Public Bodies Bill [HL]
Earl Howe Excerpts(13 years ago)
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Baroness Thornton
My Lords, I thank the noble Baroness, Lady Deech, my noble friend Lady Warwick and other noble Lords for their determination to have the future work of the HFEA and the HTA clarified during the course of the Bill. I join others in thanking the Minister for his patience and accessibility in discussing the different aspects of the issue.
We have had another excellent debate that has illustrated why it was necessary to bring the issue back to the Floor of the House for further discussion. The House needs to heed the voices raised across the Chamber—as well as the pleas contained in the letters that we have received from some of the parents of Alder Hey children, the letter in the Times this morning signed by a galaxy of medical experts and the briefing from the BMA on behalf of several organisations—as a sign of increasing concern.
Since Report, the Minister has kindly written to me explaining further the Government’s proposals for the HFEA and the HTA and the staged break-up that seems to be the Government’s preferred option at the moment. In brief, the break-up involves HFEA and HTA functions being transferred to the CQC except for research-related functions, which will be transferred to the health research regulatory agency, presumably covering what have been broadly referred to as the ethical issues. To facilitate this, as the noble Baroness, Lady Deech, explained, a special health authority will be created in 2011-12 and there will be primary legislation to establish the agency proper in the second Session of this Parliament. Presumably, the ethical issues will therefore be dealt with by the interim body in that process. Notwithstanding the proposals of the noble Lord, Lord Willis, regarding the Health and Social Care Bill when—indeed, if—it reaches us, it is clear that there will be primary legislation to establish the new research body.
I am further grateful to the Minister for his explanatory letter because it served to strengthen my view that these bodies should never have been in the Bill in the first place. It also illustrated for me the question that I want to put to him: why go through such disruption, risk, lack of stability, potential loss of expertise and expense for the next two years prior to the introduction of primary legislation to establish the new health research agency, which will address all of these issues? Why not agree the amendment that establishes an independent assessment of the work of both bodies? That could feed into the pre-legislative process and consultation, which will include all the questions that need to be asked, leading to primary legislation in about two years’ time. If the Government go down the route that the Minister is proposing, they intend to launch a consultation this summer, as outlined in the Minister’s letter to me, and then presumably will break up the agencies at some point towards the end of this year and the beginning of next. That means that at the beginning of 2012 the agencies would be broken up and then, by the end of 2012, we would start the pre-legislative programme to set up the new research agency.
That is why we on these Benches will be supporting all these amendments. It is not that either the HTA or the HFEA should be preserved for ever; indeed, it is clear that my noble friend Lord Winston and the noble Lord, Lord Patel, have grave problems with the HFEA. I make the point to the noble Lords, which I have also done outside the Chamber, that that is not the point of the Bill. Passing the amendments would actually be more likely to address their concerns than would leaving the situation as it is. In other words, there is no guarantee that their concerns about the HFEA, which I am sure are legitimate, would be addressed if we left the Bill as it is without the reassurances.
The one thing that we know is that there is going to be a health research agency. It is an idea of merit. It is also a proposal that is ideally suited to the expertise and inclination of this House; the Select Committee, the pre-legislative scrutiny, the draft Bill and, if I may say, the skills that the Minister brought to bear when he helped to create both these agencies make this the place where that process should start. I am certain that that would ensure a good outcome.
The amendments are different from the simple deletion amendments that we tabled in Committee and on Report, particularly the third amendment, because it accepts the principle that the Minister may transfer or modify the functions under Clause 5 in respect of these bodies but would require the Minister to have first established the Government’s new regulatory body with a separate ethics committee. It would ensure that there were no gaps between what is happening now with the current bodies and the Government’s intended independent regulatory body in future, a point that many noble Lords have made. However, it would not preclude an examination and independent assessment of the work of both these bodies. It would ensure that the critically important ethical functions performed by these bodies were recognised and catered for, which, in a way, is where we came in at the first stage of the Bill.
Earl Howe
My Lords, I thank noble Lords who have moved or spoken to these amendments. I recognise and understand the sentiments underlying them. I do not in the least wish to argue against or downplay the importance of cost-effectiveness in any legislative changes that we propose, or of ensuring that the right successor arrangements are in place for discharging the relevant functions of the HFEA and HTA. I therefore hope that what I am about to say will satisfy noble Lords that in most key respects I am in the same place as they are regarding the points at issue.
Since our debate on Report I have written to the noble Baroness, Lady Thornton, to set out my reflections on the points that she and others have made. There were common themes: a desire for greater clarity on where the Government intend to transfer the functions of the HFEA and HTA to; concern that the dispersal of functions across a range of bodies would risk fragmenting regulation; and concern over loss of expertise. I have considered these concerns carefully. As I have made clear, we intend to consult in the late summer on the options as to where certain functions would be most appropriately transferred. That remains our aim. However, having taken into account the strength of feeling about keeping functions together, we now intend to proceed on the basis that our preferred option is for all HFEA and HTA functions to be transferred to the Care Quality Commission, except for certain research-related functions that will transfer to the proposed health research regulatory agency. We shall therefore consult on this basis but, at the same time, remain open to receiving views on the way forward from all stakeholders through the consultation process. I hope noble Lords will agree that this preferred option will address concerns about the potential impact of fragmentation.
The noble Baroness, Lady Deech, expressed the fear that the Government’s proposals would lead to a vacuum as regards the ethical focus of these bodies—in the decision-making process for research and treatment involving embryos in particular. Let me explain what we intend. Ethical safeguards—for example, the type of embryo and gamete that can be used in treatment, the need to consider the welfare of the child, and the need for consent in respect of human tissue—are clearly enshrined in legislation in accordance with the wishes of Parliament. These safeguards will remain firmly in place.
In keeping an integrated approach to HFEA functions, the CQC would be the focal point for ethical considerations of treatment licensing that arise from the Human Fertilisation and Embryology Act. There is no reason whatever to suppose that it is not up to fulfilling that role. I say to my noble friend Lord Newton that my department’s officials have had discussions with the CQC senior managers about the proposed transfer of functions. The CQC is confident that these can be taken on effectively. The health research agency will provide a focal point for the ethical consideration of research using embryos. It will draw on expert advice, as the HFEA does now. The aim is to simplify and rationalise the ethical approvals process for all kinds of research. Far from the ethical focus for each type of activity being lost, it will be actively preserved.
My noble friend Lord Willis suggested that we might use the Health and Social Care Bill, now in another place, as the vehicle for the proposed changes, rather than this Bill. I recognise the force of his proposal. He will know why we have chosen not to go down that road. We do not want to add to what is already a substantial Bill. It is important, too, that the Government retain momentum for their planned changes across the ALB sector. The ALB review process has already garnered significant rationalisation across the health sector and we do not want that rolled back. By keeping the HTA and the HFEA within the Public Bodies Bill, we can deal discretely with complex issues and undertake detailed consultation and impact assessments in a timely and considered way. We also, as I have indicated on several earlier occasions, wish to avoid reopening the Human Tissue Act and the Human Fertilisation and Embryology Act, which command widespread agreement. Our desire to maintain momentum is why we plan to establish a special health authority to continue and strengthen the work of the National Research Ethics Service and to be a starting point for the simplification of research approval processes. That special health authority would be the platform on which we would build the fully fledged research regulator.
Lord Willis of Knaresborough
Does the Minister not understand the incredulity of many of us? This is a Bill that deals with getting rid of quangos, yet the Minister’s solution is to set up a quango to create time in order to set up a bona fide agency. Surely the Minister sees that by simply delaying the whole process until the agency is in place, everything can be transferred either to the CQC or to the new agency, all at once, without an interim body.
Earl Howe
I ask my noble friend to wait a few minutes; I hope I will tell him something that he will welcome.
I turn to the amendments. On Amendments 7 and 8 the issue is not so much the end point that they seek to achieve as the practical implications that they would carry if they were accepted. Let me set out what we plan to do. There will be a full public consultation on our proposals this summer. Alongside that, we will publish an impact assessment, which will include a view about the cost-effectiveness of options for transferring functions. I assure the House that the key comparison for the purposes of the assessment will be between our preferred option and the organisations’ own plans for rationalisation. I hope noble Lords will endorse the idea of a formal impact assessment as the vehicle for doing this. It is a process that, until now, has been accepted by Parliament for general legislative and policy changes. There does not seem to be any obvious reason why that should not be an appropriate way to proceed in this case.
