to and withdrawing from legally prescribed drugs? That information could be made available from GP computer records. Does the Minster agree that both the NAC and the NTA reports confuse the number of patients taking legal prescriptions with the number of users of illegal drugs?
Earl Howe
I agree with the noble Lord that it would be very nice to have a better handle on the numbers here, but the two reports found that nationally available data do not actually provide a definitive prevalence estimate of dependence on prescription and over-the-counter medicines, much as we would wish otherwise. The reports, not unreasonably, consider the full spectrum of need in relation to the issue of addiction. The key point here is that, while different people might start taking these medicines for different reasons and may present with a different range of needs, no one at all should be excluded from the treatment and support that they require. The reports distinguish between the two groups of patients, not just those who are dependent on prescription and over-the-counter medicines but also those who are dependent on illegal drug use. That enables us to make some useful comparisons.
Baroness Jolly
Cognitive behaviour therapy is often considered as an alternative to benzodiazepines. Does the Minister believe that that low-risk alternative might be available more readily through the proposed clinical commissioning groups?
Baroness Thornton
Following on from the noble Earl’s supplementary question on how to ensure that good practice becomes standard practice, how will that sit with the dismantling of strategic health authorities, PCTs and other levers that might be used to ensure progress? Who or which organisations in the proposed restructuring of the NHS will be able to ensure that patients who have an addiction to prescription drugs receive the support that they desperately need? I agree with the noble Earl that this is an emergency; it is not the first time that we have discussed this on the Floor of the House.
Earl Howe
My Lords, the responsibility for commissioning these services in future will lie with local authorities, supported by Public Health England. The noble Baroness will be aware that it is our proposal to ring-fence the public health budget. Local authorities will be informed by the joint strategic needs assessment that they carry out and will work in partnership with local delivery organisations and with local GPs, who, as I have mentioned, will be even better informed than they are at the moment thanks to the Royal College guidance.
Lord Kakkar
My Lords, how much research into the problem of prescribed drug addiction is being supported by the National Institute for Health Research?
Lord Roberts of Llandudno
My Lords, as this is a UK-wide problem, how do you link with the devolved Administrations in Wales, Scotland and Northern Ireland to make sure that the guidelines that we get here for England are shared with those in the other Administrations?
Earl Howe
My noble friend will know, as his question certainly made clear, that health is a devolved matter. However, we work very closely with our counterparts in the devolved Administrations on a basis of mutual information. I am sure that, for example, the Royal College of General Practitioners will wish to make certain that the devolved Administrations are every bit as well informed about their work as we are in the department in London.
Care Services: Older People
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Baroness Neuberger
To ask Her Majesty’s Government, in the light of the Equality and Human Rights Commission’s interim report on the care of older people in their own homes, what plans they have to ensure appropriate care that respects dignity.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, dignity and respect are the cornerstones of good quality care. The Government have made the Care Quality Commission responsible for assuring quality of care. It is the responsibility of local authorities to specify and commission care and providers to deliver it. The Government’s planned reforms for health and social care, with an emphasis on better commissioning, should increase our ability to drive up standards in services and result in improvements in quality of care.
Baroness Neuberger
My Lords, I thank my noble friend the Minister for his reply. However, is he aware that a large proportion of the responses to the interim report from the Equality and Human Rights Commission have come from the care workers themselves who feel that in present circumstances they are simply unable to provide care that provides dignity to the older people in their care? Can he assure this House that in those reforms that are going forward, measures will be taken to make sure that local authorities must commission services that allow real dignity, which probably means rather longer passages of care for the people concerned?
Earl Howe
My noble friend makes some extremely important points and I agree with the thrust of them. As she said, these are interim findings. We all look forward to the finished report later in the year, which will no doubt contain deeper analysis than we have had access to so far. There can be no place for poor quality care in care services. We should all welcome an inquiry of this kind because it clearly will expose poor practice and will point the way towards some clear messages that we must bear in mind in the context of the Health and Social Care Bill. In that context, we are seeking to achieve much more joined-up commissioning so that we have health and social care working together towards quality outcomes.
Baroness Greengross: My Lords, does the Minister agree that a reprioritising of funding towards the care of people in their own homes is essential? Would he also agree that in training both commissioners and care workers a human rights approach is a very useful tool when caring for vulnerable older and disabled people in their own homes? I declare an interest as a commissioner on the Equality and Human Rights Commission.
Earl Howe: I certainly agree with the noble Baroness that being looked after in one’s own home is the preferred option for most elderly people. That is where we have to focus our attention and, over time, increasingly our resources to deliver good quality care in that context. She makes a very good point about training. Regarding the essential qualities of a good care worker, you cannot train anyone in a kind and compassionate attitude, which is probably the foremost requirement for anyone in that field. I take her point about human rights. My department is already speaking to the Equality and Human Rights Commission and has entered into a voluntary agreement with it to help us embed equality right across health and social care and to enable the commission and stakeholders to evaluate the progress we have made.
Baroness Wheeler: My Lords, I, too, welcome the work being undertaken by the EHRC on this vital issue. We know that there are substantial problems with commissioning and standards of care delivery. For example, many local agency contracts do not provide staff with travelling time between visits, which greatly adds to the pressures on them. Stories of older people even being catheterised to avoid the costs of an extra visit are not unheard of. However, as a carer, I stress that in my own locality, care agency arrangements work very well, to a high standard and as part of an integrated care package. How will the Minister ensure that future commissioning makes this experience the norm, bearing in mind that 81 per cent of publicly funded home care today is provided by the independent sector?
Earl Howe: The noble Baroness again makes some extremely good points. At the moment we have an architecture that, first, should ensure that basic standards of quality are maintained. We have that through the Care Quality Commission, whose job it is to register domiciliary care agencies and to ensure that they have systems in place to quality-assure themselves. That must be the starting point: agencies must make sure that they are delivering the service for which they have been commissioned. Secondly, it is also a matter of ensuring that we have visibility where problems arise and that service users are encouraged to believe that they can speak up for themselves, that whistleblowing is possible, and that anyone else who observes poor quality care should feel free to speak up and to know whom to tell when they see bad care happening.
Baroness Campbell of Surbiton: My Lords, over four-fifths of local authority-funded home care is delivered by the private and voluntary sectors. In light of this, will the Government use the opportunity of the current Health and Social Care Bill to clarify that private and voluntary sector agencies providing home care services on behalf of local authorities are performing public functions under the Human Rights Act?
Earl Howe: I am sure that the noble Baroness, with her experience, can tell me a lot of what I do not know about what is built into the contracts that local authorities take out with private, independent and voluntary sector organisations. I would be surprised if the human rights obligations she refers to are not built into those contracts. It is clear that everyone has a basic human right to be treated properly wherever type of care is being delivered. The key here is to ensure that service users are aware of their rights. As I said earlier, my department is extremely keen to embed equalities and human rights in everything that it is responsible for.
Baroness Jolly: My Lords, will the Minister tell the House what proportion of domiciliary care providers are owned by private equity companies?
Earl Howe: I am afraid that I do not have that figure in my brief. I am not sure whether my department will either but if I can find it out I will let her know, gladly.
