Health and Social Care Bill

Earl Howe Excerpts

Tuesday 11th October 2011 Lords Chamber

Moved By

[Earl Howe]

That the Bill be read a second time.

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

My Lords, this is a Bill of profound importance for the quality and delivery of health and care in England, for patients and for all those who care for them. As such it has been, quite rightly, the subject of intense scrutiny, not only in another place, but also more widely. Indeed, the intensity of the spotlight directed at its content over the last few months is borne out by the number of your Lordships who wish to speak today and tomorrow. I look forward to the debate ahead of us.

In approaching this Bill, I believe it is instructive to look backwards to its roots as well as forward to what it seeks to achieve. In opposition, the two coalition parties asked themselves the same simple question: “How can we make the NHS better?”. In asking that question we were clear about several things. We were clear that the founding principles of the NHS—that it should be a comprehensive service, free at the point of use, regardless of ability to pay, and funded from general taxation—should remain sacrosanct. We were also clear that we should reject any system that discriminated between rich and poor. The NHS should aspire to the highest standards of service for all our citizens, but in seeking ways to make the health service better, it was necessary to identify the challenges that it faces. What are they?

The first, and most obvious, is rising demand for healthcare from a growing and ageing population and the increase in long-term conditions. The second is the rising expectations of patients about what should be on offer to them from a health service in the 21st century, including new drugs and technologies. The third is the financial challenge—the inexorably rising costs of providing services against an increasingly constrained budget.

Two key principles emerge from this analysis: the need for maximum efficiency in the way the health budget is spent; and the need to make the service patient-centred. For many years, politicians have spoken of the NHS as a patient-centred service, but how can a service be truly patient-centred if decisions about the treatments and pathways of care that are available to patients are taken at several removes from those who know best what the needs of patients are—namely, the patients themselves and the healthcare professionals who look after them?

How can a health service be patient-centred if the measures of its performance overlook what for patients matters most, namely the outcomes that it achieves and the quality of care that patients receive? What of NHS efficiency, when so much of its budget is consumed by layers of administration, when its productivity over the last few years has fallen, and when patients experience poor handovers between different parts of the NHS and between the NHS and social care?

There is a fundamental problem, too, in NHS accountability. The original National Health Service Act 1946 provided for a comprehensive health service, but it did so by employing a simple legal precept—that responsibility for everything that happened in the NHS should lie with the Secretary of State. That may have held good in the 1940s, when the challenges facing the NHS were largely the management of acute short-term conditions, but it does not hold good now. The Secretary of State has for decades delegated his functions for the commissioning and provision of healthcare services to other bodies. The reason for that is simple: managing the range of healthcare needs for our diverse population is now so complex that no one would argue that it is a task best carried out from Whitehall. This has resulted in a vacuum in NHS accountability, with no measures or mechanisms whereby PCTs and trusts can be held locally to account. We in Parliament can only turn to the Secretary of State: he in turn can only give one answer—PCTs and trusts are autonomous organisations, their decisions are taken independently, in accordance with local priorities, and it is not appropriate for these decisions to be subject to interference from the centre. So the fact that the Secretary of State is responsible for making sure that there is an NHS available to all clashes with the fiction—for that is what it is—that he is somehow responsible for all clinical decision-making in the NHS. This results in a poor deal for the person at the centre of things—the patient.

During the last few years, it became clear to politicians of all persuasions that there was another nettle that the NHS had to grasp: the need to improve quality. We know that, measured against accepted benchmarks, the outcomes experienced in the NHS sometimes fail to match up to those achieved in comparable countries. The OECD has reported that if the NHS were to perform as well as the best performing health systems, we could increase life expectancy in the UK by three years.

Towards the end of the previous Government, the noble Lord, Lord Darzi, sounded a clarion call to managers and clinicians around the quality imperative. The focus of the noble Lord’s work—to define what quality means and to drive forward that agenda by fostering innovation, transparency, and choice, by strengthening regulation and by encapsulating the rights and legitimate expectations of patients and staff in an NHS constitution—was unarguably right. But his time in office was short. There was much more that still needed doing.

Our plans for the NHS therefore focused on three main themes: accountability, efficiency and quality—keeping at the centre the most important theme of all, the interests of patients. Modernisation of the health service, we were clear, had to involve a fundamental shift in the balance of power, away from politicians and on to patients themselves through increased choice and information, and on to doctors and health professionals, giving them real budgets and empowering them to use those resources in a cost-effective way to drive up quality. That shift would have two advantages: it would serve to depoliticise the NHS; and it would promote efficiency and quality by making those who take clinical decisions on behalf of their patients responsible for the financial consequences of those decisions. Both GP fundholding in the 1990s and, more recently, practice-based commissioning showed that empowering clinicians directly could improve the quality of care that patients experience. The potential is truly enormous: allowing doctors, nurses, hospital specialists, social services and other professionals the freedom to design care pathways that are integrated, and to commission them on behalf of their patients, will, we firmly believe, transform the quality of care and treatment that the service delivers.

At the same time, the clinicians on whom this greater autonomy is bestowed should be held accountable as never before—not only for their use of public money but also for the outcomes they achieve for patients. Unlike the largely illusory accountability of the present system, we were clear that doctors should be held to account in a transparent way by the patients and the communities whom they serve. Success and failure have to be measured in better and more meaningful ways, by reference to outcomes, not processes. For their part, elected politicians should be held accountable in a dual fashion: first, to Parliament, for the performance of the health service as a whole, defined principally in terms of outcomes; and, in parallel, for directly overseeing and delivering the public health agenda so critical for the long-term health of the nation—an agenda which, too often, has tended to assume a lower priority for government at times when the NHS budget has come under strain.

The fruits of this deliberation were laid out in various Conservative and Liberal Democrat publications from 2006 onwards, including a White Paper, in our manifestos at the last election, the coalition agreement and, finally, a government White Paper from which this Bill directly stems. The democratic mandate for our proposals is absolutely clear.

This brings me to the amendment tabled by the noble Lord, Lord Rea. It is important that we remember what the Labour Party manifesto said on health at the last election:

“We will continue to press ahead with bold NHS reforms. All hospitals will become Foundation Trusts … Failing hospitals will have their management replaced. We will support an active role for the independent sector working alongside the NHS in the provision of care … Patient power will be increased”.

Even Labour accepted at the last election that doing nothing is not an option for the NHS. Many of the principles in this Bill were ones that they wholeheartedly embraced. But the nature of the change must be different. Instead of putting in tiers of management and controlling everything from the centre, we are removing bureaucratic structures so that the front line is empowered as never before to deliver better patient care. This Bill achieves that by means of a better framework which allows power to be devolved from the centre so that innovation is unleashed—

[Lord Clinton-Davis]

Why was none of this mentioned in the Conservative manifesto at the election?

[Earl Howe]

I commend the manifesto to the noble Lord because our plans were very clearly set out in it. It allows power to be devolved from the centre so that innovation is unleashed from the bottom up, supported by clear lines of accountability. It is, in fact, the inverse of a topdown reorganisation.

The Bill is long and complex because for the first time in statute it seeks to define the functions and duties of every element in the chain of accountability within a reformed healthcare system, and to join up those functions and duties into a coherent whole. Whereas in the past it has been possible for a Government to change the NHS simply by direction, in the future it will be impossible to do so without recourse to Parliament. Much that was defined in regulations and directions is now to be covered clearly in statute. Daunting as it may seem to some of your Lordships, we were clear that this was an ambition whose realisation was well worth the effort. At the same time as introducing change, it is a Bill which seeks to build on much of the existing and therefore familiar features of the NHS architecture put in place by the previous Administration. Noble lords will know of the Nicholson challenge: to deliver up to £20 billion of savings in the NHS over the next four years, all of which money will be ploughed back into patient care. Savings on this scale are not possible to achieve without system-wide change, and the measures in this Bill are inseparable from that process.

Let me now focus on its content. This Bill is about several things. It is about liberating the NHS and those within it to enable them to work better and more accountably in the interests of patients. It is about streamlining the architecture of the NHS to make it more efficient and transparent. And it is about creating a public health service that is configured to tackle the major challenges to the nation’s health and well-being that face us over the years ahead. The key to achieving this, we believe, is a strengthened and more logical spread of accountabilities. Put simply, the Bill provides that the Secretary of State should remain accountable to Parliament, as he has been since 1948, for promoting a comprehensive health service and for the funds voted each year by Parliament for the health budget.

Let me be clear—the Bill does not undermine the Secretary of State’s ultimate accountability for the NHS or the responsibility that he carries for a comprehensive service. I am fully aware of concerns raised on this point, and I respectfully refer your Lordships to the response we published yesterday to the Lords Select Committee on the Constitution on this very matter. We are unequivocally clear that the Bill safeguards the Secretary of State’s accountability. However, we are willing to listen to and consider the concerns that have been raised and make any necessary amendment to put the matter beyond doubt.

The duty to commission and provide healthcare day to day, which hitherto the Secretary of State has delegated to the NHS, will instead be conferred on NHS bodies directly. Clause 6 proposes that below the Secretary of State there should be a new body, the NHS Commissioning Board, directly responsible for holding and distributing the NHS commissioning budget and for assuming many of the functions now performed by strategic health authorities and patient care trusts, which will be abolished. But the board will not operate without political oversight. The Secretary of State will issue a mandate detailing the outcomes for which the board will be held accountable. The mandate will be subject to public consultation and laid before Parliament, creating a clear line of political accountability. Unlike the current operating framework, the Bill gives the Secretary of State an explicit duty to report on how the board has performed against the mandate. But, as an independent body, the board will be a buffer against the short-term, politically motivated whims of government.