In addition, as I have said previously, there will be a further consultation on the proposed regulations in due course before these are laid. Taken together, these three safeguards should be sufficient to meet the aspirations of noble Lords for achieving a robust evaluation. The approach that we propose on consultation and impact assessment will, I suggest, produce a result that is thorough, transparent, balanced and, therefore, fit for purpose. The amendments, taken literally, would have us go further by suggesting a formal process of independent assessment of cost-effectiveness. This would be neither necessary nor desirable. With the best will in the world, any such assessment would be costly to the public purse, highly subjective—as any assessment of cost-effectiveness is bound to be—and very difficult to measure definitively. Practically, it would get us no further forward than a standard impact assessment. In any issue of this kind, we need to take care that legislation does not set conditions that are impossible to meet. That is why I hope the assurances that I have given will be enough to persuade the noble Baroness not to press these amendments.
In turning to Amendment 9, I will address the question posed by my noble friend Lord Willis. The amendment seeks to ensure that no HFEA or HTA functions would be transferred using the powers in this Bill until the health research regulatory agency has been established. I fully appreciate the reasoning behind this. It very much accords with the Government’s wish to avoid a piecemeal approach to the transfer of functions. In my letter of 27 April to the noble Baroness, Lady Thornton, I said that,
“in principle our preference would be to consult on the draft secondary legislation during 2012 and to commence it after the primary legislation is place that will give the health research regulatory agency the necessary legal basis. In that way, transfer could take place as a single and clear exercise, and in a co-ordinated and least disruptive way”.
In the light of this amendment and the points made today in support of it, I am prepared to go further and give a firm commitment that, subject to the will and views of Parliament, the Government will proceed on the basis of transferring functions from the HFEA and HTA only once the research regulatory agency is established in legislation. I hope that this commitment will satisfy the House. There are problems with including the amendment in the Bill from a legal perspective. It is difficult to envisage how, within this Bill, we could describe with the necessary level of legal certainty the new research body that would need to be established. The detail of what a new regulator will look like and the functions it should hold is a matter for Parliament to debate and determine as and when the relevant legislation comes before it. To make provision for a future body in this Bill risks both describing it in a way that is not accurate, thus making the power to transfer functions redundant, and attempting to limit the discretion of Parliament in relation to future legislation.
The amendment also seeks to provide in this Bill that the research agency,
“must have a separate ethics committee to undertake … ethical consideration functions”
transferred to it from the HFEA and HTA. I fully appreciate the need for assurance that the research regulatory agency will have access to the relevant expertise to deal with the licensing of embryo research and any research-related functions that may transfer to it from the HTA. Therefore, I repeat the assurance that we have consistently given that expertise will follow function, and that we expect that the research agency will have access to expert peer reviewers and others in the relevant fields that are currently available to the HFEA and HTA. However, I suggest that the level of detail on matters such as expert committees is again more appropriate for consideration by Parliament in relation to any legislation that will seek to establish the research regulatory agency rather than attempting to include it prematurely in this Bill.
Although, for the reasons I have given, I cannot accept the amendment, as I indicated at the beginning of my remarks, I would like to believe that noble Lords who have spoken will not now be too far removed from the Government’s own position on these matters. In view of our developed approach to the transfer of functions and our clear intention to consult on our proposals in an open and transparent way, I hope that the noble Baroness will feel able to withdraw the amendment.
NHS: Waiting Times
Earl Howe Excerpts(13 years ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the four-hour A&E waiting time standard was replaced by a set of clinical quality indicators, incorporating measures of timeliness, in April 2011. The proportion of patients waiting for less than four hours during the four weeks up to 24 April 2011 was 96.7 per cent compared to 98.3 per cent in April 2010. The average median referral-to-treatment waiting time for admitted patients was nine weeks in February 2011 and 8.4 weeks in May 2010.
Baroness McDonagh
I thank the noble Earl for that Answer. It would be clearer to the House to explain that waiting times for in-patients are at a three-year, all-time high since the 18-week target was set and that A&E waits are rising sharply. I am sure the Minister accepts the evidence that longer waits for treatment cost more per patient and clinical outcomes are worse. Can he tell the House how much on average it is costing per additional patient for those waiting over the 18-week target, which amounts to tens of thousands of patients each month?
Earl Howe
My Lords, first, referral-to-treatment times fluctuate. Having looked at how the figures have moved over the past year or two, my advice is that they are broadly stable. The figures to which the noble Baroness referred were struck at a particularly pressurised time for the NHS. As she knows, there are all kinds of reasons why during the winter referral-to-treatment times tend to lengthen. However, the right in the NHS constitution to be treated within 18 weeks remains. On accident and emergency waiting times, our clear advice from clinicians was that the four-hour target should be adjusted to reflect the clinical case mix and clinical priorities.
Lord Kakkar
My Lords, I am sure the noble Earl is aware of the recent report from the Royal College of Surgeons on emergency surgical standards. Does he share its concerns about the potential detrimental impact of waiting list targets for elective procedures on clinical outcomes for patients requiring emergency operations? In asking the question, I declare an interest as a practising surgeon and professor of surgery.
Earl Howe
My Lords, we are quite clear that timeliness remains an important ingredient in the care of patients. However, we are also clear that it is not the only measure of quality. On emergency surgery, there is no reason to expect that patients will be treated any less urgently in the future than they have been in the past. What matters is clinical priorities being set correctly.
Baroness Sharples
Is my noble friend aware that very recently I was in A&E on a trolley at St Thomas’s for just under five hours waiting for a bed?
Earl Howe
My Lords, that does concern me. I do not think anyone could endorse the practice of patients remaining on trolleys. I hope my noble friend was seen and tended to in a timely manner, but what she describes does not sound to me as though it conforms with good clinical practice. However, I stress to her that the figures I have show that nationally hospitals as a whole are adhering to the new standards that have been set.
Baroness Finlay of Llandaff
My Lords, do the Government recognise that, until the shortfall of 1,280 A&E consultants is met, the quality indicators will not be met because they require consultant sign-off? They must not be interpreted as rigid targets because of the variability of clinical scenarios that present. Indeed, the Primary Care Foundation report showed that this consultant shortfall must be met because only 15 to 25 per cent of attendances could be seen by co-located primary care. That figure is much lower than other people had previously estimated.
Baroness Hussein-Ece
My Lords, attendance at A&E has steadily gone up by more than 1.3 million over the past five years. How much is this the result of the lack of access to GP out-of-hours services? Is it not the case that too many people are presenting at A&E who should be seen at a primary care setting?
Earl Howe
My Lords, I agree with my noble friend completely. That is why we are quite clear that general practitioners have to take much greater direct responsibility for out-of-hours care. At the moment they can, if they choose, divorce themselves from that responsibility and I think that was a retrograde move. Equally, we are clear that we should encourage general practitioners to look at ways of avoiding unplanned emergency admissions to hospital in the first place. That will reduce pressure on A&E.
Lord Reid of Cardowan
My Lords, I declare an interest as the person who introduced the 18-week target and limit. Clinical outcomes and efficiency are important but equally important are the pain and distress of the patients—and often their families—in waiting a long time. The Minister refers to things being no worse than in the past but in the past the waiting time after diagnosis—not counting the first consultation with a consultant or GP—to operation was two years and three years for the whole patient journey. That has now been reduced to 18 weeks and six weeks after diagnosis. Does the Minister accept that it would be a tragedy, inflicting huge pain and distress on many people, if that was now to be abandoned?
Earl Howe
My Lords, I agree with much of what the noble Lord said. There is no doubt that great strides were made under the previous Government to reduce waiting times. That is entirely to the advantage of patients. However, the noble Lord will know that, as I mentioned earlier, the NHS constitution still retains the right for treatment within 18 weeks and the contracts between commissioners and providers still retain the financial penalties if the 18-week target is broken.
Baroness Wall of New Barnet
My Lords, will the Minister reflect on the discussion that he and I have had in the past around how important waiting times are to patients? Despite the new six-week “more quality” input into how the analysis is done and the processes to which my noble friend Lady Finlay has just referred, there is still an issue when people leave hospital. They say they waited longer. We need to rethink what that really means. In the context of waiting lists, if we separate elective and A&E, as my husband is proposing, then we will do away with all of that.
Earl Howe
My Lords, the central point that the noble Baroness makes is absolutely right. We have to look at quality in the round. There is more to quality than simply timeliness, although, as I have said, timeliness of treatment is important. We need to develop indicators that show the full range of the level of care and service that patients receive. We are doing that.