Health: Hepatitis C
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Baroness Randerson
To ask Her Majesty’s Government what assessment they have made of the number of people infected with hepatitis C who remain undiagnosed.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, to the end of 2009, the latest year for which complete data are currently available, a cumulative total of 79,165 laboratory diagnoses of hepatitis C had been reported to the Health Protection Agency. The HPA advises that the number of laboratory diagnoses made will be higher than this because of underreporting, but the number of undiagnosed individuals is not known.
Baroness Randerson
The Health Protection Agency refers to a very much higher number of people—possibly 250,000—being infected with hepatitis C. That is its estimate, and there are other estimates of up to 450,000. I very much welcome my noble friend’s detailed Answer, but since 1997 the number of cases of hepatitis C reported each year has almost trebled. The majority are still undiagnosed, and I ask that in future there is more systematic and proactive screening of prisoners in prison to ensure that we diagnose more cases.
Earl Howe
My noble friend is absolutely right that there is a range of estimates of both the incidence and the prevalence of hepatitis C. I could spend some time explaining why that is, but it is partly to do with the long incubation period of hepatitis C, the symptoms of which do not manifest themselves for many years. My noble friend is also right that prisons tend to be a repository of this condition. In recent years, the story there has been good. The provision of information for prisoners and prison staff on hepatitis C and other blood-borne viruses has increased. There has also been increased access to hepatitis C testing for prisoners. We have had improved access to treatment for prisoners with hepatitis C and to drug treatment generally, which is of course absolutely germane to this condition. I believe that the focus is there, but that there is more to do.
Lord Morris of Manchester
My Lords, can the Minister tell the House how many patients infected with hepatitis C by contaminated NHS blood have since died in consequence?
Earl Howe
My Lords, I am sure that the noble Lord will know that precise figures are not available for that group, but I hope he will also recognise that we have taken steps to improve the financial help available to these unfortunate victims of the contaminated blood disaster of the 1970s and 1980s.
Lord Walton of Detchant
My Lords, does the Minister agree that under GMC rules on informed consent, it is not proper to take a sample of blood for another purpose and then to screen that blood for the presence of hepatitis without the consent of the individual? However, does he further agree that for research purposes or for epidemiological research, it is perfectly proper to screen large batches of blood samples taken for other purposes, such as epidemiological research, provided that the results are anonymised?
Baroness Gardner of Parkes
My Lords, obviously there is no general screening programme for hepatitis, and we appreciate the severity of cases such as that involving contaminated blood, which has just been referred to, but can the Minister explain what an ordinary person should be looking for before submitting themselves for screening? It must be advantageous to have such conditions diagnosed early rather than late.
Earl Howe
My noble friend is absolutely right that early diagnosis is always a good thing for this condition as it is for many others. We know who the risk groups are, and therefore the important thing is to target screening and testing at those groups. Predominantly, the at-risk groups are injecting drug users or former injecting drug users; they account for well over 80 per cent of cases of hepatitis C. Those groups are the focus of our efforts in primary and community care, and especially in prisons.
Lord Patel
My Lords, does the Minister agree that some ethical issues might arise in the mass anonymous screening of blood samples if a treatment was available for the disease that was being screened?
Earl Howe
In the case of hepatitis C, treatments recommended by NICE are of course available that, if taken early enough, can dramatically affect the course of the disease. I think we are in danger of straying into legislative territory that is perhaps the occasion for a wider debate as to how, if at all, we might expand the scope of the Human Tissue Act so as to reach those cases that I think the noble Lord is referring to.
Baroness Thornton
My Lords, we all welcomed the Government’s Statement in January announcing increased support for those with hepatitis C. Will the Minister please tell us what progress is being made to deliver the exception from means-testing of the new payments and the provision of prepayment prescription certificates, and which national charities are in receipt of the additional funding of £100,000 to support the victims of hepatitis C and their families?
Earl Howe
My Lords, the Caxton Foundation has been established to address the group of hepatitis C victims identified in the Government’s Statement earlier this year: that is, those victims of the contaminated blood disaster who went on to develop hepatitis C. I understand that the foundation will begin to make payments later this year that will include payments to those who are eligible for the free prescriptions service to which she referred.
Southern Cross
Earl Howe Excerpts(12 years, 10 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall now repeat as a Statement the Answer given earlier today by my honourable friend the Minister for care services to an Urgent Question tabled in another place about the steps that the Government are taking regarding Southern Cross Healthcare. The Statement is as follows.
“The Government have made it very clear that the welfare of residents living in Southern Cross homes is paramount. We appreciate that recent events and media speculation have caused concern to residents in Southern Cross care homes and their relatives and families. I very much regret that. I would like to assure everybody that no one will find themselves homeless or without care. The Government will not stand by and let that happen.
Department of Health officials have been in frequent contact with Southern Cross’s senior management over the last three months and that will continue. We are engaged with the company, the landlords and lenders and are monitoring the situation closely. The Government are acting to ensure that all parties involved are working towards swift resolution, with a comprehensive plan for the future which must have the welfare of residents at its heart. It is for Southern Cross, its landlords and those with an interest in the business to put in place a plan that stabilises the business and ensures operational continuity of the care homes. That work is happening and we must let it continue. Let me be very clear: this is a commercial sector problem and we look to the commercial sector to solve it. All the business interests understand their responsibilities. The Government are also working closely with the Association of Directors of Adult Social Services, the Local Government Association, local authorities and the CQC to ensure that robust local arrangements are in place to address the consequences in the event that the company’s restructuring plan failed to put the business on a stable footing.
Yesterday, a meeting took place between Southern Cross, lenders and the landlords’ committee. They agreed to work together to deliver a consensual solution to the company’s current financial problems over the next four months. They also made clear that the continuity and quality of care to all 31,000 residents will be maintained and every resident will be well looked after. This is a welcome development and the Government are encouraged by this positive agreement by the main stakeholders. The exact details of the restructuring plan over the next four months will be set out over the next few days and the following weeks. The Government will continue to keep close contact with the process. I will keep the House informed.
Local authorities have a duty to provide care to anyone who has an urgent need for it. All parties are aware of their roles and responsibilities should that happen and will take decisive action to ensure that no resident is left homeless or without care. The statement released yesterday provides further reassurance that the continuity of care of the residents is at the centre of the consensual restructuring agreement”.
That concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Lord, Lord Beecham, for his comments and questions. He asked a number of the latter. First, he asked specifically about the HMRC. I asked that question myself of my officials. It is quite clear that any discussion with Her Majesty’s Revenue and Customs has to be a matter for the company. HMRC makes its own judgments in any discussions with companies. It is a separate statutory body; it may not be lobbied by another government department, nor is it at liberty to discuss the detail of individual company tax affairs with anyone outside HMRC. So it is very much in the hands of the company if it so chooses to enter into the kinds of discussions to which the noble Lord alluded.