Clause 7 creates clinical commissioning groups as statutory bodies authorised by the board which will commission local healthcare services. CCGs, consisting of groups of GP practices and with doctors in control, will be stewards of the bulk of the NHS commissioning budget and will be held transparently and rigorously to account for the use of those funds against a set of quality and outcome measures. The defining characteristic of CCGs as compared to PCTs will be their clinical ethos. It is doctors and their fellow clinicians, not managers, who know the needs of patients best. By making clinicians financially responsible for the clinical decisions that they take, we will not only drive efficiency but also achieve a step change towards a genuinely patient-centred service.

Real accountability to the patient will be achieved in a number of ways. It will be achieved by empowering patients with information and involving them in decisions around their care. But it will also be achieved by empowering local groups of patient representatives to be involved in how services are commissioned, provided and scrutinised. Clauses 178 to 186 propose the creation of HealthWatch. Local HealthWatch will be based on the existing local involvement networks, or LINks, but with added clout. Funded through local authorities, they will act as the independent eyes, ears and voice of patients and service users in a local area. At the national level, a new body, HealthWatch England, will be established to support local HealthWatch and to act as the national care watchdog wherever quality of care is called into serious question. By making HealthWatch England a committee of the Care Quality Commission, as is proposed in the Bill, we will enable the voice of patients and the public to be heard at the very heart of health and social care regulation.

But liberating the NHS goes further. It means enabling the governors of foundation trusts, who represent the public, patients and staff, to exercise more meaningful influence over strategic decisions made by their trust boards. It means freeing foundation trusts from the private income cap; a constraint which they repeatedly tell us is arbitrary and unnecessary, and whose removal will enable them—without jeopardising their NHS focus—to generate income which can be deployed for the benefit of NHS patients. Clauses 148 to 177 cover these proposals. Noble lords will recall the debate we had on this subject two years ago.

In developing healthcare provision, the previous Government began to champion the cause of patient choice as a driver of quality, and in doing so moved us in the direction of a more plural service with the introduction of independent sector treatment centres, social enterprises and charities operating alongside mainstream NHS providers. We have long agreed that this was the right direction of travel. Competition and choice will no doubt prove a major theme in some of our later debates on the Bill, but let me say for now that we are absolutely clear from past evidence that where competition can operate to improve the service on offer to patients, or to address a need that the NHS fails to meet, we should let the system facilitate it. However, competition only has a place when it is clearly and unequivocally in the interests of patients.

This is where we were critical of one aspect of the previous Government’s policies. The playing field was levelled against the NHS. ISTCs were given guarantees and price subsidies that were not available to public sector providers. That is why we want to ensure that all providers of healthcare operate to the same clear rules. This, in turn, necessitates an independent body capable of holding the ring. That body, we propose, should be Monitor in its new guise as a sector-specific regulator for the health service, with functions and duties framed to enable it to bear down on unfair competition, conflicts of interest and unsustainable pricing. It will operate in accordance with the principles and rules for co-operation and competition, which were introduced by the previous Administration.

For a long time now, the idea of a local democratic mandate for healthcare provision has been a pipedream of many. For the first time, this Bill imposes duties on local authorities that will see the creation of health and well-being boards, bodies charged with assessing and addressing the health and social care needs of a local area. This represents a huge opportunity for improving the commissioning of health and social care. Health and well-being boards will consist of, as a minimum, representatives from clinical commissioning groups, social care, public health and patient groups including local healthwatch, plus elected representatives. They will provide a forum for joined-up decision-making on service configuration and local priorities. Joint health and well-being strategies will not simply inform clinical commissioning in a local area, CCGs will also be required to have regard to them when preparing their commissioning plans, with safeguards in place should they fail to do so. The democratic underpinning this gives to service provision is a major and exciting change.

At the same time, the Government’s clear focus on public health will usher in a new public health architecture. At a local level, for the first time since 1974, local authorities will become the hubs for commissioning and delivering public health services, led by directors of public health and supported by a ring-fenced budget. At the centre, under the direct auspices of the Secretary of State, a new executive agency, Public Health England, will bring together health protection functions currently distributed between a number of different organisations. In driving forward public health strategies at a national level, it will inform and support local authorities in their work, thus ensuring a joined-up system. We believe it is of vital importance that public health should receive the emphasis due to it, if we are to tackle the long-term challenges to the nation’s health and well-being that currently face us.

Alongside this, we will modernise and streamline the Department of Health’s arm’s-length bodies. The Bill abolishes bodies that are no longer required, thus releasing more money to the front line. At the same time, NICE and the NHS Information Centre will have their future secured by being established in primary legislation for the first time.

The changes we have set out will be introduced in measured stages over a period of years, and our plans for transition will ensure that the health service is well prepared; for example, no clinical commissioning group will be authorised to take on any part of the commissioning budget until it is ready and willing to so; Monitor will continue to have transitional intervention powers over all foundation trusts until 2016 to maintain high standards of governance during the transition; and to avoid instability, there will be a careful transition process on education and training.

In framing the provisions of this Bill, Ministers have talked and listened to a great many people; not only before the election but since, with a public engagement on our White Paper in 2010 and, in the spring of this year, the very productive two-month listening exercise. Throughout this time we have encountered consistent and widespread agreement for the key principles underpinning our policies; in particular, since the listening exercise, a shared view among professionals about the way those principles should be put into practice. At the same time, reform of the NHS is seen not just as an option but as absolutely essential for its future.

In addition to this consultation and engagement, this Bill has also undergone significant scrutiny in the other place. The Bill’s first Committee stage lasted 28 sittings—longer than any Bill in nine years. Following the Future Forum’s report, the Bill was recommitted for a further 12 sittings. The Bill was therefore scrutinised over more sittings in the other place—40 in total—than any other Public Bill in the whole period from 1997 to 2010. I direct that point in particular to the noble Lord, Lord Rea.

I conclude with a brief word about the Motion tabled by the noble Lord, Lord Owen, which I shall speak to in detail when I wind up the debate. Suffice it to say for now that while I fully recognise the strength of his concerns, I regard the proposal he has made as posing an unacceptable risk to the passage of this Bill and hence to the Government’s programme for the health service. He is proposing an unusual process. The only basis on which such a process might be workable would be with the prior reassurance, for the Government, of a strict time limit on the Bill’s Committee stage as a whole. Regrettably, I was unable to reach agreement with the noble Lord that this was a reasonable basis on which to proceed. I therefore do not think that his Motion should be supported.

The case for change is clear and compelling, and I am personally in no doubt that the changes set out in this Bill are right for our NHS and—more importantly—right for patients. I hope very much that your Lordships, in reserving your powers to scrutinise the detail of the Bill with your usual care, will wish to endorse the ideas and the vision that it presents. This is a Bill with but a single purpose: to deliver, for the long term, a sustainable NHS, true to its founding principles. It is on that basis that I am proud to commend the Bill to the House, and I beg to move.

Amendment to the Motion

Moved by

Health: Non-communicable Diseases

Earl Howe Excerpts

Thursday 6th October 2011 Lords Chamber

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

My Lords, I thank the noble Lord, Lord Crisp, for introducing a debate on an issue of such global importance. Indeed, I am grateful to all noble Lords who have spoken so powerfully and I welcome in particular the noble Lord, Lord Collins of Highbury, to his Front-Bench responsibilities. Non-communicable diseases, or NCDs, kill millions of people across the world every year. Indeed, they are responsible for three in five of all deaths and bring illness and disability to countless more. People with NCDs are high users of health services worldwide. In England alone, around 70p in every £1 spent on health and care is spent caring for people with a long-term condition, the majority of which are as a consequence of the so-called four big killers: cancer, cardiovascular disease, chronic lung diseases and diabetes.

I listened with huge interest to the noble Baroness, Lady Hayman, and I am so glad that she gave way to temptation by joining our debate today. To pick up on what she said, non-communicable and communicable diseases combined can both devastate the lives of individuals and hinder the growth of whole countries. This is particularly the case in developing nations, which face the double burden of communicable and non-communicable diseases. The true prevalence of non-communicable diseases is often hidden in a number of countries, simply due to the lack of data. I shall come on to that in a moment.

The noble Baroness, Lady Masham, is right: the scale of the challenge is huge but it is not insurmountable. We start from a position of collective international commitment to act. The UK, along with other Commonwealth countries, has called for global action. The recent UN high-level meeting about NCDs, which a number of noble Lords referred to, raised awareness of the issue and culminated in a unanimous declaration by all member states stating their commitment to taking concerted action to prevent, manage and treat NCDs. There is a helpful practical focus on tackling the common risk factors and the WHO has introduced the idea of “best buys” that can be introduced by all countries at little cost.

My right honourable friend the Secretary of State for Health participated fully in that meeting. I take note of the disappointment expressed by the noble Lord, Lord May, but at the same time the meeting was an important first step and a sound basis for sustained action in the years and decades to come.

In reply to the noble Baroness, Lady Murphy, I say that mental health is referred to in the political declaration and the UK supported this inclusion, but we wanted to ensure support for the primary focus to be on tackling the common underlying risk factors and wider social and environmental determinants for the four big killers. We do not in the least underestimate the burden of mental ill health. I hope that the mental health strategy is evidence of that, but we believe that, once we see benefits from this initial focus, there will be positive impacts on health and well-being far beyond these four disease groups, including mental health. The linkages in risk factors were highlighted in the UN declaration.

Global health has long been a priority for the UK Government. I can tell the noble Baronesses, Lady Masham and Lady Hayman, that we are trying, working through both the Department of Health and the Department for International Development, to help developing countries to build health systems that can meet today’s challenges, including the problem of NCDs but also all causes of ill health, especially for the poorest in society.

The UK also supports multilateral organisations. We are the third largest donor to the World Health Organization and we support initiatives such as the Global Alliance for Vaccines and Immunisations, GAVI, to which the UK is the largest contributor. Indeed, GAVI has immunised over 250 million children against hepatitis B and saved over 3 million lives as a result. I was interested in the work of the noble Baroness, Lady Hayman, in promoting vaccine uptake in the third world.