NHS: Chiropody and Podiatry Services
Earl Howe Excerpts(13 years ago)
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Baroness Gardner of Parkes
To ask Her Majesty’s Government what plans they have to ensure the continuing provision of training and practice in chiropody and podiatry services under new commissioning consortia and the National Commissioning Board.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is the responsibility of local National Health Service organisations to commission services to meet the needs of their community and the education and training necessary to deliver them, including the provision of chiropody and podiatry services. This will continue in the future.
Baroness Gardner of Parkes
I thank the Minister for that reply. Does he share my concern that GP consortia may lack the necessary strategic overview to prioritise longer-term preventive care options and ensure future podiatric care? Can he further clarify whether Health Education England, or some other body, will have full responsibility for seeing that adequate numbers of podiatrists and chiropodists are trained?
Earl Howe
My Lords, let me first make it clear to my noble friend that GP consortia will not be responsible for commissioning training—at a local level that will be the responsibility of the skills networks, made up of healthcare providers. Health Education England will be a new organisation with new executive powers. It will provide national leadership on planning and developing the healthcare workforce and promoting high-quality education and training that is responsive to the changing needs of patients and local communities.
Lord Harrison
Is the noble Earl aware of the recent study by the American Podiatric Medical Association which demonstrates that early recognition of foot ulcers or foot problems in diabetics can prevent hospitalisation, or indeed amputation, if action is taken early and resources are commanded to deal with potential problems?
Earl Howe
My Lords, I am aware of that study. If we apply the lessons learnt to the UK, the noble Lord may already know that approximately 100 people have an amputation due to foot ulceration, as a complication of diabetes, every week. The International Diabetes Federation has estimated that 85 per cent of these amputations could be prevented through early intervention by a diabetic foot team that includes a specialist podiatrist. Indeed, the diabetes foot protection team in Southampton, to take one area, reduced in-patient stays from 50 to 18 bed days and saved £1.2 million in the first three years.
Baroness Trumpington
My Lords, is my noble friend the Minister aware that I consider that any feet over the age of six months are utterly revolting? However, I have a serious question: will wounded servicemen, who are unable to reach their own feet due to injury, be given free chiropody?
Earl Howe
I am grateful to my noble friend. She will know that the injuries sustained by our service men and women in the theatres of conflict form a high priority for the National Health Service and the Defence Medical Services. Indeed, chiropody and foot care will play a large part, I am sure, in ensuring the mobility of those wounded personnel. The key will be to ensure that there are sufficient chiropodists and podiatrists to deliver the services required, and that requires a process of local determination and prioritisation to ensure that workforce numbers meet healthcare needs.
Lord Morris of Manchester
My Lords, I have an interest to declare as president of the Society of Chiropodists and Podiatrists. Can the Minister give the House the Government’s estimate of the number of NHS patients who have suffered preventable amputations due to lack of state-qualified podiatric care?
Earl Howe
My Lords, it is obviously difficult for me to give the noble Lord a precise figure but his central point is absolutely correct. We know that many people suffer needless amputations who, if they had had early intervention, would be spared that appalling outcome. The role of chiropodists and podiatrists, as he will know more than anyone, is in the field of prevention not least for patients with diabetes but also in the care of the elderly to ensure mobility and proper foot care.
Baroness Jolly
My Lords, in some parts of the UK it is not possible to train as a podiatric surgeon. Consequently, podiatric surgery is not widely available. Will my noble friend tell the House whether in England the Government are planning to encourage more centres for training appropriately qualified podiatrists, thus remedying the situation?
Earl Howe
My Lords, my noble friend makes an important point. She will know that there are universities that specialise in the training of chiropodists and podiatrists, and we place great reliance on them. What will emerge from the new architecture that is foreshadowed by the Health and Social Care Bill is a much greater sense of local prioritisation regarding needs. Flowing from that, with the advice and guidance of Health Education England, which will be the national body supervising workforce requirements, we may well see further centres of excellence in training emerging.
Baroness Thornton
My Lords, I hope that the Minister will forgive me for being slightly personal, but I wonder how often he trims his toenails. I expect that he can actually reach his own toenails unlike many elderly people who cannot reach theirs, do not have anyone to do it for them and cannot afford a podiatrist. Would the Minister be happy to have his toenails trimmed once every three months, which seems to be the standard offer by health centres and GPs at the moment? I am sure that he will share my concern that even that service is under threat from the cuts at PCT level. Will the Minister undertake to ensure that podiatry services for the elderly become a priority for the National Commissioning Board?
Earl Howe
My Lords, I am fortunate in being able to cut my own toenails. However, the noble Baroness makes a serious point about the elderly. It is often the lack of that simple service that prevents elderly people being as mobile as they wish and sometimes confines them to their own homes. This is a serious issue in terms of the way that we can prevent unplanned hospital admissions due to elderly people falling over. The process that I have referred to whereby we will see joint health and well-being strategies emerging from the health and well-being boards at local level should ensure a sufficient supply of the workforce over a period of time.
NHS: Consultation on Reform
Earl Howe Excerpts(13 years ago)
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Lord Foulkes of Cumnock
To ask Her Majesty’s Government how they propose to report the outcome of the consultation on NHS reform to Parliament.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we ran a public consultation on NHS reform last year and received some 6,000 responses. As a result, we brought forward important changes to our modernisation proposals. We are now taking advantage of the natural pause in the legislative process to listen and reflect, supported by advice from the new NHS Future Forum. The Government will then respond to the forum’s report and the wider listening exercise, setting out the improvements that we will make to the Bill based on what we have heard.
Lord Foulkes of Cumnock
My Lords, did the Minister see the Statement by the Secretary of State that the reason for the pause was because the Bill was allegedly not understood and he had to explain it better? Will he explain to Mr Lansley that it is precisely because the Bill is well understood that there is such widespread opposition, including an unprecedented vote of no confidence by the Royal College of Nursing? Will he give a guarantee that substantial amendments will be brought before Parliament after the current consultation? Otherwise, it will be seen as a complete sham.
Earl Howe
My Lords, I think there is widespread agreement that the principles on which the Bill is based, such as devolving control of the NHS to local levels, placing patients at the heart of decisions about their own care and improving public accountability are the right principles for us to be guided by, but that there are also, as the noble Lord said, questions and concerns, some quite deep, about what we are doing and the mechanics of putting the principles into practice. As the Prime Minister and Deputy Prime Minister made clear, this is a genuine chance to make a difference. Where there are good suggestions to improve the legislation, those changes will be made.
Baroness Tyler of Enfield
My Lords, what steps are the Government taking to plug the gaps in the membership of the NHS Future Forum? Will the minutes of the forum be made available to the public?
Earl Howe
My Lords, the forum, as I understand it, is now fully composed. The appointments were made over the past 10 days or so. I am not aware of any further appointments. The plan is for the forum to produce a report which will be published at the end of the day. I will, however, write to the noble Baroness as regards the minutes, which are a matter for the chair of the forum, which is independent of the Government, as she will know.
Baroness Wall of New Barnet
My Lords, does the noble Earl agree that the pause and the mechanics that he has talked about have to be dealt with—there are lots of issues around that—but that the pause or gap is causing great concern to people working in the health service? Pause is an incidental word as regards the feelings of people who are going through this process and are caring for patients but are not sure what method they are supposed to be using. Will the noble Earl please tell us when we will know what is happening and how these people can get on with the job that they want to do?
Earl Howe
My Lords, I am aware of that concern. This matter has occupied the minds of Ministers. I say to those who are serving in the NHS day by day and, indeed, to the pathfinder consortia and the early implementer local authorities that they should continue with the work that they are doing because it is from them that we most wish to hear about the practical lessons that our proposals may point to. It is, I am sure, an unsettling time for them but we hope that after this period of reflection we can continue with the passage of the Bill with proper momentum.
Lord Ribeiro
Does the Minister agree with me that the principles referred to earlier underpin the NHS reforms? These principles are supported by the coalition Government and follow on from the same reforms that were introduced by the previous Government. I would like him to acknowledge that these principles should be reaffirmed in any response to the listening exercise.
Earl Howe
My noble friend is quite right: the principles that underpin the Bill and—I emphasise this—the principles that have always underpinned the National Health Service, are not going to change. He is right that the approach that we are adopting is in many senses an evolutionary one, following on from initiatives taken by the previous Government. I am grateful to him for pointing that out and I am sure that this will be a feature of the government response that we shall publish in due course.
Baroness Masham of Ilton
My Lords, does the Minister agree with me that there is some concern about so much of public health going over to local authorities? Will he give an assurance that directors of public health will be well qualified in public health?