The noble Lord asked whether the LGA would be involved in the discussions over the company’s future. As is clear from the Statement, we regard the primary agents in this matter as being the company, its landlords and the lenders involved. They are the people on whose shoulders a restructuring plan depends. Nevertheless, he is right to suggest that the LGA is important in this context; it is involved with the discussions that we have had and will continue to have for some time—not only with the LGA, but with ADAS and the CQC, as well as the representatives of providers—to work through and define better the responsibilities of each party involved, so that if problems arise at a local level, either in this context or in any other similar context, the response will be appropriate. It is important to have that clarity of responsibility.
The noble Lord asked about the Southern Cross workforce. The key point here is the safety and well-being of the residents. We tasked the CQC to enter into discussions with Southern Cross when it announced redundancies the other day. The CQC’s role is to ensure that all care homes meet essential standards of quality and safety and it has confirmed that it will continue to require Southern Cross to demonstrate that all its homes are meeting these essential standards. Any failure to do so may result in enforcement action. I cannot go beyond that and comment on the prospects for the continued employment of the current workforce. All I would say is that the agreement reached yesterday will dispel a great deal of the uncertainty that they must have been feeling in recent days, because we now have the prospect of stability and certainty over the next few months as Southern Cross continues as a viable business with the support of its lenders and landlords.
The noble Lord moved on to suggest that it was the policies adopted by a previous Conservative Government in encouraging a diverse and plural market for care home provision that has brought us to this pass. I am slightly surprised to hear him say that because I think that one benefit of that policy has been a much greater array of choice open to individuals than there was before—and indeed a choice not just of location but of quality. To cite the problems of Southern Cross as a confounding factor to that is, I think, unfair. The problem with Southern Cross is not the quality of the provision of care but its business model.
I do not think that there has been any suggestion that the residents of Southern Cross homes have, as a generality, been badly looked after; rather, the issue is that the business model that the directors of Southern Cross adopted was unsustainable. We hope that the restructuring that is now apparently in prospect will address that and that the company can carry on giving the care that it has always done to its residents. Nevertheless, as we said last week when we had a Question in your Lordships' House on this topic, and in reply to the noble Lord’s comment about individuals being treated as a business commodity—if I may rephrase his question—that is of course a distasteful idea. To the extent that that has happened, we must acknowledge it. All I would say is that it has not affected the care that those residents have received. If it has disadvantaged anyone, it has been the shareholders.
The noble Lord suggested that because the Statement made it clear that we regard this as a commercial matter for the commercial organisations to solve, therefore this is not a health and social care issue. Again, that is a little unfair. The Government do not for one minute shirk their own responsibilities in this matter. We have been absolutely at the front in encouraging all parties to come together to reach this consensual agreement, to place the interests of the residents first and to put aside private interests and prejudices as much as possible. It is very encouraging that the statement issued yesterday did just that. There is consensus between the key parties that the interests of the residents are at the front of their minds. The restructuring is something that they are aiming to work through in as short a time as possible. I believe that that is cause for encouragement.
The noble Lord asked about the future and what might happen, not only in the case of Southern Cross but, I took him to mean, in the care sector generally. I am sure that as we go forward, if all goes well, we will see the kind of diverse market emerging in care home ownership that we have in domiciliary care where, as the noble Lord will be aware, there is a very diverse range of ownership by social enterprises, charities and private organisations of one kind or another that provide domiciliary care. There is scope to make the residential care home sector equally diverse over time. However, as we do that, we need to ensure that it is not just a diverse market but a stable one. I am the first to acknowledge that lessons will need to be learnt from this sorry episode over Southern Cross. If I have failed to answer any of the noble Lord’s questions, I shall certainly make up for that in writing.
Baroness Barker
My Lords, after 13 years of a Labour Government who were not in any way reluctant to diversify the residential care market, there is an even greater plurality of providers than there ever was before. One issue that has arisen out of this case is the capacity of the CQC to evaluate the stability and viability in the long term of a company that is owned by a private equity firm. That is a complex task that might challenge even the Financial Services Authority. Does the Minister agree that in order to reach the stable and viable market that he has suggested, there is a need to look at this in a much wider sense than just this case? Does he agree that the discussions that must inevitably follow the publication of the Dilnot inquiry in July should focus on the role of private equity-funded companies in the residential care market and, as he has also suggested, in the domiciliary care market?
Earl Howe
My noble friend raises an important issue. As she knows, care providers have to be able to demonstrate to the Care Quality Commission that they have the financial resources needed to continue to provide services of the required quality. We have embarked on a wide-ranging programme of reform for social care. We are currently considering the Law Commission’s recommendations for modernising social care law and, as my noble friend mentioned, the report of the Commission on Funding of Care and Support is imminent. There are many lessons that have to be learnt from the events of recent weeks. We want to reflect on them as part of our wider reform agenda for social care.
On private equity finance, I simply make my own observation to my noble friend: I do not think that private equity finance is at the root of the problems that we have been seeing but the business model, which is rather a different issue. It was the choices and decisions made by the management of Southern Cross that made the business fundamentally unsustainable. I do not see that as a reflection directly on private equity providers. We have been clear that we were going to take action to ensure that there was proper oversight of the market in social care. That is why the Health and Social Care Bill specifically allows us to extend to social care, if we chose to do so, the proper financial regulatory regime that we are putting in place for the NHS. However, I suggest that regulation is not the only solution; we need to approach this in a measured way, not least because there are complex negotiations under way. We need to look at social care reform as a whole, which is exactly what we have committed to doing.
Lord Campbell-Savours
My Lords, on the question of the business model that the Minister just referred to, does not this whole sorry saga reveal how completely out of touch with the world of reality were the main board and executive directors of Three Delta, who advised the Qatar Investment Authority to spend billions buying property in the healthcare sector on the back of inflated and totally unrealistic rent levels paid by companies such as Southern Cross? Were the Qataris made aware of the huge risk involved? What were the so-called great and the good like Sir Peter Middleton, Nick Land, Sir Christopher Howes and David Mellor—a former government Minister—doing when any estate agent in the commercial property sector could have told them that the commercial care property market was both overgeared and overpriced?
Finally, will Messrs Scott, Murphy, Sizer and Colvin, formerly directors of Southern Cross, be prosecuted for insider dealing in Southern Cross shares when they privately promoted the sale of shares in the months immediately prior to their profits warning and collapse in the share price? Is this whole affair not riddled with greed and stupidity?
Earl Howe
My Lords, I fear that I am unable to answer the noble Lord’s questions, for which I apologise, but I understand why he has asked them. If I have some concise answers that I can send him, I will certainly do so by way of a letter.
I think that the noble Lord and I agree that we are looking at a fundamentally unsound business model. As I understand it, it is a unique business model in the care home sector, where a deliberate decision was taken for the company not to own its own care homes but rather to pay the rent on them. The market clearly moved against it in more than one sense. The company’s problems are partly attributable to the occupancy levels of some of their care homes. Southern Cross occupancy levels have gone down, I understand, more than those of other care homes. It is not about fee levels; other providers of residential care are not in the same position as Southern Cross. I believe that Southern Cross’s problems relate to the rental agreements—the leases—that they entered into. It is those things that the restructuring aims to fix.