Whatever we do, though, I fear that we need to face one unpalatable fact: we will not be able to eradicate NCDs, unlike smallpox. There is no obesity inoculation. Prevention alone, important though it is, cannot be the sole answer either at home or abroad. Globally, we continue to work to strengthen health systems so that they can provide early, cost-effective care to all who need it, including the poor and vulnerable.

I mentioned that we are strengthening the capacity of countries to deliver improved health services. This is a key area of DfID’s work. So, too, is the health partnership scheme, which facilitates links between UK health institutions and professionals from developing countries to improve health outcomes by sharing skills and capacity building. We are also supporting the medical training initiative, designed for doctors from developing countries to benefit from training in the NHS and foster exchange programmes. I pick up the point made by the noble Baroness, Lady Hayman, that we can learn from others overseas.

I can tell the noble Lord, Lord Crisp, that we also support research on global health. For example, DfID has recently launched PRIME, which stands for “programme for improving mental health care”. That is a new multinational research programme that will focus on the development, acceptability and impact of mental health care packages for priority mental disorders. We have also supported research on tobacco, and I can let the noble Lord have further details on those programmes if he is interested.

The noble Lord asked me about access to essential medicines. This is a priority for us. We are supporting countries to develop domestic health financing mechanisms to ensure sustainable and long-term funding for cost-effective interventions to tackle NCDs, not just drugs but diagnostics and vaccines as well.

Health services have a key part to play in reducing health inequalities in terms of access and quality and working with others to improve health outcomes. We need health systems not simply to treat disease but to be reoriented towards preventative action. As ever, as the noble Lords, Lord Crisp and Lord Kennedy, reminded us, prevention is better than cure—preventing the onset of disease rather than merely treating the symptoms.

Our health reforms in the UK are designed to strengthen our approach to improving public health. On the Health and Social Care Bill we will debate how there is a new health improvement duty for local authorities, supported by a ring-fenced public health budget. This will allow local decisions on health improvement to be taken about the interventions that are most suited to local needs. We think that that will represent a very responsive system, more so than we have at the moment. We are committed to reducing health inequalities, which is why for the first time, subject to parliamentary approval, we are putting into legislation a duty on the Secretary of State for Health focused on the need to reduce inequalities. That makes this the strongest health inequalities duty we have ever had.

First and foremost in the UK, we focus on prevention through an integrated approach as the major non-communicable diseases share a number of common risk factors. We address the causes of the causes, the underlying wider social and environmental determinants. The conditions in which people are born, grow, work and age, their education, employment and housing—all these shape the health of individuals and communities. The Public Health Cabinet Sub-Committee, which we established, allows a wide range of Cabinet Ministers to agree how best to respond to the public health challenges. The importance of taking a whole-of-government approach is emphasised in the UN political declaration.

We are a world leader on collecting data on public health, and other countries draw on our approach to surveillance. WHO is looking now to strengthen global monitoring of the prevalence of NCDs and the common risk factors, which is essential if we are to establish the kind of meaningful targets referred to by the noble Lord, Lord Rea. In England we are putting in place a new strategic outcomes framework for public health at national and local levels—again, in an effort to benchmark these matters—which will be based on the evidence of where the biggest challenges are for health and well-being.

On the domestic front, we are making progress on some of the key areas of action highlighted by the UN and we stand ready to share those experiences with others. NCDs share common risk factors—tobacco use, unhealthy diets, physical inactivity and alcohol misuse. Our actions, particularly on tobacco control and reducing salt intake, have been highlighted by WHO as international best practice.

The noble Lords, Lord Rea, Lord May and Lord Collins, rightly lay particular emphasis on tobacco policy. The UK strongly supports the WHO Framework Convention on Tobacco Control, and we take it very seriously. Tobacco use is by far the biggest risk factor for NCDs, so effective policies to reduce smoking rates are essential. We urge all countries that are not yet parties to the treaty to sign up to it as quickly as possible, and equally we urge all those who are signatories to implement the treaty fully, as we have done in this country. The convention encourages parties to take comprehensive action on tobacco control. The Tobacco Control Plan for England, published in March, sets out a range of actions that will bear down on tobacco use.

The noble Lord, Lord Collins, mentioned salt. As he knows, we have made considerable progress in recent years by working in partnership with industry and others to reduce salt intake. It has gone down by about 10 per cent in the past few years, which has served to prevent over 4,000 deaths a year and saved the NHS a great deal of money. We are taking that work forward as one of the pledges contained within the Public Health Responsibility Deal.

As well as these initiatives, which aim to tackle population health here in England, we are working to strengthen our primary care system, putting the patient and their GP at the heart of service delivery. This will reduce the impact of non-communicable diseases through programmes such as the NHS Health Check, which I hope is of particular interest to the noble Lords, Lord Kennedy and Lord Collins. Our NHS Health Check programme assesses people's risk of heart disease, stroke, diabetes and kidney disease. It has the potential to prevent 1,600 heart attacks and strokes a year—so I am told—to prevent over 4,000 people a year from developing diabetes and to detect at least 20,000 cases of diabetes or kidney disease earlier. It is an important programme.

The noble Lord, Lord Crisp, asked me about the training and the DfID programme. He suggested that DfID was too rigid on this, and too focused on NGOs. Health system strengthening includes training as a key part of DfID’s work. Globally, we provide training through a number of different organisations, including government organisations, NGOs and our contributions to multilateral organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. DfID estimates that 25 per cent of its aid to health supports human resources, including training.

The noble Baroness, Lady Hayman, spoke about neglected tropical diseases. I am pleased to tell her that, only yesterday, the UK announced that we would support the final push to eradicate guinea worm from the world. My honourable friend Stephen O’Brien yesterday issued a challenge: we will increase our support to guinea worm eradication and fill up to one-third of the financing gap, provided that others step forward and fill the other two-thirds. This funding would form a vital part of the push from former US President Jimmy Carter to ensure that guinea worm is consigned to the history books alongside smallpox. We have already committed £25 million over five years to tackle schistosomiasis, or bilharzia.

The noble Lords, Lord Crisp and Lord Rea, and my noble friend Lord McColl expressed doubts about engagement with the food industry in this country. We start with the recognition that people’s lifestyle choices are affecting their health. The Government cannot address this challenge alone through central, top-down diktat. Everyone has a part to play, not just government but also business, industry, retailers, the third sector and individuals themselves. The Responsibility Deal is not a substitute for the development of government policy on public health; it complements it. We also know that businesses can reach consumers and deliver information in ways that other organisations, including government organisations, cannot.

My noble friend Lord McColl spoke very powerfully on obesity. I would like to think that he and I are not so far apart as he perhaps indicated. We are clear that the Government cannot tackle obesity alone. It is an issue for society as a whole. We all have a role to play. We will shortly be publishing our plans for how obesity will be tackled in the new public health and NHS systems in England, and the role of key partners. I could not help feeling, listening to my noble friend, that we might be talking at cross purposes. There is surely a distinction between keeping healthy people healthy—and the advice that goes with that—and helping obese people become less unhealthy. For the latter group, my noble friend’s advice is surely spot on. The NICE advice, I suggest, is relevant and accurate for the former group. Diet has an important role, and we are indeed working to improve it, reducing the consumption of fat, sugar and excess calories. However, it is not tenable to suggest that physical activity is not important. I wonder whether my noble friend and I can agree that physical activity helps to balance the energy consumed. I look forward to a little conversation with him about that afterwards.

The noble Lord, Lord Roberts of Llandudno, spoke extremely convincingly about alcohol. Retailers, producers and pubs ought to promote, name, market and sell their products in a responsible way. We need to see leadership from them to produce a radical and better balance between business interests and social harm. I am encouraged to tell him that there has been a wide sign-up to the first set of collective pledges under the Responsibility Deal. Networks are already developing the next tranche of pledges. Again, by working closely with industry, we help it to shoulder its responsibilities and can go further and faster in developing the initiatives that we all want.

The noble Lords, Lord Kennedy and Lord Collins, referred quite rightly to diabetes. Our national diabetes service framework, begun in 2003, has been reinvigorated this year by a new NICE quality standard for diabetes against which future care will be measured. Our national diabetic retinopathy screening programme has been offered to 98 per cent of people with diabetes; that is a great record. A National Health Check programme for 40 to 74 year-olds in England includes an assessment for those at risk of developing type 2 diabetes as well as cardiovascular and kidney disease. That programme has real potential to identify people at risk of diabetes early and prevent its debilitating complications.

Now, I have a few apologies to make; first, to the noble Baroness, Lady Masham, who asked me about the training of doctors for pain control. I do not have information on that in front of me, but I will certainly write to her. I shall also write to the noble Lord, Lord Kakkar, who asked me about the proportion of NIHR funding on cardiovascular disease and any research network that there may be on that disease in the Commonwealth. He also asked me about UK funding for research on cardiovascular disease in developing countries, and I can tell him that the Indian Council for Medical Research is collaborating on several research topics related to NCDs; indeed, there is a collaborative research programme in Mumbai studying the impact of nutrition in pregnancy and early childhood on the risk of heart disease in later life, and its intergenerational effects.

I hope that what I have said will reassure the House that we are taking action on all fronts to prevent and manage NCDs both nationally and globally. However, concerted action is needed across Governments and industry to meet the challenges of NCDs. The human and economic consequences of inaction are too grave for us all to do anything else.

Health: Breast Cancer

Earl Howe Excerpts

Monday 3rd October 2011 Lords Chamber

[Baroness Morgan of Drefelin]

To ask Her Majesty’s Government what assessment they have made of the impact Improving Outcomes: A Strategy for Cancer, issued by the Department of Health, has had on women with breast cancer.

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

My Lords, our cancer outcome strategy sets out our ambition to improve outcomes for all cancer patients and save an additional 5,000 lives every year by 2014-15. Specifically on breast cancer, the strategy outlined commitments on local awareness campaigns, expanding breast cancer screening, measuring the prevalence of metastatic breast cancer, and one-day stays for breast surgery. Good progress is being made in all these areas and the strategy’s first annual report will be published in the winter.