Earl Howe
The noble Baroness makes a very important point about local directors of public health, who most certainly do need the right qualifications for that role. As she will know, they will be jointly appointed by local authorities and by the Secretary of State and we need to ensure that they can perform their role properly. The four main themes to the listening exercise are: choice and competition; public accountability and patient involvement; clinical advice and leadership—that may be an area that impacts on her question; and education and training. In some ways it is difficult to separate those issues; they are all of a piece and we do need to look at them very carefully.
Baroness Thornton
My Lords, if the current listening exercise hears the almost universal concerns about the Government’s proposal to introduce a new economic regulator into the heart of the NHS—concerns, I have to say, that were expressed but ignored by the Secretary of State right through the autumn and the spring—will the Government be removing that part of the Health and Social Care Bill?
Earl Howe
My Lords, no, because we are clear that the current system requires independent oversight of competition within the health service. Essentially, we have an unregulated health service at the moment; the Government in which she played a distinguished part as a Minister rolled out the independent sector treatment centre programme but its terms were, in the judgment of many, not fair. We need independent scrutiny and determination of pricing in the health service to ensure that there is a fairer playing field for all those providers of NHS services.
NHS Reform
Earl Howe Excerpts(13 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the NHS operating framework 2011-12 set out that, to retain effective management capacity in all PCTs until their abolition in 2013, subject to parliamentary approval, PCTs should form clusters managed by single executive teams. This clustering arrangement will support PCTs in preparing for and transitioning functions to GP consortia.
Lord Dubs
My Lords, does the Minister not agree that too much reorganisation is more than the health service can stand? What on earth is the point of abolishing PCTs and re-establishing them in clusters two years before they are going to be abolished? It makes no sense at all unless the Government are going to change their mind about the main legislation.
Earl Howe
My Lords, when we went out to consultation on the White Paper last summer, concerns were raised that the transition could lead to too much disruption and a decline in the quality of services, as well as a loss of accountability, so the department decided to expand the approach to managed consolidation of PCT capacity and establish the clusters nationwide. That has been done already in London and the north-east and will pave the way for the NHS commissioning board to develop its roles. It will maintain accountability and grip during 2011-12 and the subsequent year, once strategic health authorities have been abolished. We are using existing legislative powers and it will help to oversee delivery in the coming two years.
Lord Kakkar
Is the Minister able to confirm that the future GP commissioning consortia will be constituted in such a way that they are obliged to conduct their responsibilities according to the Nolan principles?
Earl Howe
That is a very interesting question. GPs should already be subscribing to the Nolan principles. They are attributes which they would wish to demonstrate in their working lives anyway—having said which, it is the responsibility of every public body to ensure that it takes account of the Nolan principles. Consortia will be public bodies, ergo they will have to take account of the Nolan principles.
Baroness Jolly
Would my noble friend tell the House whether any staff have already been seconded to the pathfinder commissioning consortia, as a result of the clustering of the PCTs?
Earl Howe
We are assigning particular staff to pathfinder consortia. Those staff will remain within the PCT clusters. They will not transfer officially to the consortia because the consortia are not officially in existence yet. The point here is to have staff who are dedicated to supporting the emerging consortia over the next few months. This is already in train.
Baroness Thornton
My Lords, given the progress that has already been made in dismantling the PCTs and the strategic health authorities ahead of legislation, and the millions given to GP consortia to establish their role as commissioners, are the Government not in danger of pre-legislative implementation? Does it not beg the question as to where the role for pre-legislative scrutiny, or indeed any meaningful scrutiny in the House, might be on the matter? Will the Minister assure the House that, when we eventually receive the Health and Social Care Bill, reorganisation will not have progressed beyond the point of no return?
Earl Howe
My Lords, the noble Baroness will know that her own party’s plans included a 30 per cent reduction in administrative and managerial costs throughout the health service. We agree with that and we have got on with it. It is right that, when a Government come in and announce their intentions, as we did, expectations should be managed, as we are doing, and uncertainties should be allayed. The way to do that is to get on with the process.
Baroness Finlay of Llandaff
Can the Minister tell us how the clinical governance arrangements in primary care will be safeguarded during a time of transition, particularly because clinical decision-making can be adversely affected when people are concentrating on many management restructures?
Earl Howe
My Lords, we are clear that the essential functions of the primary care trusts should continue. That includes monitoring clinical governance within primary care. Having said that, I am sure that the noble Baroness will agree that clinical governance in the primary care context has not been all that it might be, which is why we believe that the new arrangements will considerably strengthen that governance.
Lord Naseby
My Lords, does my noble friend agree that it was common knowledge that PCTs needed reorganising because they were not meeting patient needs? Furthermore, doctors themselves found that the PCTs were getting in the way of treating their patients properly. Frankly, had not PCTs also created a huge bureaucracy, so that money was being soaked up in bureaucracy rather than being used for patient care?
Earl Howe
I agree with every word my noble friend said. It is illustrative of the truth of his remarks that, in the final year of the Labour Government, the administrative costs of the NHS rose by no less than £220 million. The rise in administrative costs was exponential. My noble friend is right: at the moment we largely have an NHS that is managerially and administratively led, rather than clinically led. We want to reverse that balance.
Baroness Farrington of Ribbleton
Will the Minister give the House two assurances? One is that the Government have done nothing that is not legal in anticipation of the Health and Social Care Bill being passed. Secondly, although he may not have the figures with him, what are the relative administrative costs of private healthcare providers and the NHS?
NHS Reform
Earl Howe Excerpts(13 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House, I shall now repeat a Statement that was made in another place this afternoon by my right honourable friend the Secretary of State for Health. The Statement is as follows:
“With permission, Mr Speaker, I should like to make a Statement about NHS modernisation. At the outset I should say that modernisation of the NHS is necessary, it is in patients’ interests and it is the right thing to do to secure the NHS for future generations.
The Health and Social Care Bill is one part of a broader vision of health and health services in this country, which are among the best in the world, where we have world-leading measurement of the results that we achieve for patients, where patients always experience ‘no decision about me without me’, where national standards and funding secure a high-quality, comprehensive service available to all, based on need, not ability to pay, and where the power to deliver is in the hands of local doctors, nurses, health professionals and local communities.
The House will know that the Bill completed its Committee Stage last Thursday. I was also able to announce last week that a further 43 GP-led commissioning consortia had successfully applied to be pathfinder commissioning groups. We now have a total of 220 groups representing 87 per cent of the country; that is 45 million patients whose GP surgeries are committed to showing how they can further improve services for their patients. In addition, 90 per cent of relevant local authorities have come forward to be early implementers of health and well-being boards, bringing democratic leadership to health, public health and social care at local level.
This progress is very encouraging. Our desire is to move forward with the support of doctors, nurses and others who work in the NHS and make a difference to the lives of so many, day in, day out, but we recognise that this speed of progress has brought with it some substantive concerns, expressed in various quarters. Some of those concerns are misplaced or based on misrepresentations, but we recognise that some are genuine. We want to continue to listen to, engage with and learn from experts, patients and front-line staff within the NHS and beyond and to respond accordingly.
I can therefore tell the House that we propose to take the opportunity of a natural break in the passage of the Bill to pause, listen to and engage with all those who want the NHS to succeed and subsequently to bring forward amendments to improve the plans further in the normal way. We have, of course, listened and improved the plans already. We strengthened the overview and scrutiny process of local authorities in response to consultation and in Committee we made amendments to make it absolutely clear that competition will be on the basis of quality, not price. Patients will choose and GPs will refer on the basis of comparisons of quality, not price.
Let me indicate some areas where I anticipate that we will be able to make improvements in order to build and sustain the support for the modernisation that we recognise to be crucial. Choice, competition and the involvement of the private sector should only ever be a means to improve services for patients, not ends in themselves. Some services, such as A&E or major trauma, clearly will never be based on competition and people will want to know that private companies cannot cherry pick NHS activity, undermining existing NHS providers. That competition must be fair. Under Labour, the private sector got a preferential deal and £250 million was paid for operations that never happened. We have to stop that. People want to know that the GP commissioning groups cannot have a conflict of interest, are transparent in their decisions and are accountable not only nationally but locally through the democratic input to health and well-being boards. We, too, want this to be the case. People want to know that the patient’s voice through Healthwatch and in commissioning is genuinely influential. Doctors and nurses in the service have been clear that they want the changes to support truly integrated services, breaking down the institutional barriers that have held back modernisation in the past.