Lord Brooke of Alverthorpe
My Lords, I thank the noble Earl for his Statement. I listened carefully to what he said about the need for clarity on where responsibility lay. He also stated that there were lessons to be learnt. Will he say when the Government will conclude their review of these lessons, and when and how they will make them public? With the imminent privatisation of the Royal Mail, which has a lot of property worth quite a lot of money, will the Minister say whether some lessons learnt in this exercise might be useful in the context of ensuring that we do not run into similar problems there?
Earl Howe
My Lords, I would love to be able to comment on the Royal Mail, but noble Lords will be sorry to hear that I have not received the necessary briefing. On the timescale of our review, as I indicated to my noble friend Lady Barker, there are a number of elements to our review of social care policy. One is the Dilnot report, which we are expecting at the beginning of July. Another is the Law Commission report. However, a third is undoubtedly the lessons learnt from this episode. It is fair to say that it would be rash of me to give the noble Lord a date on which we will conclude all three strands of that review. It is likely that we will be able to be more definite later on this summer.
Lord Clinton-Davis
If it becomes clear within a reasonable time that Southern Cross and others are unable to put the business on a stable footing, what will then happen, primarily to the residents but also to the workforce? Can the Minister suggest what he has in mind as a fallback position?
Earl Howe
My Lords, the Department of Health is being very clear with the company that we expect it to maintain service continuity and quality of care while the restructuring process is going on. As I have said, our principal concern is for the safety and well-being of the residents of the care homes that might be affected. The CQC will pay particular attention to any care homes where there is a concern that quality may be at risk or inadequate. We are continuing to talk to ADASS, the LGA and the CQC to ensure that contingency plans are in place which will allow for the continuation of care under any eventuality. If the noble Lord will forgive me, I would rather not be drawn into hypotheses as to what might happen if the restructuring does not take place. We must encourage the company to believe that that is the prime and sole option before it. If there is ever a question of a change in the arrangements for providing residential care to any resident of a Southern Cross care home, or indeed any other, the rights of those residents remain absolutely clear in law. The duties of local authorities are absolutely clear in law. I believe that all residents in Southern Cross’s homes can rest assured that local authorities are well seized of those duties and processes.
Baroness Morgan of Drefelin
My Lords, the Minister has reassured the House that he does not see Southern Cross as the first of many providers to go into crisis. Can he share with the House the advice that he has had to enable him to give us those assurances that Southern Cross is not just the first of a number of providers to go into crisis?
Earl Howe
My Lords, I cannot issue a government guarantee on the continuing business health of every single care home provider in the country; that would be extremely rash. Of course, we know that over the years some providers have gone out of business. What we are seeing in the country at the moment is much more of a trend towards looking after people in their own homes rather than in residential settings. At the same time, the market is doing the opposite because there are more and more elderly people requiring care of some kind. This industry is not going to disappear overnight or, indeed, at all. Over the indefinite future we will require a residential care home industry, particularly as the number of elderly continues to increase. The key will be to ensure that the quality of provision is maintained. Competition will undoubtedly remain, but it is a telling indicator of the current state of the market that there is an overprovision at present of about 50,000 care home places nationally. That perhaps is a sign that local authorities are successfully meeting the wishes and needs of their service users in providing care in the settings which most people want; namely, their own homes.
Baroness Masham of Ilton
My Lords, what safeguards are being put into place so that this situation does not happen again in other care homes and possibly in hospitals?
Earl Howe
My Lords, I think I have already indicated that the Government are proactively engaged with all the key parties involved in this situation, not just Southern Cross but the LGA, ADASS, the CQC and others. The precise situation in which we find ourselves with Southern Cross is unlikely to arise again because my understanding is that the business model adopted by Southern Cross is unique. Nevertheless, every privately operated residential care home business will, no doubt, have its own level of business risk, whatever that may be—either slight or something rather less slight. However, the alternative that the noble Lord, Lord Beecham, seemed to desire was a return to the state provision of care homes. The noble Lord is shaking his head, and I am glad of that, because I think neither his party when in government, nor certainly ours, would wish that on the public. I think that all of us believe in choice for the individual, and this is what the current market provides. Nevertheless, there are risks.
The noble Baroness asked about hospitals. To the extent that NHS care is delivered in independent settings, a business risk is inevitably associated with that. However, we are clear in the Health and Social Care Bill that there needs to be a system whereby essential services are protected for the benefit of patients. When the Bill reaches us, we will no doubt debate those provisions.
Baroness Wall of New Barnet
I am sure that the noble Earl will be assured that my noble friend did not imply or say what the noble Earl thought he said. It is really important for us to focus on the business side of this issue and the economics of how it is run. The noble Earl is absolutely right to say that there is no complaint at all—in fact, all the carers of residents in those homes are distressed because they may be moved from somewhere that has taken care of their people. It is important, therefore, that none of us loses sight of the real issue—the care of these people, which has been good. Otherwise, the home would be in a very different state and, God forbid, we would be having a very different discussion if the issue was the care of the residents rather than the economics of running the home.
How deeply is the Care Quality Commission involved in this? My own trust has been talking to the CQC because, as the noble Earl will know, there are knock-on effects for hospitals all around the country when those homes are under threat, and on what might happen to elderly people who would normally be discharged from hospitals into those homes. We should all please remember—I am sure that the noble Earl is remembering—that the patients really matter in this, and we should ensure that we get them into safe places where they are looked after. The economics of this are very important, and I am not in any way dismissing that, but we need to measure that up against the care that has been provided for those people in Southern Cross homes, and, I hope, will continue to be provided. The care is valued. It is about the market that goes on out there, and any of us would be foolish to suggest that there is an alternative.
Earl Howe
I am grateful to the noble Baroness, and I am also clear about the position of the noble Lord, Lord Beecham. She is of course right. Our first concern should be for the safety and welfare of residents. That is why, as I said earlier, some time ago we asked the Care Quality Commission to engage in close discussion with Southern Cross when the news of the impending redundancies was made public. We did that precisely to ensure that standards would not be compromised. My understanding is that there are no concerns on that front. Southern Cross has, in that sense, behaved impeccably in ensuring that residents have not suffered, other than from the inevitable uncertainty that the publicity over this matter has generated. Going forward, the principles that the noble Baroness has articulated are absolutely right. However, she would agree with me—as I think she did—that questions need to be asked about the financial models adopted by care homes or, indeed, by any independent business providing public services.
Lord Campbell-Savours
Were we not told after Jon Manel of the BBC's exposure of what was going on in care homes in 2008 that lessons would be learnt and that there would be a review; and was not an inquiry set up by the department at the request of the then Minister, the noble Baroness, Lady Thornton? Were we not given assurances that that would not happen again? Is not the reality that these reviews and statements about lessons to be learnt all end up in the long grass, because this area of care is basically out of control?
Earl Howe
I do not agree with the noble Lord that this area of care is out of control. The situation that arose at the time to which the noble Lord refers was of quite a different nature from the one we are looking at at the moment. As I recall, it was about the quality of care delivered in particular care homes. We now have the CQC, which is responsible for policing quality of care across the NHS and social care. The previous Government put that arrangement in place. We are content with it. We think that the arrangements are robust. The CQC does very good work.