[Baroness Morgan of Drefelin]

My Lords, may I remind the House of my interest as chief executive of the research charity Breast Cancer Campaign? I thank the Minister for his response. I have two brief questions. We know that radiotherapy is a very cost-effective treatment, improving outcomes for people with cancer at 5 per cent of the NHS cancer spend. Can the Minister explain to the House what progress is being made to ensure that the additional investment set out in the outcomes strategy is actually being converted into improved outcomes rather than lost in the bottom line? Can the Minister say what steps are being taken to improve access for women to IMRT radiotherapy, which is, of course, the modern version of this treatment and which can be so beneficial for appropriate referrals?

--- Later in debate ---

[Earl Howe]

My Lords, the noble Baroness, with her expert knowledge in this area, is absolutely right that access to appropriate treatment, delivered to a high standard, is critical to improving outcomes. We have made a commitment to expanding radiotherapy capacity by investing around £150 million more over the next four years. That is intended specifically to increase the utilisation of existing equipment, establish additional services and make sure that all patients who need the therapy can get it. We are investigating a tariff for IMRT; that is part of our work towards the aspiration to ensure that IMRT is available in at least one centre per cancer network by 2012. It is a matter for local decision-making, but an IMRT development programme is now in place.

[Lord Alderdice]

My Lords, would my noble friend agree that progress in this important area of breast cancer is likely to be found in the identification of molecular markers and the design of appropriate targeted medications, as has been the case in breast cancer with HER2 and Herceptin, for example? Would he acknowledge that it is a very expensive treatment? Although it really improves quality of life as well as mortality and outcome, the expense of not only the medication but the tests themselves is considerable. How will the NHS cope with this important but very expensive progress?

[Earl Howe]

My noble friend makes an extremely important point. That is why we need a body such as NICE, the National Institute for Health and Clinical Excellence, to advise the health service on what treatments represent cost-effective value for money. The tendency of drugs to impose considerable cost on the NHS is very great, as he points out. It is important that clinicians focus on those drugs that really do the best for patients. I am aware that a number of drugs are currently being assessed by NICE with regard to breast cancer.

[Baroness Thornton]

My Lords, I apologise for my conference throat—it is all the cheering I did last week. The Government published a strategy for cancer in January 2011 and set a target of improving cancer survival rates, so that by 2014-15 an extra 5,000 lives will be saved each year. What progress has been made towards meeting the target that was expressed in Improving Outcomes: A Strategy for Cancer and saving those extra 5,000 lives a year?

[Earl Howe]

My Lords, there are broadly three ways in which we can attain that target. The main way is through early diagnosis—in particular, by making sure that women are aware of the signs and symptoms that could indicate breast cancer—but also by improving access to screening and to radiotherapy, which has already been covered in the question from the noble Baroness, Lady Morgan. To support the NHS to achieve earlier diagnosis of cancer, the strategy has been backed by over £450 million over the next four years. That is part of over £750 million additional funding for cancer over the spending review period.

[Lord Patel]

My Lords, we know that one of the reasons for the poor outcomes on cancers is the late referrals of patients who suffer from cancers. We are now likely to have performance management of primary care doctors being based on their referral patterns. Can the Minister confirm that there will be no financial incentive for reducing referrals of suspected cancer patients for treatment?

[Earl Howe]

Yes, I can, my Lords. It is very important that doctors should feel absolutely free to refer patients. I remind the noble Lord that it is a right for patients, under the NHS constitution, to expect to be referred within the laid-down waiting time maximum periods, so we are very clear that there should be nothing to interfere with doctors’ clinical judgment in this area.

[Baroness Fookes]

My Lords, am I right in thinking that screening comes to an end after a certain age for women? If that is correct, does it make any sense when the incidence of breast cancer increases with age?

[Earl Howe]

My Lords, my noble friend is right that we have historically targeted women in a certain age group for breast cancer screening. We are looking to see whether that age group should be widened but it is generally true to say that screening is more cost-effective in older women. It has certainly been the case that the breast screening programme over the past number of years has increased the detection of cancer and saved an estimated 1,400 lives a year.

[Lord Hughes of Woodside]

My Lords, can the Minister confirm that there is something in the NHS called the two-week procedure whereby GPs can refer patients to a hospital and they are therefore seen by that hospital within those two weeks? If I am right in that, will that be more widely used and advertised so that patients know what they can ask of their GP?

[Earl Howe]

The noble Lord is right. We are not changing that target, which we believe is clinically well founded. It is largely up to GPs to make sure that, if cancer is suspected, that referral pathway should be followed.

NHS Future Forum

Earl Howe Excerpts

Thursday 15th September 2011 Lords Chamber

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

My Lords, I agree with the noble Baroness, Lady Thornton, that this has been a timely debate. I thank the noble Baroness, Lady Wheeler, for calling it and all noble Lords who have spoken and contributed so eloquently. To pick up the baton handed to me by the noble Baroness, Lady Donaghy, who remarked what big plans my colleagues and I have in the Government's programme of modernisation of the NHS, the debate has indeed covered a great deal of ground. I will do my best to cover most of the key issues in my speech. To the extent that I do not, I will of course follow up those points in writing.

The noble Baroness, Lady Wheeler, asked why we needed to legislate at all. The Health and Social Care Bill seeks to create a stronger, more responsive and more innovative NHS—an NHS led by clinicians, with patients in control of their own care and with a resolute and unflinching focus on results. We must streamline the architecture of the health service to improve its efficiency.

My noble friend Lord Ribeiro directed us towards exactly the right starting point by referring to the core principles underpinning the Bill. Despite widespread support for these principles—and there has been such support—some thought that the detail of the Bill could be improved to better support those principles. So we took the unprecedented step of asking a group of independent health experts, the Future Forum, to recommend changes to the Bill. I would like once again to thank Professor Steve Field, the members of the NHS Future Forum, the hundreds of organisations and thousands of people who contributed to the listening exercise. We accepted all of the forum’s core recommendations and we have since made significant changes during the Bill’s Second Committee stage. I cannot accept the criticism of the noble Baroness, Lady Thornton, of the process. Stakeholders have in fact welcomed how the forum conducted itself—for example, Mike Farrar of the NHS Confederation and Hamish Meldrum of the BMA. I believe that the process has been hugely positive and has helped us to improve a number of our plans in different ways.

First, I would like to run briefly through some of the key changes that the Government are making. My noble friend Lord Ribeiro, as might have been expected of him, referred to clinical leadership. Some were concerned that too narrow a group of clinicians would be charged with designing services, so we have amended the Bill to place stronger duties on commissioners to ensure that all relevant health professionals are involved in the design and commissioning of services at every level—including clinical networks in relation to specific conditions and new clinical senates for broader areas. The governing bodies of clinical commissioning groups will need to appoint at least one registered nurse and one secondary care specialist.

The noble Lord, Lord Rea, questioned whether there would be public health input into the commissioning process. The Bill should require commissioning consortia or groups to obtain all relevant multiprofessional advice to inform their commissioning decisions, including public health but also other types of advice. The authorisation and annual assessment process should be used to assure this. We will make sure that a range of professionals plays an integral part in clinical commissioning of patient care and we have amended the Bill to place stronger duties on commissioners to obtain that advice.

We are committed to harnessing the benefits that competition and choice bring for patient care but let me make it clear, particularly to the noble Lords, Lord Rea and Lord Sawyer, that competition will never be about serving the interests of corporations. It will be about serving only the interests of patients and we have made changes to the Bill to reflect this. We have removed Monitor’s duty to promote competition as though it were an end in itself. Instead, it will be under a duty to support services integrated around the needs of patients and the continuous improvement of quality. The choice of “any qualified provider” will be limited to those areas where there is a national or local tariff, ensuring that competition is only ever based on quality, not price. That will also ensure that there can be no cherry picking. I will come back to that point in a moment. There will be and can be no privatisation of the NHS. In fact, it will be illegal for current or future Ministers, the NHS Commissioning Board or Monitor to favour the private sector over the public sector, or indeed vice versa. While some will undoubtedly disagree, what matters is the outcome of care provided and the end results for patients, not the nature of the provider—public, private or otherwise.

The noble Baroness, Lady Wheeler, suggested that we had not implemented the Future Forum’s recommendations on board meetings being held in public. It is not correct to say that we have not amended the Bill in regard to that, as we have made it a requirement for every clinical commissioning group to have a governing body with decision-making powers. To enhance transparency and accountability, governing bodies will be required to meet in public and publish their minutes, while clinical commissioning groups will have to publish details of contracts with health services. Openness and transparency will be the bedrock of a new, more patient-centred, outcome-focused and accountable NHS. We have amended the Bill in the way that I have described but, in addition, we have said that the governing bodies of commissioning groups must have at least two lay members: one to champion patient and public involvement, the other focused on overseeing key elements of governance such as audit, remuneration and managing conflicts of interest. Foundation trust governing boards will also need to meet in public.

The theme of integration loomed quite large in a number of noble Lords’ contributions. Excellent care often means integrated care. We have strengthened the NHS Commissioning Board’s duty to integrate services and introduced an equivalent duty for clinical commissioning groups. Health and well-being boards will be required to involve the public when identifying local needs and developing the joint health and well-being strategy. In future, I think there will be far more effective arrangements than exist currently for ensuring joined-up working across the NHS, public health and social care—a theme picked up by the noble Baroness, Lady Pitkeathley. We will have an NHS Commissioning Board setting common frameworks in which clinical commissioning groups commission services, a regulator to ensure that standards in care are met and greater transparency of outcomes, which will drive up efficiency and quality. I add that we have asked the NHS Future Forum to look at integration as part of its continued conversations with patients, service users and professionals. The forum will report back to Ministers later this year on what it has heard.