As I told the House on 16 March, we are committed to listening and we will take every opportunity to improve the Bill. The principles of the Bill are: that patients should always share in decisions about their care; that front-line staff should lead the design of local services; that patients should have access to whichever services offer the best quality; that all NHS trusts should gain the freedoms of foundation trust status; that we should take out day-to-day political interference through the establishment of a national NHS Commissioning Board and through strong independent regulation for safety, quality and effectiveness; that the public’s and patients’ voice must be strengthened; and that local government should be in the lead in public health strategy. These are the principles of a world-class NHS that command widespread professional and public backing. All these principles will be pursued through the Bill and our commitment to them as a coalition Government is undiminished. We support and are encouraged by all those across England who are leading these changes nationally and locally and we want them to know that they can be confident in taking this work forward. Our objective is to listen to them and to support them as we take the Bill through.
No change is not an option. With an ageing and increasing population, new technologies and rising costs, we have to adapt and improve. Innovation and clinical leadership will be key. We want to reverse a decade of declining productivity. We have to make productive care and preventive services the norm and we must continue to cut the costs of administration, of quangos and of bureaucracy.
The House knows my commitment to the NHS and my passion for it to succeed. To protect the NHS for the future must mean change—not in the values of the NHS but through bringing forward and empowering leadership within the NHS to secure the quality of services on which we all depend. Change is never easy, but the NHS is well placed to respond. I can tell the House today that the NHS is in a healthy financial position. Waiting times remain at historic low levels, as promised under the NHS constitution. Patients with symptoms of cancer now see a specialist more quickly than ever before. MRSA is at the lowest level since records began. We have helped over 2,000 patients to have access to new cancer drugs that previously would have been denied to them. This is a testament to the excellent work of NHS staff up and down the country and we thank them for their efforts to achieve these results for their patients.
This coalition Government are increasing NHS funding by £11.5 billion over this Parliament, but the service cannot afford to waste any money. We can sustain and build on these improvements only by modernising the service to be ever more efficient and effective with taxpayers’ money. The Bill is a once-in-a-generation opportunity to set the NHS on a sustainable course, building on the commitment and skills of the people who work for it. Our purpose is simple—to provide the best healthcare service anywhere in the world. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Earl Howe
My Lords, I am grateful to the noble Baroness for her not entirely critical response, in that she acknowledged that we are listening to the concerns that have been expressed. I am almost tempted to remind the House of that dictum of Oscar Wilde or at least to modify it: if there is one thing worse than not listening, it is listening.
I believe that it is right for the Government to take advantage of a few weeks where Parliament is going into recess in order to take stock of some of the criticisms that we know are being voiced about the possible effects of the Bill; indeed, some arose in last Thursday’s debate in your Lordships’ House.
Let me answer the noble Baroness’s points in turn. We are clear that the modernisation of the NHS is a necessity and not an option. There is significant evidence that our reforms across the country, as evidenced by the pathfinders mentioned in the Statement, are welcomed by general practitioners. We have been engaged in a continuous process of listening and engaging. The consultation process following the publication of the White Paper, our response to that and our clarification of the kind of competition that we wish to see in the health service are all examples of that approach.
We remain completely committed to the principles of the Bill that patients should be involved in decision-making about their care, that there should be a stronger patient voice and that there should be stronger clinical leadership in the way in which services are commissioned. We are completely committed—I hope that the House will hardly need me to say this—to the founding principle of the NHS: universal access free at the point of use, regardless of the ability to pay. Indeed, that is what the reforms are about. They are about protecting the NHS now so that it can survive into the future.
This pause—and that is all it is—is about taking advantage of the short break in the parliamentary process of the passage of the Bill as we go into the Easter Recess by listening to how these measures are being received on the ground and taking stock of the feedback that we get. It is about ensuring that those implementing the changes on the front line have everything that they need to help the NHS to improve for the better.
We have listened and we will continue to listen. The noble Baroness was a little doubtful that the Government had ever been in listening mode. I hope that she will recognise that, in response to the White Paper consultation last summer, we made a number of changes to our proposals: strengthening the role of health and well-being boards; creating a clearer identity for Healthwatch England; increasing the transparency in commissioning by requiring all GP consortia to have a published constitution; and changing our proposal that maternity services should be commissioned by the NHS Commissioning Board. All those were a response to feedback that we had had. When we introduced the Bill in January, we amended it in a number of ways to respond to particular concerns that had been raised in another place. I have already mentioned competition only being on the basis of quality and not price. We are continuing to listen to the messages that have come out of Committee stage in another place.
It is a pity to hear the noble Baroness criticise our plans for an economic regulator, as that is the way in which we see a fairer playing field emerging for providers to the NHS. We do not have the guarantee of a fair playing field at the moment. As the Statement pointed out, her Government—for the best of motives—engaged the independent sector in providing services to the NHS, but they did so on very preferential terms, which in my book were unfair to and disadvantaged the NHS. We want the system to be blind to the ownership of providers so that patient choice and the quality of services determine where care is provided for the individual patient and so that there is no bias, or as little bias as possible, in the system. You can achieve that only through independent regulation.
It is not true to say that we want a market free-for-all; that is far from the truth. Again, however, this listening exercise will enable us to take stock of opinions on that score. Moreover, if there are some unintended consequences emerging from the Bill as worded, we will certainly address them. We have no wish to get this wrong. As the noble Baroness said, this is too important a matter to get wrong. I hope that, despite her scepticism of and opposition to much of what the Government are seeking to do, she will seek to engage constructively in order to ensure that we take advantage of the opportunity that we now have to drive further efficiencies and quality in the way in which care is commissioned in the NHS. We want to put the patient truly at the centre of healthcare and thereby create a more cost-effective service for the taxpayer. I believe that we will come out of this period of reflection stronger, because no doubt we will have some clear messages that we will need to reflect and act on.
Lord Alderdice
My Lords, I am grateful to my noble friend for repeating the Statement made in another place and I will not rehearse our support on these Benches for reform of the health service. Some of those reasons were wonderfully spelt out by the noble Lord, Lord Turnberg, in his debate on the NHS last week. However, it is no secret that Members on these Benches do not regard the Bill as it presently stands as perfect. Despite the fact that it did not receive a great deal of attention in the speculative narrative of the noble Baroness, Lady Thornton, it is known that my colleagues want to see changes and indeed have welcomed some of the changes that we have already seen.
I wonder if I may press my noble friend on two issues. The first was also raised by the noble Baroness—the timescale. My noble friend indicated that he sees the timescale as using the Recess, but the Health Secretary wishes to engage and consult with a substantial number of people. Given that, when the Bill comes back after Report in the other place with amendments, which we would welcome, can we expect it to come to this House before the Summer Recess or will the natural break take us a little further? That may be necessary, and some clarity would be helpful, if my noble friend can provide it.
Secondly, in repeating the Statement my noble friend mentioned increasing accountability,
“locally, through the democratic input to the Health and Wellbeing Boards”.
I and my colleagues welcome this, but can he spell it out a little further? At present, the locally elected democratic input to health and well-being boards is extremely modest, so we would be keen to see an indication that something rather more substantial might be possible.
Earl Howe
I am grateful to my noble friend. In answer to his first question, it is likely that the period of listening and engagement will extend through the Easter Recess and beyond. The precise duration of the intermission has not been fixed yet because much will depend on the volume of feedback that we receive. While I have not spoken to the usual channels about this, I am still working on the premise that your Lordships’ House will receive the Bill prior to the Summer Recess. I believe that, if the House agrees, we can thereby reach the Bill’s conclusion within a reasonable space of time. That will enable us to adhere to the current timetable for the implementation of our proposals. But that statement does come with what I might call a health warning because we are clear that we want to listen to the opinions of everybody who counts in this, and it could be that the period of reflection may extend into the late spring. But no doubt I will be able to enlighten him further in due course.
My noble friend mentioned the democratic input at health and well-being board level. This is one of the issues that we will want to receive opinions about because I know there has been disquiet on this front. He knows that his party was instrumental in building into our plans the democratic element of health and well-being boards and the fact that they should be situated at local authority level. That was a very positive contribution made by the Liberal Democrat Party which has, by and large, been widely accepted. If there are ways we can bolster that democratic accountability without cutting through the core principles that we have articulated for decision-making in the health service, then we are willing to look at them.