Of course, with the best will in the world, mistakes occur. One can easily point the finger at the CQC. As I said, in the case of Winterbourne View, that would be an easy but unfair thing to do. All that the CQC can be expected to do is to take a snapshot at any given moment of what it sees and hears. When I say that lessons need to be learnt, I reiterate to the noble Lord, Lord Campbell-Savours, that my counterpart in the Department for Business, Innovation and Skills is considering the lessons to be learnt about the business models that apply not just to the care home sector but generically where public services are provided.
NHS: Future Forum
Earl Howe Excerpts(12 years, 11 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall now repeat a Statement that has been made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:
“With permission, Mr Speaker, and further to the Written Ministerial Statement I laid in the House earlier today, I wish to make a statement on the Government’s response to the NHS Future Forum.
We established the independent Future Forum on 6 April, under the chairmanship of Professor Steve Field, to look again at our proposals on the modernisation of the NHS. Yesterday it published its report and recommendations. I would like to thank Professor Field and his 44 senior colleagues from across health and social care who have worked so hard these past eight weeks. I would also like to thank the more than 8,000 members of the public, health professionals, and representatives from over 250 stakeholder organisations who attended some 250 events across the country; also the tens of thousands who wrote to us with their views. I want also to thank the many officials in my department who supported this unprecedented engagement across the country.
I said two months ago that we would pause, listen, reflect and improve our plans. Our commitment to engage and improve the Bill has been genuine and has been rewarded with an independent, expert and immensely valuable report and recommendations from the NHS Future Forum. I can tell the House that we will ask the forum to continue its work, including looking at the implementation of proposals in areas including education and training and public health.
In his report, Professor Field set out clearly that the NHS must change if it is to respond to challenges and realise the opportunities of more preventative, personalised, integrated and effective care. It said that the principles of NHS modernisation were supported: to put patients at the heart of care; to focus on quality and outcomes for patients; and to give clinicians a central role in commissioning health services.
In the forum’s work, it set out to make proposals for improving the Bill, and its implementation; to provide reassurance and safeguards; and to recommend changes where needed. As Professor Field put it, the forum did this not to resist change, but to embrace it, guided by the values of the NHS and a relentless focus on the provision of high quality care and improved outcomes for patients.
We accept the NHS Future Forum’s core recommendations. We will make significant changes to implement those recommendations and, in some cases, offer further specific assurances which we know have been sought. There are many proposed changes and we will publish our more detailed response shortly. But I would now like to tell the House some of the main changes we will make.
The Bill will make clear that the Secretary of State will have a duty to promote a comprehensive health service, as in the 1946 Act, and be accountable for securing its provision and for the oversight of the national bodies charged with doing so. We will also place duties on the Secretary of State to maintain a system for professional education and training within the health service, and a duty to promote research.
One of the most vital areas of modernisation to get right is the commissioning of local services. For commissioning to be effective, it must draw upon a wide range of people when designing local services, including clinicians, patients and patient groups, carers and charities. We will amend the Bill so that the governing body of every clinical commissioning group will have at least two lay members—one focusing on public and patient involvement, the other overseeing key elements of governance, such as audit, remuneration and managing conflicts of interest.
While we should not centrally prescribe the make-up of the governing body, it will also need to include at least one registered nurse and one secondary care specialist doctor. To avoid any potential conflict of interest, neither should be employed by a local health provider. These governing bodies will meet in public and publish their minutes. The clinical commissioning groups will also need to publish details of all contracts they have with health service providers.
To support commissioning, the independent NHS commissioning board will host ‘clinical senates’, providing expert advice on the shape and fit of healthcare across a wider area of the country, and it will develop existing clinical networks, which will advise on how specific services, such as cancer, stroke or mental health, can be better designed to provide integrated, effective care. Building on this multi-professional involvement, clinical commissioning groups will have a duty to promote integrated health and social care around the needs of their users.
To encourage greater integration with social care and public health, the boundaries of clinical commissioning groups should not normally cross those of local authorities. If they do, clinical commissioning groups will need to demonstrate to the NHS commissioning board a clear rationale for doing so in terms of benefit to patients.
I have always said that I want there to be ‘no decision about me, without me’ for patients when it comes to their own care. The same goes for the design of local services, so we will further clarify the duties on the NHS commissioning board and clinical commissioning groups to involve patients, carers and the public. Commissioning groups will have to consult the public on their annual commissioning plans and involve them in any changes that would affect patient services.
One of the main ways that patients will influence the NHS will be through the exercise of informed choice. We will amend the Bill to strengthen and emphasise commissioners’ duty to promote patient choice. Choice of any qualified provider will be limited to those areas where there is a national or local tariff, ensuring that competition is based solely on quality. This tariff development, alongside a best-value approach to tendered services, will safeguard against cherry-picking.
Monitor’s core duty will be to protect and promote the interests of patients. We will remove its duty to promote competition as though that 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. It will have a power to tackle specific abuses and restrictions of competition that act against patients’ interests. Competition will be a means by which NHS commissioners are able to improve the quality of services for patients.
We will keep the existing competition rules introduced by the last Government—the Principles and Rules for Co-operation and Competition—and give them a firmer statutory underpinning. The Co-operation and Competition Panel, which oversees the rules, will transfer to Monitor and retain its distinct identity. And we will amend the Bill to make it illegal for the Secretary of State or regulator to encourage the growth of one type of provider over another. There must be a level playing field.
We will strengthen the role of health and well-being boards in local councils, making sure that they are involved throughout the commissioning process and that local health service plans are aligned with local health and well-being strategies.
In a number of areas, we will make the timetable for change more flexible to ensure that no one is forced to take on new responsibilities before they are ready, while enabling those who are ready to make faster progress.
If any of the remaining NHS trusts cannot meet foundation trust criteria by 2014, we will support them to achieve it subsequently. But all NHS trusts will be required to become foundation trusts as soon as clinically feasible, with an agreed deadline for each trust.
We will ensure a safe and robust transition for the education and training system. It is vital that change is introduced carefully and without creating instability, and we will take the time to get it right, as the Future Forum has recommended. During the transition, we will retain postgraduate deaneries and give them a clear home within the NHS family. On any qualified provider, its extension will be phased carefully to reflect and support the availability of choice for patients.
Strategic health authorities and primary care trusts will cease to exist in April 2013. By April 2013, all GP practices will be members of either a fully or partly authorised clinical commissioning group or one in shadow form. There will be no two-tier NHS. However, individual clinical commissioning groups will not be authorised to take over any part of the commissioning budget until they are ready to do so. GPs need not take managerial responsibility in a commissioning group if they do not want to. April 2013 will not be a ‘drop dead’ date for the new commissioners. Where a clinical commissioning group is not able to take on some or all aspects of commissioning, the local arms of the NHS commissioning board will commission on its behalf. Those groups keen to press on will not in any way be prevented from becoming fully authorised as soon as they are ready.