The pace of change has also caused concern for some people, so in a number of areas we have made the timetable for change more flexible. No one will be forced to take on new responsibilities before they are ready to do so. However, those who wish to progress more quickly will not be prevented from doing so.

Let me now turn to some of the specific concerns which have been raised during the debate. The noble Baroness, Lady Wheeler, and my noble friend Lady Jolly referred to the Secretary of State’s duties—concerns that were echoed by the noble Baroness, Lady Donaghy, and the noble Lord, Lord Sawyer. At present, the Secretary of State has a duty to provide or secure services himself but delegates that responsibility to strategic health authorities or primary care trusts by directions. Generally, he delegates nearly all his commissioning responsibilities to SHAs or PCTs, but he has the powers to alter that and vary the extent of delegations. Under the new system, the function of arranging the provision of services—that is to say, commissioning—will be conferred directly on the board and clinical commissioning groups by Parliament, providing stability for the system and removing the Secretary of State’s ability to intervene arbitrarily in the day-to-day management of the commissioning process. That will free up those with the relevant expertise to focus on commissioning the best possible services for patients, free from political micromanagement.

Ministers are accountable for the NHS and will remain so. The Bill does not change the Secretary of State's overarching duty to promote a comprehensive health service, which has underpinned the NHS since it was founded. The Bill simply makes it clear that it should not be the responsibility of Ministers to provide or commission services directly. That should be the job of front-line organisations, free from interference. We are putting patients and professionals in the driving seat in order to create better quality care and better value for taxpayers.

The noble Lord, Lord Sawyer, said that there was not enough in the Bill to provide clarity. I understand why he makes that point. Every Bill that we scrutinise in this House needs to get the balance right between what is on its face and what is in regulations. We have republished our delegated powers memorandum, which sets out our justification for taking the delegated powers that the Bill proposes, and I hope that memorandum is well read and scrutinised.

The noble Baroness, Lady Wheeler, and others including the noble Lords, Lord Warner and Lord Sawyer, suggested that we were adding layers of bureaucracy. I think the noble Baroness said that the number of bodies would be increasing from 163 to 521, if I did not mishear her. I simply cannot accept that; it is not true that we are creating additional bureaucracy. The changes we made to the Bill as a result of the listening exercise do not create any extra statutory organisations at all and I do not recognise the figure that she cited. We remain absolutely committed to our promise to cut bureaucracy. We are removing layers of management by abolishing 151 PCTs, 10 strategic health authorities and half of the national health quangos. Administration costs across the health system will be cut by a third in real terms by 2014-15.

The noble Baroness, Lady Wheeler, spoke generally about the Future Forum recommendations, particularly about some that in her eyes the Government did not accept. We accept all the core recommendations of the Future Forum report but there are some areas that need further work before the final decision is taken. Those include further work on the feasibility of a citizens’ right to challenge poor quality services and lack of choice, and work to improve how continuing professional development is provided.

Some but not all of the forum’s core recommendations to the Bill require amendments to the Bill. For example, clinical networks and clinical senates will be hosted by the commissioning board, and will not need to be provided for by amendments to the Bill.

The noble Lord, Lord Warner, asked about phase 2 of the Future Forum’s activities. We announced in August that the forum will provide further independent advice on four themes: information, education and training, integrated care and public health. While the first phase of the forum’s work focused largely on the Bill, the second is focusing on non-legislative aspects of the reforms. It will report back to the Government later this year and publish its advice, as I indicated earlier, and we will draw on that advice as we work to implement the reforms across the piece.

My noble friend Lady Jolly took up the subject of education and training, which was also the theme of a number of other noble Lords’ contributions. It is vital that any changes to the funding of education and training have to be introduced in a careful phased way that does not create instability. We are therefore going to take our time to develop the proposals, working with our health and social care partners, and through further consultation. We will be publishing more details about that in the autumn and will bring forward an amendment in due course.

We think that individual employers with appropriate professional input and leadership are best placed to plan and develop their own workforce and assess what workforce and skills are needed on the front line to provide affordable, safe and high-quality care. Health Education England is being established to support healthcare providers and provide national oversight of workforce planning, education and training. It will be a lean and expert organisation and will provide leadership for effective workforce planning and the provision of high-quality education and training that supports innovation, value for money and better skills. We have also been working closely with strategic health authorities, which are managing the transition to the new system.

I turn to specific questions about the subject of competition, an issue raised by the noble Baronesses, Lady Wheeler and Lady Donaghy, and the noble Lord, Lord Rea, among others. “Promoting competition”, which was the original wording in the Bill, could have been interpreted in a number of ways. It could have been interpreted as proactively encouraging new providers of NHS-funded services to come forward or existing suppliers to compete for more services, irrespective of what was in the best interests of patients. Addressing anti-competitive behaviour is about preventing potential abuses by providers and commissioners to ensure that the system works in the best interests of patients. “Promoting competition” might also have been interpreted as requiring action where Monitor felt that there was insufficient competition in place, such as where there was a single dominant supplier of a particular service. The Bill now provides that Monitor should consider acting in such cases only if the provision of services is not economic, efficient or effective, or if a provider is abusing its market position to the detriment of patients.

A number of noble Lords were worried about cherry picking, especially the noble Lord, Lord Rea, and the noble Baroness, Lady Thornton. Those two noble Lords in particular were mistaken in their analysis of the position. We have consistently said that we would prevent private companies from cherry picking easy, profitable NHS services. We fully agree with the Future Forum’s call for additional safeguards against private providers being able to cherry pick profitable NHS business. We have made changes to the Bill to ensure that competition is about quality, not price; for example, there will now be a specific duty on Monitor to ensure that providers are paid in line with the complexity of the cases that they treat. Providers will have to set and apply transparent eligibility and selection criteria.

In her wide-ranging speech, the noble Baroness, Lady Wheeler, also covered the subject of the private patient income cap. Professor Field told the Commons committee in June that the Future Forum heard a wide range of views on that subject. He expressed the personal view that, because of the mixed views on this area, the forum could not make a strong recommendation as a body. In the eyes of many, the current cap is arbitrary and unfair. Foundation trusts tell us that the private income cap is unnecessary and restricts their ability to innovate and maximise income to deliver improved NHS services. We are confident that, as and when the cap is lifted, private income will benefit NHS patients. We are determined that that should be seen to happen. However, we will explore whether and how to amend the Bill to ensure that foundation trusts explain how their non-NHS income is benefiting NHS patients.

My noble friends Lady Jolly and Lord Ribeiro and the noble Lord, Lord Warner, spoke about reconfiguration. Although I have extensive notes on that important subject, I suspect that there is not time to cover it now. However, we will no doubt return to it, as we will to the many questions asked of me by the noble Baroness, Lady Pitkeathley.

I shall cover a couple of smaller issues. My noble friend Lady Jolly asked whether directors of public health would report directly to the chief executive of a local authority. We expect directors of public health to be of chief officer status and to report directly to the chief executives of local authorities. We are engaging with local government and public health stakeholders about how best to ensure that they have appropriate status.

Now that the Bill has passed to this House, I look forward to the debates that we will have in the weeks and months ahead. In preparation for those, my office will be in touch with interested Peers to arrange briefings with the Bill team and Library officials about any of the issues that we have been debating today and indeed any others that are troubling noble Lords. Those are likely to take place between Second Reading and Committee.

On the question of organigrams, I refer the noble Baroness to the original White Paper that we published, which contains a rather good one. We will also shortly be publishing a statement of accountabilities in the NHS, which will set out the roles and responsibilities of each organisation in the system.

Thanks to the excellent work of members of the Future Forum, the Bill has the potential to free clinicians to lead, to enable patients to take control and to focus the NHS on improving the quality of outcomes—principles that I hope we can all agree upon as we move forward to the next very interesting stage of the parliamentary process.

NHS: Cost-effectiveness

Earl Howe Excerpts

Monday 12th September 2011 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government whether the Department of Health will draw attention to the recent report in the Journal of the Royal Society of Medicine on the cost-effectiveness of the National Health Service.

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

My Lords, the department welcomes the report to which the noble Baroness refers, and recognises the significant gains in health achieved by the National Health Service since 1979. However, its evidence is limited and does not support broad generalisations on NHS cost-effectiveness. The NHS can still make major improvements to the health of the nation and must continue to respond to pressures from an ageing population, new technology and rising patient expectations.

[Baroness Thornton]

My Lords, I thank the Minister for that Answer. The Government seek to justify the hugely risky reforms of the NHS by saying that our NHS is not fit for purpose in a variety of ways, including not being cost-effective. We all know that improvements can be made—there is no doubt about that at all—but how does the Minister reconcile that with yet another authoritative report in the Royal Society of Medicine journal which says, among other things, that in terms of cost-effectiveness—that is, economic input versus clinical output—the UK NHS is one of the most cost-effective in the world, particularly in reducing mortality rates, and that among other systems, the US healthcare system is one of the least cost-effective?

[Earl Howe]

My Lords, I must point out one thing about this report: it does not make any claims for how cost-effective our health system was at any given point in time. What it does is measure the improvement in mortality over a period and then assess the cost-effectiveness of that improvement, which is a very different thing. Yes, the NHS has made great strides in improving mortality rates, but that is the only metric that the report deals with. It completely ignores other measures of quality. It is also completely silent about anything that happened after 2005, so recent years are not covered.

[Lord Clement-Jones]

Is not the really difficult and vital context in which we find ourselves at the moment the fact that we need significantly to improve productivity in the NHS in line with the so-called Nicholson challenge, which was endorsed by both this Government and the previous one? Can the Minister remind us of the record under the previous Government and tell us what he expects to be the outcome of the current health reforms?