Lord Touhig
My Lords, the Minister said that the NHS was in a healthy financial position and that the Government intend to increase NHS spending by £11.5 billion over the life of this Parliament. Yet, in the last financial year, the NHS had an underspend of £5.5 billion and the forecast this year is a further underspend of another billion. The Chancellor has said that he intends not to hand this money over to the NHS but to keep it in the Treasury. The Nuffield Trust says that this is a retrospective cut in health spending. Does the Minister agree?
Earl Howe
My Lords, the noble Lord needs to bear in mind that the forecast surplus for 2010-11 represents a very small proportion of the department’s budget. It is greatly to the credit of the health service and the department that they have managed to come in on the right side of the line and by a margin that, in the scheme of things, is not significant. I say that without being at all blasé about the figure of £1.4 billion. I suggest to the noble Lord that that represents good financial management. Yes, the money that represents the surplus cannot be carried forward into the subsequent year but that is not the same thing as saying that providers, for example foundation trusts, may not use their carry-forward balances. That is still possible at provider level. I hope, on reflection, that the noble Lord will not think too badly of the way the service has been run in the past few months.
Lord Blackwell
My Lords, I am sure the Minister must be correct that, in a reform of this scale and magnitude, it is right to take as much advantage as possible to listen to those who can help in the implementation and timing of the reforms. I hope he can also assure the House that the Government will not be diverted from the essential purpose of these reforms by those who have never accepted that public services do not need to be run by a central organisation in a public monopoly. As my noble friend will be well aware, we were already some way down this road in 1997 with GP fundholder practices. We wasted five years when the then Government reversed those changes and went back to a centralised organisation before realising that that would not work and had to restart the process of introducing delegation and alternative providers into the NHS.
We are now 10 years further on from that and it is important that the changes are not lost in the voices that will always oppose changes that are necessary to reform the way that the NHS works. I hope that, while listening to those voices, the Minister can assure us that these essential reforms will be carried through and that the period of uncertainty for the NHS will not be any longer than it needs to be before we can get to the kind of reformed NHS that we all want to see.
Earl Howe
My Lords, I am grateful to my noble friend and can give him those assurances. He is right: we have somehow got ourselves into the position of having a National Health Service that is, in essence, managerially and administratively led instead of being clinically led. That has happened by a process of accretion and slow and steady development. We need to get back to one of the principles that the incoming Labour Government articulated in 1997 when they introduced primary care groups. That was an attempt by them to do exactly what we are trying to do: to have clinically led commissioning in the health service. Unfortunately, to my mind, primary care groups morphed into primary care trusts and thereby became administrative units which became more and more divorced from clinical decision-making.
I can reassure my noble friend that we do not want to dilute the principle of clinically led commissioning. We believe that it is right and that we can build on the experience of the past; not just primary care groups, but also the good parts of fundholding, which had some good elements, and practice-based commissioning groups, which the previous Government introduced. This is an important opportunity, as I said earlier, to capitalise on the NHS as it now is and to shed some of the unhelpful elements that get in the way of driving quality and patient care.
Lord Patel
My Lords, the Statement suggests that the Government are satisfied with the performance of the health service, both fiscally and in the quality of care it provides. It is therefore surprising that the Statement also says that we need to improve productivity and quality. How does an economic regulator promote competition based on quality?
Earl Howe
The economic regulator will do two things. It will fix prices for the purposes of the tariff and it will preside over the marketplace—such as it exists—in healthcare so that anti-competitive conduct will be prohibited. It will bear down upon conflicts of interest and anti-competitive practices of all kinds and, in conjunction with the NHS commissioning board, it will ensure that the pricing system in the NHS incentivises quality. There are, as the noble Lord knows, a number of levers that we can use to do that through the tariff.
Lord Warner
Is the Minister aware that many people are concerned about whether the Government will listen excessively to those who make the greatest noise among some of the vested interests that the Bill tries to tackle? Is he aware that many people wish to look at the Bill forensically to make sure that changes in commissioning lead to more competent commissioners, something we have not achieved in the past: that we start to dismantle some of the barriers to entry in order to create more diverse providers; and that we look very seriously at the pricing system to make sure that it does not just put money into the pockets of acute hospitals, but brings more care closer to home?
Earl Howe
I am grateful to the noble Lord, Lord Warner, whose book, I may say—without indicating that I am in receipt of a commission for saying so—deserves reading by every thinking healthcare commentator. He is right, of course; we need to ensure that the vision that I think is shared by many in this House, regardless of party, can be successfully implemented. I recognise the implication of his question, which is that this House is eminently capable of examining the Bill forensically. When it comes to us I have no doubt that we will do that however long it takes, and I look forward to that. However, it would be a rather cloth-eared Government who were insensitive to the voices that have been heard in recent days outside this Chamber and another place. We need to dispel many of the misunderstandings that exist as well as address some of the genuine misgivings that people have. It is right that, without losing too much momentum in the process, we take these few weeks to do just that.
Lord Ribeiro
My Lords, I thank my noble friend for repeating the Statement. The health reforms are necessary because they address the complexity and cost of medical care, which are growing daily as our population also grows. Our elderly population is growing simply because of the improvements in healthcare over the past few years. Here I acknowledge the unprecedented funding provided by the previous Government to stimulate the health service in its development. This Government have agreed to enhance that funding.
The noble Lord, Lord Darzi, signalled a change from process management to service delivery based on quality. This Government have accepted the challenge to pursue a quality agenda, knowing that, although quality care is costly, at the end of the day—particularly in my speciality, surgery—there is no question that good quality care, particularly the use of minimally invasive surgery, leads to early discharges of patients and better outcomes. I hope that this principle of quality is something that the Government will pursue. Is it my noble friend’s intention that the emphasis in health reforms should remain on quality outcomes being the bedrock of the reforms?
Earl Howe
I can reassure my noble friend Lord Ribeiro instantly on that. He will know, I am sure, that the acronym that was coined by the previous Government, QIPP, which stands for “quality, innovation, prevention and productivity”, is symbolic of a whole series of workstreams not just in the Department of Health but throughout the health service to ensure that quality is maintained and enhanced in the service. Unless we deliver higher quality to patients, the service will not be sustainable. Some people say that higher quality care costs more money but, as my noble friend will know from his own craft speciality, the better the care that you deliver the less costly it often is because care that is delivered in a substandard way often results in unintended consequences, such as patients returning to hospital with complications. We need to drive safe care and right care in the system.
Many of the levers that we have to improve quality are not in the Health and Social Care Bill at all—for example, the need to roll out the information agenda, without which there can be little transparency of quality. Those activities are being pursued with energy and drive in my department.
Lord Beecham
My Lords, months after the Bill was launched upon an unsuspecting world—including, apparently, the Prime Minister—it seems to have been admitted to the fracture clinic if not to the intensive care ward. A number of questions arise from the Statement itself. For example, the Statement says:
“Some services, like A&E or major trauma, clearly will never be based on competition”.
Is not the implication that other services will be based on competition? Will the Minister comment on the predominant role of Monitor as a promoter of competition, as opposed to being simply an economic regulator?
On the GP commissioning groups or consortia, will the Government look again at the composition of those groups as well as their degree of local accountability? Will he also look at the powers of the health and well-being boards? Does he have any views about those in addition to the question of their composition?
As for the NHS being in a healthy financial position, does the Minister have any comment on tonight’s story in the Evening Standard about people who were made redundant last Friday having to be re-engaged by PCTs and other organisations, at considerable cost to the NHS?
Earl Howe
My Lords, those who have been re-engaged by the health service, having taken redundancy or early retirement, will forfeit their redundancy pay because there is a clawback arrangement in force, as I told the House the other day.
The noble Lord asked a number of questions. I want to be very brief because I am aware that the noble Baroness, Lady Masham, wants to get in before the time is up. Monitor was described as a promoter of competition. Expressed in stark terms like that, it sounds as though its job will be to go around drumming up competition where there is none already. That is not a correct reading of its functions; it is there to bear down on anti-competitive conduct and to ensure fair competition. The composition of consortia is a concern that we have heard about, and we will listen to that concern. It is now up to the pathfinder consortium to think about this kind of question. The early implementers of health and well-being boards are starting to think about those powers and how they can be used and we will listen to whatever they have to tell us.
Baroness Masham of Ilton
My Lords, is the Minister aware that patients very often cannot get an appointment with the GP of their choice so there is no continuity? If GPs have to undertake administration on the consortia, will this not get worse? Would it not be better if the consortia consisted of a mixture of GPs, specialists, nurses, administrators and patients? Working together would surely be better than working in conflict.