I also told the House on 4 April that we would secure proper scrutiny for any changes we made to the Bill. In order to do this, without trespassing on the House’s time to review the Bill as a whole at Report, we will ask the House to recommit the relevant parts of the Bill to a Public Bill Committee shortly.
Through the recommendations of the NHS Future Forum and our response we have demonstrated our willingness to listen and to improve our plans, to make big changes—not to abandon the principles of reform, which the Future Forum itself said were supported across the service, but to be clear that the NHS is too important and modernisation too vital for us not to be sure of getting the legislation right.
The service can adapt and improve as we modernise and change. But the legislation cannot be continuously changed. On the contrary, it must be an enduring structure and statement. So it must reflect our commitment to the NHS constitution and values. It must incorporate the safeguards and accountabilities which we require. It must protect and enhance patients’ rights and services, and it must be crystal clear about the duties and priorities which we will expect of all NHS bodies and in local government for the future.
Professor Field’s report says that it is time for the pause to end. Strengthened by the forum’s report and recommendations, we will now ask the House to re-engage with delivering the changes and the modernisation that the NHS needs. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Baroness Thornton
My Lords, I thank the Minister for repeating the Statement. I start by paying tribute to him for the way in which he has facilitated the debate about the future of the NHS thus far across the House. The all-Peer seminars benefited hugely from the fact that his office ensured the input from senior department officials. I have to add that his noble friend Lady Northover attended every one of those seminars. They have continued and, I believe, have ensured a greater understanding of the Bill from which it can only benefit. Notwithstanding Nick Clegg waving about his list of changes and claiming all, I think we might find out as we move on how influential the Minister has been in bringing about changes to the Bill. However,
“there is more joy in heaven when one sinner repents”.
About a year ago the Minister gently chided me, when he launched the health White Paper, by saying:
“I hope that when the noble Baroness digests this White Paper, she will come to view it rather more favourably than she has indicated”.—[Official Report, 12/7/10; col. 535.]
On this occasion, lest the noble Earl misunderstands me, I will say that I welcome the findings of the Future Forum, although I think that we would both agree that it cannot possibly have covered all the important issues in the NHS in eight weeks. In the detailed response that accompanies the Statement, the Government have gone further than the Future Forum in their proposed changes to the Bill; they are very significant. I particularly welcome issues such as the commitment to the NHS constitution. However, it begs the question of whether we might need a whole new Bill, or no Bill at all, if we all now agree that evolution is better than revolution.
I will mention the process. In this House we are more familiar with the parliamentary process whereby you consult, legislate and implement—not the other way around, which is what seems to have happened here. However, the Future Forum was a device that I think everyone understood. There was a pressing political need to get the coalition Government—Nick Clegg, David Cameron and in particular Andrew Lansley—off the hook. I will say this only once, despite severe temptation; the uniformly fulsome and enthusiastic welcome from Nick Clegg and David Cameron for the White Paper and the Bill ring rather hollow today. However unworthy the motivation, the end of the pause means one very good outcome for which we should all be grateful—probably none more so than patients and staff—namely, that the Prime Minister, Deputy Prime Minister and Secretary of State will cease their endless visits to hospitals to prove how much they love the NHS.
The chairman of the Future Forum said that opposition to the Bill stemmed from “genuine fear and anxiety”. He went on to say that NHS staff feared for their jobs, and feared that their NHS was about to be broken up and—their word—“privatised”. Thank goodness the Future Forum had the wisdom to listen to what so many people have been saying for a year to the Prime Minister and the Secretary of State: during the consultation period, after the Bill was published, with increasing volume during its passage in the Commons, and despite two very sensible Health Select Committee reports. Does the Minister think that the terrible mess that the Government have found themselves in could have been avoided, and have they learnt their lessons?
Since we are now promised significant changes, will the Minister confirm that there will be a new and proper impact assessment and a new set of Explanatory Notes, and that there will be consultation on the changes proposed through amendments before recommittal? Will there be a formal response to the well argued report of the Health Select Committee and its recommendations, not all of which agree with the Future Forum report? Most importantly in many ways, if there is to be a long period of enactment when the Bill is passed—and, as the Minister explained, no drop -dead moments—a very strong recommendation of the Future Forum report must be acted on; namely, the production of a timetabling and transition plan. This must be in place as soon as possible and must be robust. When does the Minister envisage that it will be published?
As the House would expect, since Part 3 is still in the Bill we will seek reassurances on competition, the composition of consortia, NICE, the minimum references to social care that are there, and, for example, the lack of references to mental health. We will pursue all these issues in due course. Will it be possible for the Minister to use his good offices to ask the Government to make time available for a longer debate in the House about these issues before we receive the Bill? When does the noble Earl think that we might start consideration of the Bill?
While the uncertainty continues, the NHS is going backwards. The Future Forum suggested—and we all know—that there is widespread demoralisation and even fear in the NHS. Good managers are being denigrated and made redundant, front-line staff are facing the sack and major projects and initiatives have been put on hold, as nobody knows what structures will be in place in the next few weeks, let alone the coming months. That is the result of the earlier rush, which can now be remedied by a robust transition plan.
It is to the credit of all the organisations—patient groups, carers, long-term conditions, medical and others—that have persisted in making their views known and whose views the Future Forum heard. During this period, my colleagues and I concentrated on asking people to look at and understand the Bill because we were confident that the more people understood this legislation, the less happy they would be about the threat to our NHS and to patients. We will be doing the same with the new Bill. We will look at it carefully in detail, and I will again be asking whether it meets the concerns that they and their organisations have raised. I say that because almost every single suggestion in the Future Forum report was put down as an amendment by my colleagues in the Commons in Standing Committee. I suggest to the Government that they might save a lot of time and trouble if they adopted all the other amendments that we put down that were not in the Future Forum. Honestly, what a way to conduct the reform of our most precious national asset. The lesson I take from the past year is this: it is very important not to suspend our critical faculties, even in the face of what seems a huge and, at the moment, welcome change. I am sure that this House will not do that. We have a very important job to do in making sense of this Bill and in ensuring that whatever the Government say today, their rhetoric is matched by the reality. We need to consider these suggested changes in this light. We have much work to do, and the sooner we start, the better.
Earl Howe
My Lords, I am grateful for the constructive and positive tone that the noble Baroness adopted in her response. I am grateful to her for her welcome of the Future Forum report, and I thank her for expressing appreciation for the seminars which my department is continuing to run. I can return the compliment in expressing my gratitude for the seminars that she has organised to inform Peers.
There is no disguising the fact that this is an extremely wide and detailed programme of modernisation. There is a great deal to absorb. It is important for noble Lords to understand as fully as possible what the proposals amount to before the Bill reaches your Lordships' House. She is right: they are significant changes. However, I would disagree with her about there being no need for a Bill. Since these changes are so extensive, it is appropriate that Parliament should have the opportunity of approving what is proposed for the National Health Service which, as the Statement said, is designed to be an enduring structure that successive Governments can back. Certainly, lessons have been learnt. I think that when we consulted on the White Paper last year, it was clear that there was general acceptance of the key principles that we set out in it, but when the Bill, which set out how we proposed to implement those principles, was published, the concerns bubbled to the surface, which was why we thought it right, and I still think it right, to have the listening exercise.