[Earl Howe]

I am grateful to my noble friend. A Written Answer was published in Hansard recently that tracked the changes in productivity of the NHS between 1996 and 2008. He will know if he read it that there was a decrease in productivity over that period of around 3.1 per cent. The pressures on the NHS are increasing. In order for it to respond to the needs of the future, including an ageing population and the cost of new technologies, it needs to adapt to new ways of working that reduce cost pressures while delivering improved outcomes. The measures that are before Parliament seek to do just that.

[Baroness Farrington of Ribbleton]

My Lords, can the Minister give an example of any major reorganisation and restructuring that has not cost more money and put the brakes on improvements in the service that were being made, particularly when the Government bringing in to the system such major changes comprise two parties that said that there would be no major reorganisation of the National Health Service were they to be in government?

[Earl Howe]

I commend to the noble Baroness the impact assessment that we published on the Bill. It shows clearly that, over the next 10 years, the savings that we will bring about will dwarf the cost of making the changes that we propose.

[Lord Patel]

Does the Minister agree that improving the quality of healthcare will lead to higher costs?

[Earl Howe]

No, I do not. There are plenty of examples of quality costing less because the system gets it right first time. We see this time and again, for example in the Quit programme. The simplest example is that if we can treat patients correctly in hospital and keep them in for the shortest amount of time, we save a great deal of money.

[Lord McColl of Dulwich]

My Lords, on the subject of cost-effectiveness, does my noble friend agree that we are in the middle of the most serious epidemic to afflict this country for 100 years—namely the obesity epidemic? The cure is free: you just have to eat less. Why does the Department of Health insist that exercise is important in this equation?

[Earl Howe]

My Lords, the department takes its cue from NICE. I am sure that my noble friend will agree that exercise is never irrelevant to the question of obesity. I think that my noble friend's difficulty centres on how relevant it is in relation to reducing calorie intake. No doubt the debate on that will continue.

[Baroness Pitkeathley]

My Lords, does the noble Earl agree that no system of health, particularly with an ageing population, can be effective and efficient unless we also provide the best possible social care to link with it?

[Earl Howe]

I agree with the noble Baroness. One of the aims of our reforms is to integrate health and social care in a much more seamless way. There is another element to our reforms, which may have escaped noble Lords' notice. It is our wish to bear down on health inequalities in a much more systematic way than we have done hitherto. Both health and social care have a part to play in that.

[Lord Tugendhat]

My Lords, I declare an interest as chairman of the Imperial College Healthcare NHS Trust. Does my noble friend not agree that whenever an international organisation such as the OECD or the IMF has good words to say about the conduct of the British economy, the Chancellor of the Exchequer always welcomes them and uses them as an argument to support the Government’s economic policy? Would it not be helpful, when other organisations have good words to say about the NHS, for the Government to welcome them with equal fervour? Of course the NHS can improve and must modernise and move with the times; but when significant institutions such as the Commonwealth Fund in America, and the one that has just been quoted, have good words to say about the NHS, surely the Minister should be less carping.

[Earl Howe]

My Lords, in my opening words I said that we welcomed the report. I stressed that we fully acknowledge the improvements that have been made by the NHS over the past few years, which the report highlights. However, it is limited in its scope. The difficulty with all these reports is comparing like with like, particularly with different health systems. I am not decrying the work that went into the report, but I will say that perhaps some OECD reports take us closer to how well the UK's health system is performing in relation to those of other countries.

[Baroness Williams of Crosby]

My Lords, will the Government take a larger look at the scope and permanence of the NHS’s success in recent years? Does the Minister agree that a key factor is the share of GDP devoted to the NHS and the results that it produces? The NHS has consistently produced better results with a much lower share of GDP than some comparative health services, including that of the United States.

[Earl Howe]

My noble friend is right. There is also another measure that counts—not just the percentage share of GDP, but the absolute amount of money in the health budget that goes into our NHS. As she will know, the amounts of money have increased substantially over recent years. That produces a rather different ratio from the one in the report referred to in the Question.

Smoking

Earl Howe Excerpts

Thursday 8th September 2011 Lords Chamber

[Lord Ribeiro]

To ask Her Majesty’s Government whether they will introduce legislation to stop adults smoking in cars when children are present.

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

My Lords, exposure to second-hand smoke is hazardous, especially to children’s health. Since smoke-free legislation was introduced in England in 2007, evidence shows that the number of children being exposed to second-hand smoke has continued to fall. However, some children are still exposed in the home and in family cars. We want to encourage people to create family environments free from second-hand smoke. The Government are proposing a range of voluntary measures that we believe can achieve more, more quickly, than legislation.

[Lord Ribeiro]

My Lords, I thank the Minister for his considered response. The evidence of damage to children from passive smoking is well documented. Thirty jurisdictions in Canada, Australia and the United States have banned smoking in cars when children are present. In Canada, exposure to smoking in cars fell by one-third to one-half in some provinces over a six-year period. Is my noble friend aware that the concentration of smoke in the back of a car is considerably greater than that in the front, even if the driver’s window is open? Is he prepared to follow the example of the Welsh Assembly and introduce legislation if efforts to change behaviour fail?

[Earl Howe]

My noble friend speaks with great authority on this subject, and I find little to disagree with in anything that he has said. He is absolutely right that children are particularly vulnerable to the harms of second-hand smoke: more than 300,000 children in the UK present passive smoking-related illnesses to their GP every year. We have to take this matter seriously, and we are. However, despite the evidence my noble friend cites from Canada, it is still early days to judge how effective that legislation has been, over and above voluntary measures. The second issue that poses problems is enforcement. However, we continue to look at these questions very closely.

[Lord Hughes of Woodside]

My Lords, as a former heavy smoker, I still have a guilty conscience over what I must have done to my own children. I fully support every effort to attack passive smoking. But did the Minister see in a report in today’s press that a council somewhere in England has refused to allow an adoption because the male of the family had once smoked a cigar at a wedding and had once smoked a cigar at a party? Is this not taking things to a totally ridiculous level?

[Earl Howe]

My Lords, I did not see that report, but what the noble Lord says disturbs me. I think we all want to see an increase in adoption rates and we do not want to see potentially good adopters turned aside for what may appear to be trivial reasons.

[Lord Foulkes of Cumnock]

My Lords, I moved Private Member’s legislation in the other place in the early 1980s and got nowhere on it. Only when legislation was moved was there a real reduction—a complete ban—on smoking in public places and only through legislation can effective action be achieved. Is it not also the case that smokers lighting up cigarettes in cars are dangerous in terms of road safety? That is an extra reason for doing it. Will the Minister therefore stop pussy-footing around and saying that this can be achieved voluntarily, when we all know that it can only really, successfully and effectively, be achieved through legislation?

[Earl Howe]

My Lords, I do not agree with the noble Lord’s analysis. It is true that, on current evidence, the legislation is having a beneficial effect; I would not dissent from that. However, we know that voluntary behaviour change is eminently possible. It would explain why, between 1996 and 2007 when the legislation came in, secondhand smoking exposure in children in England declined by 70 per cent. That was driven by not only the evidence but also awareness campaigns and increased awareness in the lead-up to the legislation. Therefore, voluntary action can have a beneficial and marked effect.

[Baroness McIntosh of Hudnall]

My Lords, since the Minister mentioned enforcement, I wonder whether he would like to comment on the issue more generally. I take the point of my noble friend Lord Foulkes about road safety issues that arise from smoking in cars, as well as health issues. Is the Minister content that enough is being done to enforce restrictions that are already in place, for example on the use of mobile phones in cars? Is it not the case that the burden of enforcement always will fall mostly on the police, and that they are unlikely to be able to carry out those duties very effectively when they are under such pressure to cut their numbers?

[Earl Howe]

The noble Baroness makes a very good point. Currently, enforcement in the hands of the police centres mainly on dangerous driving. That may take the form of people illegally using mobile phones while driving or perhaps smoking in a dangerous way. However, I take her point that there is a limit on the extent to which the police can be expected to extend their remit. There is also a sensitivity in this area. The idea of police stopping a car in which somebody in the front seat is smoking on suspicion that there might be a child inside may stray over the boundary of what society would consider an acceptable use of police time.

[Baroness Howarth of Breckland]

My Lords, I know that the Minister is very concerned about the effects on children. Could he remind me of the timetable to remove displays from tobacconists’ stores so that children do not see them and are not encouraged to smoke, because that legislation can already be put in place and carried through?

[Earl Howe]

The noble Baroness is right. We believe that the Government’s commitment around the introduction of tobacco display legislation strikes the right balance. We have amended the implementation dates. Displays will come to an end in large shops on 6 April next year, and in small shops on 6 April 2015.

[Baroness Thornton]

My Lords, my Government and this Government should be proud that today there are more than 2.5 million fewer smokers in England than there were in 1998. The noble Lord, Lord Ribeiro, points to the challenge of how to make certain behaviours unacceptable. Does the Minister believe that the Government’s nudge policy will work here? Will the Government invest in a public information campaign aimed at substantially and permanently changing public behaviour in this respect?

[Earl Howe]

My Lords, we are going to publish a tobacco marketing plan later this year which will lay out precisely what we propose to do at a local level. It is our intention to support local efforts to raise awareness and use the insights that we know about from behavioural science to influence positive changes in behaviour, including around the social norms of not smoking when children are present. Voluntary local initiatives are already working. There is a very good example of that in Lincolnshire at the moment. We want to roll out more programmes like that.

[Viscount Simon]

My Lords, legislation already exists to ban smoking in commercial vehicles and in company cars because of the road safety aspects and also, presumably, because of health. Would it not be easy to ban smoking in all vehicles?

[Earl Howe]

My Lords, as I indicated earlier, we certainly have not ruled out the possibility of legislation, but we need to be sure about the evidence that legislation will have a greater beneficial effect than voluntary action on its own. It is a case of balancing the pros and cons. We have touched upon the enforcement issue and I do not think that that will go away, but on the other hand, the benefits of legislation in other jurisdictions may turn out to be compelling.