Earl Howe
The noble Baroness is absolutely right about working together, and our vision for good, clinically led commissioning is that all clinicians, not just GPs but everyone with a stake in the patient pathway, should join together and determine what good care looks like. However, she is mistaken in her first assumption. We are not asking thousands of GPs to become administrators. It will take only a very few to took after the commissioning of care in consortia, and the administration will be taken care of by management employed by the consortia.
Health: Obesity
Earl Howe Excerpts(13 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank my noble friend for raising this important issue, about which he knows a very great deal. I value the insights that he was able to give us in his most informative introductory speech.
Obesity is one of our biggest public health challenges. In England, three-fifths of all adults and more than a quarter of children aged two to 10 are overweight or obese. The noble Baroness, Lady Thornton, reminded us of some other statistics in that connection.
Already, more teenagers and young adults are being diagnosed with type 2 diabetes. Experts tell us that if obesity stays at anywhere near its current high levels the health of the population will deteriorate dramatically in the years ahead. For instance, the National Heart Forum has predicted that, by 2050, the number of people getting diabetes because of their weight will nearly double and those with heart disease caused by obesity will rise by 44 per cent.
Our first thought has to be the human cost. Just as obesity cuts years from a person’s life, it also takes life from a person’s years. Statistics do not really convey the long-term effects of diabetes. They include limb amputations, long-term disability, chronic pain and heart disease, robbing people of their energy, their independence and their chances of a decent quality of life.
The other consideration is financial cost. Obesity already costs the NHS £4.2 billion. That figure is set to double by 2050. The prognosis is simple: make rapid progress or face a personal and financial catastrophe within a generation. As a country, we need to change our behaviour. The White Paper on public health sets out a new approach to improving people’s health that is locally centred, outcomes-driven and professionally led.
New local health and well-being boards will help to bring together the NHS and local government under a shared local strategy. The outcomes framework for public health will provide consistent measures to judge progress, and this includes two potential indicators covering obesity. Public Health England, a new, dedicated national public health service, will provide the resources, ideas and evidence to support local strategies. A specific obesity document will follow, setting out how the new system will work to reduce obesity levels.
However, as important as systems and structures may be, this is also about changing cultures. It is about encouraging greater personal responsibility. We have found that the state does not have all the answers, and the more the state intervenes, the more individual responsibility shrinks back. Rather than nannying people, we must nudge them, as the noble Lord, Lord Patel, reminded us, giving them the support and encouragement they need to look after their own health.
Although the noble Lord, Lord Patel, raised this subject, he expressed some doubts about its efficacy. I simply say to him that the Government cannot change people’s behaviour; what they can do is help people to change their behaviour themselves by encouraging them, rewarding them, making it easier and making it the norm. We can provide information to individuals to help them to make informed decisions about their health and we can provide encouragement, which we are already doing.
The noble Lord was doubtful whether the voluntary approach would work. I share his wish for an evidence-based evaluation of whatever we do. That is a core component of the responsibility deal and we are investing in it. However, as part of our new approach, we will consider what can be achieved through voluntary approaches before considering regulation. People’s lifestyle choices are affecting their health. The Government cannot address that challenge on their own. We believe that collective voluntary effort can deliver more progress and do so more quickly than regulation. Through the public health responsibility deal, we can tap into the unrealised potential of a wide range of resources that can promote healthier lifestyles and support people in achieving them. We have examples of working with industry, and this approach works. Change4Life is a recent example of how we have successfully worked with industry. We firmly believe that collective voluntary efforts can deliver real progress. The responsibility deal and deliverables arising from it have to deliver real improvements to public health, and we are looking at what independent monitoring or evaluation will be needed to that end.
While obesity often has complex social, psychological and cultural foundations, its basic cause is simple. My noble friend Lord McColl spoke about energy balance in its broadest sense. He is right: people become overweight because they take in more calories than is necessary and they do not burn off the excess calories that they do not need. I do not think that my noble friend was arguing against that proposition. It is a point clearly made in the NICE guidance on obesity and being overweight, and it is central to the Government’s approach. The NICE guidelines on obesity address the prevention, identification and management of obesity. They stress the importance of addressing both diet and energy out. The guidelines were based on the best available evidence that NICE had at its disposal at the time. However, my noble friend will be reassured to hear that NICE’s clinical guidelines are updated as required so that recommendations take into account important new information, and the obesity guideline is no exception to that.
My noble friend referred to the work of Professor Wilkin. The department is familiar with the EarlyBird diabetes study by Professor Wilkin. The study makes some useful points concerning the importance of early-life experiences for future health. It provides some useful messages on the importance of a child’s early years and the impact that this can have on the child’s future health and behaviour. However, this is one study which needs to be seen alongside other research with different findings on physical activity and weight.
My noble friend Lord McColl made very clear his emphasis on diet as the more important ingredient in weight loss. However, I think he would agree that any planned weight management programme should be tailored to the person’s preferences—their initial fitness, their health status in general and their lifestyle. The NICE guideline recognises that relatively high levels of activity may be required by certain individuals wishing to lose weight or maintain weight following weight loss. However, it also emphasises that, while an individual’s ability to be physically active may be hampered by their initial level of fitness or comorbidities, physical activity recommendations can be built up gradually, be focused on everyday activities, such as walking, and be accompanied by a reduction in sedentary behaviour. The guideline includes a raft of recommendations for clinical practice on dietary management.
Therefore, what is to be done? First, we need to give people the information and the opportunities so that people can choose to change their diet and lifestyle. A powerful way of doing this is through the Change4Life brand, which helps people to cut down on fatty and sugary foods and become more active. Another is working with industry to guide people towards healthier choices. The noble Lord, Lord Campbell-Savours, asked why we cannot ask restaurants and so on to place calorific content on menus. Through the responsibility deal, we now have 29 partners who are committed to posting calorific content on their menus in more than 4,000 restaurants. The noble Lord, Lord Patel, mentioned trans-fats, and my noble friend Lord Addington also referred to the fat content of food. They are both quite right. They will be pleased to hear that businesses have already committed themselves to removing artificial trans-fats from foods so that people can keep the tastes they enjoy without suffering such negative consequences. We shall continue to work with industry on other measures to help people to reduce their calorie intake, including reformulation. We will say more in the obesity document when it is published later this year.
A second issue is improving access to healthier food. In some areas, local shops simply do not stock healthier options. We are working with the Association of Convenience Stores to make fresh fruit and vegetables more available. The scheme has expanded incredibly quickly, with participating stores seeing a marked increase in the sale of fruit and vegetables. Of course, even if people have fresh produce, they still need to know what to do with it, so education is vital. There are many great local initiatives—involving the NHS, local authorities and a range of partners—which provide cookery schools and other local healthier eating initiatives.
The noble Baroness, Lady Thornton, spoke very eloquently about school food, and I agree with a lot of what she said. The Government are committed to ensuring that pupils can eat healthy, nutritious school food. We are supporting the School Food Trust in its work to help caterers to become more efficient while continuing to provide healthy meals. The schools budget will increase by £3.6 billion in cash terms by 2014-15—the end of the spending review period. Although the school lunch grant will not remain as a specific grant, it will be one of the grants that make up schools’ baseline funding from 2011-12. It will, however, no longer be ring-fenced; it will be for schools to decide how to spend the money.
We have not changed the current rules for free school meals. Therefore, some 900,000 pupils in the neediest families—those without work—continue to receive free meals. We took the difficult decision not to extend eligibility to low-income working families because the previous Government had underfunded this plan by £295 million. The money saved by not extending eligibility will be used more directly to improve the educational attainment of disadvantaged pupils, which is key to extending opportunities for poorer children. We are continuing to support three pilot projects of extended free school meals. We will look at the evidence from these of the costs and benefits of extending free school meals before making any future decisions on this front.
The noble Baroness, Lady Thornton, also mentioned advertising. As she knows, the television regulator, Ofcom, has placed scheduling restrictions on the broadcast advertising of food high in fat, salt and sugar during children’s programmes and programmes of particular appeal to children up to the age of 16. Since January 2009, these restrictions have applied to all channels. The Ofcom review in 2010 showed a 37 per cent reduction in the exposure of children to television HFSS advertising, with the highest reduction for children aged four to nine years, and a fall of 22 per cent in children—
Lord Campbell-Savours
Perhaps I may stop the noble Earl for a moment. In the first few moments of his speech he spelt out the scale of the crisis, yet almost all the measures that he has referred to are voluntary. They are based on an agreement with the industry or with this or that body. If that is not working—and it clearly is not, because the noble Earl himself set out the nature of the crisis—why, at an early stage, cannot we go down a more regulatory route?