The noble Baroness asked me whether we would publish a new impact assessment and Explanatory Notes. We will be updating the impact assessment and Explanatory Notes to reflect the changes to the Bill. They will be published when the Bill is introduced in this House in accordance with normal protocol. She also asked me about timetabling. We want to ensure that the Bill is given sufficient scrutiny in both Houses. We hope that the stronger consensus for change that has been built as a result of the listening exercise will be reflected when both Houses consider timing issues and that the Bill will come to this House at the earliest appropriate moment. Currently, I cannot tell the noble Baroness when that will be. It is, of course, not for us to dictate to another place how it should manage its business. She also asked about the possibility of time being available for a health-related debate. The Leader of the House is sitting beside me, and I am sure he heard that request and that it will be discussed in the usual channels.
The noble Baroness rightly insisted on a robust transition plan, which I believe we have. She will have noticed from the Statement that we have adjusted quite significantly the pace at which these changes will be rolled out. I believe that those working in the health service will be reassured by that because in some quarters there was anxiety that we were going too fast for some to be sure that they would be ready in time.
The noble Baroness asked a number of questions, many of which will be the subject of a paper we plan to publish during the next week or so. The paper will set out more precisely how we plan to implement the changes proposed by the NHS Future Forum. I am not in a position to provide all the answers today but it is clear that, above all, the NHS needs certainty, which we can now give to those who work in it. However, I can say today that there is hardly anything in our proposals that does not represent a natural evolution from the policies and programmes pursued by the previous Government: that is, the development of the quality agenda initiated by the noble Lord, Lord Darzi; extending patient choice; developing the tariff; clinically led commissioning at primary care level, which is a natural extension of practice-based commissioning; completing the foundation trust programme; the continuation of the co-operation and competition panel established by the previous Government but now within the framework of a bespoke healthcare regulator; strengthening the patient voice by the evolution of links to HealthWatch; and augmenting the role of the CQC. None of that is wholly new: the difference is that for the first time we are setting all these things out in one coherent programme and not, as did the previous Government, in a piecemeal fashion.
I believe, and I hope, that we have the basis for broad consensus. We will see when the Bill reaches this House whether that belief is borne out. Not for a minute would I wish the noble Baroness to suspend her critical faculties, or for any other noble Lord to do that. I look forward to those debates in due course.
Lord Alderdice
My Lords, I am grateful to my noble friend for repeating this important and welcome Statement. It reaffirms the coalition’s commitment to a reformed NHS, which is patient-centred, clinician-led and outcome-focused. Does he accept that the concerns, which are fully addressed in this Statement, were shared not alone on these Benches but by many Conservative colleagues, as well as patients, professionals and other stakeholders, and others in your Lordships’ House, as exemplified in the national debate instituted by the Government? Will he now confirm that, despite the anxieties that there have been, the duties and responsibilities of the Secretary of State will be reaffirmed in the Bill in the language used when our beloved NHS was established? Will he confirm that there will now be a level playing field and that private providers will not be advantaged against public providers, as was the case under the previous Labour Government? Will he further confirm that Monitor will be redesigned to be more than a mere economic utility regulator but will facilitate co-operation and integration, as well as competition on quality rather than on price?
Earl Howe
I am most grateful to my noble friend. He is right that the concerns that arose in relation to the Bill stemmed from many quarters—certainly from my own Benches and his but also from the wider public. I think we took on board those concerns almost as soon as the Bill was published. They were reflected in a large volume of correspondence, a high proportion of which I dealt with. I was keenly aware of the issues occupying people’s minds. I believe and hope that in the Future Forum’s report, and in our acceptance of that report, we have the basis for allaying most of those concerns.
My noble friend asked three questions. The first was around the duties of the Secretary of State. The Statement made clear that, as now, the Secretary of State will remain responsible for promoting a comprehensive health service. It has never been our intention to do anything else. Indeed, the Bill did not specify anything else. That will be underpinned by the new duties that the Bill already places on the Secretary of State around promoting quality improvement and reducing inequalities. We shall be setting out other duties on the Secretary of State to strengthen his accountability.
On private providers, the noble Lord is right. We are clear that private providers should not be advantaged over the NHS. Indeed, the amendments that we will make to the Bill will put that concern to rest, I hope, once and for all.
Monitor will have its duties rephrased. As the Statement also made clear, the duty to promote competition, which is now in the Bill, will be replaced by a different set of duties around patients, integration and the promotion of quality. There will be quite a different flavour to Monitor's duties.
Lord Walton of Detchant
My Lords, I, too, congratulate the noble Earl, who is so widely respected on all sides the House, on the statesmanlike way in which he and the noble Baroness, Lady Northover, have led discussions on the Bill in the past few weeks. I pay tribute also to the contribution of the Opposition. In all, we have had something like 25 seminars looking at the detail of the Bill. The developments that have been discussed and which Steve Field and his colleagues have put forward look as though they will produce major amendments to the Bill, which will be welcome on all sides of the House.
I have three specific questions. The one of greatest importance relates not only to the local clinical commissioning groups, but the clinical senates. We need to know a good deal more about them. Will they take on board some of the people who were previously employed by regional strategic authorities who are involved in the specialist commissioning of highly specialised services? That needs to be looked at carefully because of the unevenness in standards of specialised care throughout the country.
In relation to those clinical senates, will the role of universities be taken on board; not only those with medical schools but the ones that have responsibility for training other healthcare professionals? They should be thought of as having some kind of formal role in relation to those senates. I also suggest to the noble Earl in relation to clinical networks that, with the development of genomic medicine, rare diseases are becoming so important that we may need to have a clinical network for them because of the very expensive and rare orphan drugs that are being rapidly introduced for the treatment of these conditions.
Finally, the Bill as originally constructed did not deal in any depth with research or clinical education and training. The developments in this particular report on those two fields are very welcome. We look forward to having further details.
Earl Howe
I am most grateful to the noble Lord, Lord Walton, as I always am, particularly for his welcome for the idea of clinical senates. They will provide the kind of multiprofessional advice on local commissioning plans that everybody has been calling for. The senates will be hosted by the NHS Commissioning Board. The detail is still to be worked out, but it is likely that they will be located regionally. They will be in prime position to do the very thing that the noble Lord seeks: to provide expert advice on good commissioning, not just for the treatment of everyday conditions, but for specialised services, which I know is of particular concern to noble Lords.
The noble Lord suggested that there should be a role for the universities, and that is a constructive idea that I will take away. As regards clinical networks, we are certainly of the view that they have proved their worth over the past few years and we are keen to see more of them created. I hope that that will be facilitated by the structures we are putting in place.
Lord Darzi of Denham
My Lords, I welcome the Statement from the noble Earl and also congratulate him on his leadership in getting us back on track. One of the commonest sayings about a good clinician, whether a doctor or nurse, is that they listen to a patient but also seek the opinion of others if dealing with a complicated case. In this instance, the noble Earl has done both.