NHS: Hospitals

Earl Howe Excerpts

Thursday 8th September 2011 Lords Chamber

[Lord Clinton-Davis]

To ask Her Majesty’s Government what meetings they have held with private companies concerning the management of NHS hospitals; and what was the outcome of any such meetings.

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

My Lords, as part of standard policy development, officials in the Department of Health met UK-based companies and one international health expert to hear their experiences of intervening to improve underperforming organisations. These were background sessions to inform policy development. Any decisions to involve organisations such as the independent sector or foundation trusts in running NHS hospitals would be locally led. In all cases, staff will remain within the NHS and assets owned by the NHS.

[Lord Clinton-Davis]

Is there any suggestion by the Government of cutting staff or wage levels, thus putting greater emphasis on raising revenue rather than patient care, which we regard as highly important? This policy represents, does it not, the decline of the NHS rather than its reform?

[Earl Howe]

I am not sure what policy the noble Lord is referring to. There is certainly no concerted policy to decrease the pay levels of NHS staff. That is something we take very seriously. The proper remuneration of NHS staff, and their motivation, is of central importance to the well-being of patients. No, we are not diluting the NHS; the whole point of the Government’s programme is to bolster and boost the sustainability of the NHS for the long term.

[Lord Hamilton of Epsom]

Does my noble friend accept that productivity in the NHS has been absolutely abysmal over recent years and that the private sector, if it comes in to run hospitals better, may be able to raise it?

[Earl Howe]

My noble friend is right. The statistics for the productivity of the NHS over the past 10 or 12 years show that it has actually gone down by about 3 per cent in total. We certainly think that the private sector has a role to play in places where it can introduce the higher quality of service that patients actually want. There is no question, however, of the Government forcing private enterprise into health services where it is not wanted and not in the interest of patients.

[Baroness Jolly]

My Lords, within England there are already several NHS-badged private hospitals. Can my noble friend tell the House how many of these establishments were set up by the previous Government and how many of their employees are non-UK nationals?

[Earl Howe]

My Lords, I am grateful to my noble friend for that question. I am sorry to say that I do not have those figures in front of me, but she is absolutely right to make the point that the independent sector treatment centres introduced by the previous Government were a perfectly proper move to increase choice for patients, and in many cases we have seen the quality of care in those hospitals encourage the NHS to raise its own game. Competition on that basis is highly beneficial.

[Lord Patel]

Will the Minister say what assessment has been made of the causes of low productivity in the NHS?

[Earl Howe]

My Lords, it is clear that one of the causes was that the previous Government—for all the right reasons, I have to say—injected very large sums of additional money into the health service, but alongside that there was no commensurate increase in activity. A lot of the additional money went into settling pay claims. That is not to decry the many benefits that arose from the additional money, but the net effect was a decline in productivity.

[Baroness Wall of New Barnet]

Does the Minister agree that there are dangers in sweeping statements on how NHS hospitals perform and that they perform badly, because that is not the case? In many instances, not just in my own hospital—Barnet and Chase Farm—the improvement in hospital services over the past years has been incredible. Does he also agree that there are already strong and widespread relationships with the private sector in NHS hospitals and that the challenge is for NHS hospitals to be better than private hospitals so that people will choose to go to their local hospital?

[Earl Howe]

The noble Baroness is right to pull me up. If I implied that the NHS was across the board providing a lower standard of care than the private sector, I apologise because that is certainly not the case. There are some shining examples of care delivered by the NHS. However, as she will know, not all hospital trusts are as good as hers. Some give us cause for concern in a clinical sense, and they need to be challenged sometimes on the way they look at quality. That is going on at the moment with the quality, innovation, productivity and prevention programme that she will know very well.

[Baroness Thornton]

My Lords, let us get this Question back to transparency. Over a year ago, David Cameron, the Prime Minister, said:

“Greater transparency across Government is at the heart of our shared commitment to enable the public to hold politicians and public bodies to account”.

That is the point of my noble friend’s Question. I would like an assurance from the Minister that minutes and discussions are available at local and national level on the public record of meetings with private and independent healthcare providers.

[Earl Howe]

My Lords, the origin of this Question was, I believe, a freedom of information request that was replied to by my department. The background is that we have a small handful of hospitals that will struggle to achieve foundation trust status in their own right. I suggest that civil servants have to be allowed to have potentially helpful conversations with those who have experience of turning around financially challenged organisations. That is the background. We are perfectly transparent about that situation, as were the Government of which the noble Baroness was a member.

NHS: Medical Records

Earl Howe Excerpts

Wednesday 7th September 2011 Lords Chamber

[Lord Naseby]

To ask Her Majesty’s Government whether they intend to continue to computerise all NHS medical records.

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

My Lords, the Government aim to continue to computerise NHS medical records so that patient experience is enhanced, patient care is made more efficient, and patient safety is improved. However, we recognise the weakness of top-down, centrally imposed IT systems. Although elements of the programme have been successful, the policy approach taken has failed to engage the NHS sufficiently. The findings of recent reviews will contribute to planning currently under way for future informatics support to the modernised NHS.

[Lord Naseby]

Is my noble friend aware that the current programme for the NHS database has cost over £6.2 billion, has taken 10 years and is currently totally unworkable? Is he aware of any other country in the world that has attempted such a project and succeeded? As far as I can see, no other country has even attempted it. Would it not be far better if Her Majesty’s Government bit the bullet and scrapped the whole scheme, as they did with the RAF’s Nimrod programme, which was itself a brave decision?

[Earl Howe]

My Lords, I can well understand my noble friend’s acute disquiet over this matter, particularly in light of the recent report from the Public Accounts Committee. The view we have taken is that some very good things have been achieved so far, particularly from the national elements of the programme, but it is equally clear that the top-down policy approach taken to the computerisation of the NHS has not delivered the benefits at local level that everybody was hoping for and has failed to engage the NHS sufficiently. Those are the things we are now concentrating on: making sure that the governance of the programme is sound; learning lessons from what has happened; and achieving value for money.

[Lord Warner]

My Lords, I declare an interest as the former Minister responsible for this programme—one does have to own up to one’s past from time to time. Could the Minister assure the House that the Government are fully committed to the idea of an electronic patient record system as the way forward for the NHS, given its benefits for patient care, research and NHS efficiency? Could he tell the House what proportion of the population has now been able to avail itself of an electronic summary record?

[Earl Howe]

I pay tribute to the work that the noble Lord did when he was a Minister. Yes, the Government are committed to a summary care record, which, for the benefit of noble Lords, is a record that includes a defined set of key patient data, other than for patients who choose to opt out—that is an important rider. Clinicians can then access essential medical information that they need to support safe treatment and to reduce the risk of inadvertent harm, especially during emergency care. To answer the second question that the noble Lord asked, over six million patients now have a summary care record, which is a considerable increase over a few months ago.

[Lord Patel]

My Lords, would the Minister agree that to improve the quality of healthcare we would need comparable indicators of health outcomes? In the absence of nationally collected computerised data, how would we achieve this?

[Earl Howe]

My Lords, the noble Lord is absolutely right. We have to measure performance in order to improve upon it. That is why we are focused on producing an information strategy, which we hope to publish later this year. A lot of work has already gone on and the NHS Future Forum, as he may know, is looking at this area. He is absolutely right that this will be central to the performance management of the NHS.

[Baroness Jolly]

My Lords, we are now well into the 21st century. Can the Minister give us some indication as to when patients might be able to access their own records online?

[Earl Howe]

This is a commitment that we have made. We fully support the concept of patients having full access to their medical records online. A great deal of work is going on at the moment to make sure that the protocols are sound, because clearly the one thing one does not want is for the wrong people to access the wrong patient data. If we can achieve that and do it in a simple way, we shall roll the programme out as soon as we can.

[Baroness Pitkeathley]

I take on board what the noble Earl says about engaging local commitment and the failure that there has been in that so far, but does he agree that one of the most important things about local commitment is that different localities may have different systems? As far as the patient is concerned, it is absolutely essential that the systems can talk to each other. How will that be ensured if we go down the local route?

[Earl Howe]

The noble Baroness makes a very good point. I said that the top-down approach to local service provision has not worked when it has come to local service provider systems. We think that local requirements are best judged and best met by decisions being taken locally but that does not mean that they will be left on their own. There will be the necessary support from the centre wherever needed. She is again right that the key will be that these local systems must be interoperable.

[The Countess of Mar]

My Lords—

--- Later in debate ---

[The Countess of Mar]

My Lords, does the Minister agree that while technology is incredibly beneficial to the National Health Service, we must be wary of people working within the health service depending too much upon technology and ignoring the human aspects of care for people who are in hospital—talking to patients, touching them and holding their hands when they have problems? My recent experiences in hospital have been very unpleasant because people have relied entirely on technology and not listened to what I have had to say.

[Earl Howe]

The noble Countess is of course correct that good patient care is about humane and sensitive treatment by the staff who serve in the National Health Service. At the same time, I think we are all clear that technology has a role to play in enhancing patient safety and improving the quality of care that the good staff of the NHS can deliver.

[Baroness Thornton]

My Lords, can I entice the Minister into being slightly more definite about when the House might see the new IT strategy which the Government keep telling us that they are about to publish? As a former Minister, I know that the answer “soon” is one that the House always looks at with some wry smiles. If we could have a more definite date, that might be helpful.

[Earl Howe]

My Lords, we plan to make an announcement towards the latter part of the autumn about the way forward for informatics, which will mean—we are clear about this—that we continue to gain more value for money from taxpayers’ investment and ensure that informatics support is fit for purpose in the modern NHS.

Health: HIV/AIDS

Earl Howe Excerpts

Monday 5th September 2011 Lords Chamber

[Lord Fowler]

To ask Her Majesty’s Government what steps they are taking to prevent the spread of HIV and AIDS in the United Kingdom.