I am very reassured that the language has changed. As the noble Earl said, quality will remain the organising principle of the NHS. I know and he knows that quality is what unites those who deliver healthcare. Quality is what the public and patients expect. I am also reassured by the concept of using competition when necessary. I strongly support competition, have always done so and work in an organisation that competes not only in the NHS in England but also globally. I acknowledge, too, that integration should also be used as a tool where possible. The listening exercise is not at the end. It should start from now. Where will the engagement exercise lead?
Finally, and more importantly, there is the management and leadership now required to drive these important sets of reforms at a time of austerity. We have heard a lot about management. It is an easy political target but the NHS needs better management rather than less. I am pleased to see that the Government are committing to retaining the best managers and to develop managerial skills. However, this commitment is distinctly lacking in specifics. More detail and action are required before I could confidently say that the importance of management has been grasped. I say this within the context of the age of austerity. We need leadership and management to drive this set of reforms. I strongly agree that we need reforms and they need to be continual reforms rather than destructive ones. On that note, I look forward to Second Reading.
Earl Howe
My Lords, I am extremely grateful to the noble Lord, Lord Darzi, and would reassure him—I am sure that I do not need to—that our ambition is to carry through the agenda that he began when he was Minister of raising the quality of care throughout the NHS. He will see that we have defined quality in the Bill. It is the one part of the Bill that I do not think anybody has quibbled with. We have used his definition and I hope that no amendments will be tabled to change that.
The noble Lord said “competition when necessary” and I thoroughly agree with that. What we do not want to see is competition as an end in itself. It is never that. It can be there only to support better care of patients and buttress patient choice. If we believe in patient choice then we must inevitably believe in an element of competition. The key is making that competition work for patients properly, as we all would wish. Over the past few years we have seen how it can do that.
The listening exercise will not come to an end. We have asked the Future Forum to remain in being and to continue its work in a number of other areas. I am pleased to say that it has agreed to do so. Education and training will be one such area, public health another.
Finally, the noble Lord is absolutely right to direct our attention to the importance of good management. I think I read the other day in an article that he published that, if anything, the NHS has been over-administered and under-managed. I would agree with that analysis. We need good quality managers. I have never been one to denigrate managers. They are of the highest importance if we are to have a first-rate NHS. I hope to have further news on that front before long.
Lord Blackwell
My Lords, I add my congratulations to my noble friend on his Statement which has certainly reassured me that the principles in the White Paper have been maintained. Can he elaborate a little more on the development of competition and choice to which he referred? The Statement says that Monitor’s core duty will be to protect and promote the interests of patients, not to promote competition as if it were an end in itself. Can I take it from what my noble friend has said that the Government continue to believe that competition and choice are key drivers of improving the interests of patients and quality in the health service?
Following on from that, on the Government’s commitment to extending patients’ choice of any qualified provider, which is reasserted in the Statement, how will the phasing of the introduction or further expansion of alternative providers evolve in a way that will give those alternative providers the confidence to make the investments necessary so that they can play their full part in providing quality services under the NHS?
Earl Howe
I thank my noble friend for raising this important topic. I cannot provide him with the kind of detailed replies that he seeks. Those should emerge over the next few days as we work through our response fully. But I can tell him that we will amend the Bill to strengthen and emphasise the commissioner’s duty to promote choice in line with the right in the NHS constitution for patients to make choices about their NHS care and to receive information to support those choices. We believe in patients’ choice and in competition, as I have already indicated, where that is appropriate. As recommended by the Future Forum, the Secretary of State’s mandate to the board will set clear expectations about offering patients choice.
We will maintain our commitment to extending patients’ choice of any qualified provider, but we will do this in a much more phased way. We will delay starting until April 2012, and the choice of any qualified provider will be limited to services covered by national or local tariff pricing to ensure that competition, where it occurs, is based on quality. We will focus on the services where patients say they want more choice—for example, starting with selected community services—rather than seeking blanket coverage. Of course, with some services such as A&E and critical care, any qualified provider will never be practicable or in patients’ interests.
I have already referred to the changes in the duties of Monitor, in its competition functions. The NHS Commissioning Board, in consultation with Monitor, will set out guidance on how choice and competition should be applied to particular services, guided by the mandate set by Ministers. That includes guidance on how services should be bundled or integrated.
Lord Hunt of Kings Heath
My Lords, I declare an interest as chair of the Heart of England NHS foundation trust and as a consultant trainer in the NHS. Like other noble Lords, I am very grateful to the noble Earl for his stewardship of this matter in your Lordships' House. It is noticeable that the Government are continuing with their policy of placing £60 billion in the hands of commissioning consortia, which would be largely led by general practitioners. What I thought was missing from both the listening exercise and the Government’s general approach was any indication of how the standards in general practice are to be improved. A huge amount of power is to be given to general practice, yet we know that the general quality of GPs is very variable. In some parts of the country, it is very difficult to get access to GPs out of nine to five hours; in some parts, GPs have shown themselves completely unable to engage in demand management. Will these commissioning consortia be able to get to grips with poor quality GP performance?
Earl Howe
The noble Lord, Lord Hunt, raises an important issue. I agree with him that the quality of general practice has been extremely variable. We saw a report the other day, published by one of the think tanks, which said exactly that. We have some very good GPs, but we have some who, frankly, are less than the standard that we would want and expect in primary care.
We are doing a lot of work to roll out leadership programmes for general practitioners. The National Leadership Council is working with GPs to agree the skills required for commissioning and will assist GPs in developing these skills as appropriate. The NHS institute is also doing some good work in this area and we will shortly be able to provide a bit more detail on how we can develop leadership, regionally and nationwide.
The noble Lord’s question runs rather wider than that, being about the quality of care delivered by GPs. In rolling out the outcomes framework and the commissioning outcomes framework, and the transparency that goes with that, it will become rapidly apparent which GPs require more support. I have no doubt that the consortia or, as we are now calling them, clinical commissioning groups will see it as being in their interests to ensure that the poorer performers are brought up to the standard of the best.
Baroness Hollins
My Lords, I commend the Government on the depth and breadth of the consultation that has taken place. I particularly welcome the new focus for Monitor on integration and the proposed coterminosity of the clinical commissioning groups with local authorities, which is particularly important in the case of commissioning integrated mental health and learning disability services. Does the Minister agree that the changes now proposed can be expected to meet better the needs of people with serious mental illness, learning disabilities and other complex needs than the Bill as originally published, and that the focus on health inequalities will allow the Secretary of State to monitor reductions in them for those vulnerable groups?
Earl Howe
I am very glad that the noble Baroness, with her considerable expertise, raised the important subject of serious mental illness and the needs of those who are particularly disadvantaged. She is right: we now have a much better way forward in commissioning services for those particularly difficult-to-care-for groups, if I may put it that way. How services will be commissioned for those with special needs and serious mental illness will, I think, emerge as we go forward. However, in my own mind I can see that local authorities and consortia may well decide to commission services jointly. There will be the means to do that through pooled budgets and shared arrangements. We will ensure that the quality premium, the details of which are still being worked through, genuinely rewards the ironing-out of health inequalities. We are absolutely clear that one of our goals is to address health inequalities at every level, and that includes in mental health.