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

My Lords, the Government fund national HIV health promotion programmes for men who have sex with men and for African communities, the groups most affected by HIV in the UK. This is in addition to harm minimisation programmes for injecting drug users, NHS HIV prevention programmes and open-access testing and treatment services. The White Paper, Healthy Lives, Healthy People, sets out the Government’s strategy for reform of public health in England. This includes sexual health and HIV.

[Lord Fowler]

My Lords, I thank my noble friend for that reply, but does he really think that we are getting the message over on the dangers of HIV? Is it not a fact that the number of people accessing care for HIV has trebled in the past 10 years, that we now have almost 100,000 people with HIV in the United Kingdom and that the cost of treatment and care has now risen to almost £1 billion a year? Given that this is an entirely preventable disease, does not my noble friend agree that we have devoted disgracefully little to HIV prevention programmes over the past decade and that our efforts here should now be urgently increased?

[Earl Howe]

My Lords, may I begin by paying tribute to my noble friend Lord Fowler in his continuing interest in HIV and AIDS, here and internationally? He has done a huge amount to raise the issue’s profile in Parliament and more widely. I agree with much of the thrust of what he said; there is no doubt that over the past 10 or 12 years great progress has been made in a number of areas, but we are still concerned about the increasing incidence of HIV among men who have sex with men and sub-Saharan African communities, which are the groups most affected and vulnerable to HIV in the UK. That is why our prevention campaigns have been targeted primarily at those communities. There is much more work to do. The sexual health framework report that we are publishing later this year will have a separate section on HIV, and I hope that in that document my noble friend will be reassured that our efforts in this area will not let up.

[Lord May of Oxford]

Would the Minister agree that while HIV is of special importance it is also a fact that all other sexually transmitted infections are showing similar marked patterns of increase? Should not the Department of Health be showing more concern about this than it currently seems to?

[Earl Howe]

The noble Lord is right to draw attention to the rising incidence of other sexually transmitted diseases. I draw the House’s attention in particular to the large numbers of cases of chlamydia and herpes, where he is perfectly correct in saying that the statistics are rising. In other areas, the statistics are stabilising—but he is generally right in the point that he makes. The data show that in 2010 there was a 1 per cent decrease in all diagnoses, but within that there are areas on which we undoubtedly have to concentrate.

[Baroness Gould of Potternewton]

My Lords, I am sure that the Minister appreciates how important it is to have early testing. What efforts will the Government make to ensure that GPs and other primary care professionals routinely offer HIV testing to all new patients, particularly in high prevalence areas? More than that, is any action being taken to give the new GPs and other new professionals the confidence, skills and ability to be able to offer that test?

[Earl Howe]

The noble Baroness with her experience makes a central point here. We absolutely agree that increasing the offer and uptake of HIV testing in a variety of healthcare settings is important to reduce undiagnosed HIV. We welcome the BHIVA professional guidelines in this area, which have been extremely helpful. The sooner a person with HIV is diagnosed, the sooner they can benefit from treatment and also make any behavioural changes to prevent transmission. It is those behavioural changes that count most strongly.

The department funded pilots to support the implementation of recommendations from the BHIVA, and those were extremely successful. In the coming days, we will consider carefully the report that is due to be published by the Health Protection Agency to see how we can take forward its findings in this area.

[Baroness Masham of Ilton]

My Lords, as a member of the House of Lords committee that produced the report, I pay tribute to our chairman, the noble Lord, Lord Fowler, for his excellent work. Is the Minister aware that one-quarter of the people with HIV do not know that they have it? That is extremely dangerous; late diagnosis costs a lot and many of those people die early. Will he do more to promote prevention?

[Earl Howe]

The noble Baroness is correct that about one-quarter of those with HIV are unaware of it, which is why testing in a variety of healthcare settings is vital and a targeted preventative approach to the two communities that I mentioned has to continue.

[Baroness Trumpington]

My Lords, following on from the previous speaker, perhaps my question is appropriate. The Minister knows my interest in this subject but would not the legitimisation of brothels be a great help, with regular health checks therein?

[Earl Howe]

My noble friend makes a serious point. This is not a subject on which I or, as far as I know, the Government have a fixed view, but I will ensure that her question is fed into our deliberations on the sexual health framework document.

[Baroness McIntosh of Hudnall]

My Lords, as a member of the committee of the noble Lord, Lord Fowler, I ask the Minister if he agrees that the contribution made by the voluntary sector to the effort both to prevent and to inform about AIDS is very significant. It is particularly important in the combating of stigma, which, as he will be aware, is a tremendous impediment to the good take-up of treatment and testing. Will he reassure the House that funding to the voluntary organisations that are most involved in HIV/AIDS will not be affected by the cuts that are currently being undertaken?

[Earl Howe]

My Lords, I readily join the noble Baroness in paying tribute to those voluntary organisations, not least the Terrence Higgins Trust, which over the past 10 years has done a great job in leading the department’s national programme of work—we believe that that has contributed in a major way to the increased uptake of testing in clinics—while for African communities the African Health Policy Network has managed the department’s national programme, working with community-based groups in a very positive way. Those two groups in particular are being funded this year. No decisions have been made about next year because a tendering process will apply, but this work needs to continue in some form.

Health: Diabetes

Earl Howe Excerpts

Thursday 14th July 2011 Lords Chamber

[Lord Morris of Manchester]

To ask Her Majesty’s Government what further action they are taking to help patients with diabetes.

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

To support the NHS in improving outcomes, NICE has published a quality standard for diabetes, providing an authoritative definition of good-quality care and building on the existing national service framework. This year, the NHS operating framework specifically highlights the need to do more to improve in-patient care for people with diabetes, the availability of structured education and retinopathy screening for everyone with diabetes, and access to therapies, including insulin pumps.

[Lord Morris of Manchester]

My Lords, I am grateful to the noble Earl for that Answer. Is he aware that 1.4 million people with diabetes are now at risk of preventable blindness, over a million of kidney disease, and up to 8,600 a year of having a foot amputated due to delayed diagnosis and treatment; and that doctors of distinction in this specialty insist that, with adequate resources, they could do much more to maximise prevention and treatment? Knowing as I do the depth of the Minister’s own concern for this policy area, when does he expect to be able to announce specific new measures to help the rapidly increasing number of children afflicted?

[Earl Howe]

My Lords, Ministers often express thanks to those noble Lords who table Questions but I owe a particular debt to the noble Lord, Lord Morris, for highlighting one of the greatest public health challenges of our time. He is absolutely right in all that he has said. I alight particularly on his point about prevention. We are committed to preventing type 2 diabetes. All our work on promoting an active lifestyle and tackling obesity will support that aim. The NHS Health Check programme has the potential to prevent many cases of type 2 diabetes and, as the noble Lord said, to identify thousands more cases earlier in their development. The Change4Life programme—the campaign that started under the previous Government, which we are continuing —raises awareness of maintaining a healthy weight and being physically active. A great deal of work is going on in this area, which is one of the major focuses of our public health programme.

[Lord Walton of Detchant]

My Lords, the Minister has indicated that there is a clear positive correlation between the rising incidence of type 2 diabetes on the one hand and the rising incidence of obesity on the other. What action are the Government taking to advise the population at large of the dangers of overeating?

[Earl Howe]

I have already mentioned the Change4Life programme, which is designed to raise awareness across a number of public health areas, including obesity and overeating. I think also of the Healthy Schools programme, which instils the need to eat healthily and take exercise in youngsters at an early age. As the noble Lord will know, there is no magic bullet for the problem of obesity. It is something that must be addressed in a variety of ways through public health programmes and general practice.

[Baroness Gardner of Parkes]

My Lords, does the Minister agree that foot ulceration precedes 85 per cent of amputations? A study in Southampton showed that, by keeping people in hospital and treating them well through preventing foot ulcers, over 36 months not only did patient outcomes improve but the National Health Service saved £1.2 million in in-patient time.

[Earl Howe]

My Lords, I am grateful to my noble friend. I have an astonishing figure in my brief. On average, 73 amputations of lower limbs occur every week in England because of complications to do with diabetes. It is estimated that, with the right care, 80 per cent of amputations carried out on patients suffering from diabetes would be preventable. That is the scale of the challenge. We are clear that this is a major issue for diabetes. NICE has published guidelines on in-patient management of people with diabetic foot ulcers and infection. That is vital because amputations are often preceded by ulceration. That is also why the national clinical director for diabetes considers diabetic foot care and prevention to be a major priority.

[Lord Harrison]

My Lords, will the Minister give an assurance that the retinopathy screening that was introduced by the previous Labour Government, and which has been so successful, will continue apace to match his own ambition of ensuring prevention by identifying diabetic disease of the eye at an early stage?

[Earl Howe]

The noble Lord, Lord Harrison, is quite right. England, along with the devolved Administrations, leads the world in this area. It is the first time that a population-based screening programme has been introduced on such a large scale. We are committed to continuing it. More people with diabetes are now being offered retinopathy screening than ever before and to higher standards, despite the increasing number of people with diabetes. The latest data that I have show that 98 per cent of people with diabetes have been offered screening for diabetic retinopathy during the past 12 months.

[Lord Rennard]

My Lords, is the Minister aware that people with diabetes are twice as likely to be admitted to hospital as people without diabetes? Will he undertake to look at best-practice models, such as that of the University Hospitals of Leicester, where diabetes specialist nurses have been stationed in the accident and emergency department and are able, in many cases, to advise against admission to hospital and provide more appropriate treatment and support? This is believed to have saved the University Hospitals of Leicester around £100,000. Diabetes UK estimates that, if rolled out nationally, such good practice might save the NHS up to £100 million a year.

[Earl Howe]

My Lords, I am aware of that excellent beacon of good practice in Leicester, which is an example that we welcome. It is an approach that is already being taken in other parts of the country. The NICE quality standard for diabetes states that people who have the condition, and who have experienced hypoglycaemia that requires medical attention, should be referred to a specialist diabetes team for advice and support to reduce admissions in exactly the way that my noble friend described.