Earl Howe
I hope that the Committee will allow me a little extra time in view of that intervention. The answer to the noble Lord, Lord Campbell-Savours, is that if voluntary measures do not work, we will indeed consider regulation. I need to make that clear. We have a ladder of intervention at our disposal. However, as I also emphasised to him earlier, we think that we can make progress faster by means of voluntary measures. The food labelling regulations, for example, are governed by EU law, and the noble Lord will know how long it takes to change EU law. If we can make progress more rapidly by voluntary measures in this country, I am sure that he would welcome that as everybody else would.
On the other side of the coin, although equally important, is physical activity—the calories we burn rather than consume. My noble friend Lord McColl made some strong statements on that aspect of the issue but, as my noble friend Lord Addington indicated, physical activity is important in the wider context of people’s health. The public messaging on this clearly has to be balanced. We are currently reviewing the Chief Medical Officer guidelines on recommended levels of physical activity and we hope to publish those in the summer. Incidentally, I am delighted that my noble friend Lord Addington has underlined the importance of diet and exercise because I still believe that the two should be emphasised.
Finally, we need to make sure that those who need it can get the specialist help to reduce and manage their weight effectively. Weight management providers will continue to play a key role in this area. I believe that through the new public health system, with the responsibility deal and Change4Life, we can truly make a difference over the next few years.
NHS: Standards of Care and Commissioning
Earl Howe Excerpts(13 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Turnberg, for tabling a Motion which has occasioned such a fascinating and often moving debate. As has happened previously, the breadth and depth of the contributions create their own problem in that, when there is such a short time available for me to reply, I am up against the clock. To the extent that I am unable to answer specific questions today, I apologise but I will of course happily follow them up in writing.
There are many reasons why we believe it is necessary to modernise the National Health Service. With rising costs of new treatments, an ageing population and rising public expectations, the system is simply not sustainable in its present form. Most importantly, however, the NHS must modernise in order to focus relentlessly on what matters most to patients: improving health outcomes. In so many ways it is a wonderful service, but we know that it can do better and we believe that it must do better. For our ambition is not limited to maintaining the current quality of services, it is far greater—to have health outcomes that are consistently among the very best in the world. I suggest to the noble Baroness, Lady Thornton, who said that now was not the time to do any of this, that the financial situation that we face provides even more of a reason to modernise swiftly. I hope that she and other noble Lords will agree with me that this debate is really about quality.
The noble Lord, Lord Turnberg, began by raising the Parliamentary and Health Service Ombudsman’s report, Care and Compassion? I am sure that all of us can identify with the concerns that he raised about nurse training and accountability for what happens on the hospital ward. I am sure I was not alone in being very moved by the noble Lord’s speech. I fully intend that we should learn from the ombudsman’s report, which is why its findings have been highlighted to NHS boards and why the Care Quality Commission will be commencing unannounced inspection visits shortly. However, I also submit that the changes that we are making to the NHS—placing the patient at the heart of everything we do—will help to guard against this happening in the future.
As the noble Lord, Lord Warner, rightly reminded us, effective commissioning is a key piece of the jigsaw. Currently, commissioning decisions are taken by primary care trusts—remote organisations that frankly few people have heard of and fewer still understand. We propose to hand responsibility for commissioning to GP-led consortia. Why are we doing so? It is because GPs and their clinical colleagues are the people who best understand the health needs of their local populations, and, in partnership with healthcare professionals from across primary, community and secondary care, they are ideally placed to design clinical services that provide more effective, integrated and preventive care.
Lord Davies of Stamford
I am very grateful to the Minister for giving way. Will the present system of “choose and book”, which seems to me to be working extremely well, be perpetuated under the new commissioning consortia regime?
Earl Howe
Yes, my Lords. However, if the noble Lord will forgive me, I do not propose to take many interventions as the time is limited. As I say, the answer to his question is yes.
Those who question the effectiveness of these arrangements should focus on the new framework of accountability that we are proposing as it is central. The new NHS will be more directly accountable than it is now. Because of that our reforms introduce a stronger national framework for driving quality improvement than ever before. How will this accountability work? The Secretary of State will hold the NHS Commissioning Board to account for delivery against the NHS outcomes framework, published in December. The NHS Commissioning Board will then hold individual consortia to account for their performance against the indicators set out in the more locally focused commissioning outcomes framework. There was widespread and strong support for such a framework during our consultation.
The NHS Commissioning Board will decide on the shape and content of the commissioning outcomes framework over the next two years, working closely with emerging consortia and with professional and patient groups. To help maintain momentum, the department will shortly publish a discussion document, seeking more detailed views on possible features of the framework. The Health and Social Care Bill contains a new duty of quality. The NHS Commissioning Board and GP consortia will be required continually to improve the quality of NHS services. Underpinning that, the Care Quality Commission will regulate providers on safety and quality, with wide-ranging enforcement powers to protect patients should providers fail to meet requirements. Accountability works in its fullest sense only if there is transparency. We will publish clear, easy to understand information on the quality of healthcare services and the progress being made to reduce health inequalities. We also propose, subject to the passage of the Bill, that the NHS Commissioning Board be able to make payments to consortia in recognition of the outcomes they achieve collaboratively through commissioning and the effectiveness with which they manage their financial resources.
How will quality be driven through the commissioning system? Quality standards, prepared by NICE, will be at the centre of it. Quality standards bring clarity to quality, providing definitive and authoritative statements of high-quality care, based on evidence of what works best. Quality of care does not cover just the effectiveness of that care but also includes patient safety and patient experience. The three domains of quality are interconnected: they cannot exist in isolation. The Royal College of Physicians reflected on this point in its response to the consultation on the NHS outcomes framework and acknowledged that healthcare that is not safe could not be described as efficient, effective or sustainable.
Our reforms will allow a re-established NICE to produce a broad library of quality standards that will cover the majority of NHS services. NICE will also develop quality standards for social care and public health. The Secretary of State and the NHS Commissioning Board will be able to commission quality standards jointly, which will open up the opportunity for standards to cover the whole care pathway, from public health interventions in primary care through to rehabilitation and long-term support in social care, and will support the integration of health and social care services. It is important to understand that quality standards will do more than just bring clarity to quality: they will have real traction within the system, underpinning the duty of quality and linking with the new best practice tariffs that will see providers paid more for better care.
GP consortia will have a duty to support the NHS Commissioning Board in continuously improving the quality of primary medical care services. That does not alter the board's overarching responsibility for commissioning GP services and holding GP contracts. But it does mean that consortia will play a systematic role in helping to monitor, benchmark and improve the quality of GP services, including through clinical governance and clinical audit. It means also that consortia will have a core role in improving patient care across the system. That will include both the quality and accessibility of the care that GP practices provide and the wider services that consortia commission on behalf of patients.
Where does the Secretary of State sit in all this? The Health and Social Care Bill strengthens the accountability of the Secretary of State to Parliament for the provision of the comprehensive health service. For the first time, the Secretary of State will have to report each year on the performance of the health service, consult on the annual objectives set for the NHS through a mandate, and lay both documents before Parliament. The NHS Commissioning Board will be accountable to the Secretary of State for delivering against that mandate.
Nursing has been a strong theme in the debate. The noble Baroness, Lady Emerton, asked when the Government's response to the report of the commission on nursing will be published. I can assure her that the Government will respond soon to the commission's report and I apologise for not having given her an undertaking to that effect sooner. The noble Lord, Lord Turnberg, and the noble Lord, Lord Winston, raised concerns about nursing standards in hospitals. As they know, we now have matrons in post. They have a specific remit for quality of patient experience and should be accessible to patients and carers. Matrons are directly accountable to directors of nursing, who should present ward-to-board reports. We launched the Principles of Nursing Practice in November last year. This sets out an agreed set of standards and behaviours that were developed by the Royal College of Nursing in association with patient groups. These principles reinforce the NHS constitution.
The noble Lord, Lord Turnberg, asked about the duty of consortia to improve the quality of care for older people. There is no specific duty in the Bill relating to consortia and older people. However, we propose a new duty for consortia to seek continuous improvements in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience. That extends to all aspects of care.
The noble Baroness, Lady Sherlock, spoke about the recent King's Fund report. The report highlights particular variation in relation to patient involvement in decision-making, and in co-ordination and continuity of care. It also highlights the need for changes in leadership and culture. We have a strong system of general practice in this country, but we agree absolutely with the report that there is too much variation in quality. This reinforces the case for GP decommissioning, because one of the key aims behind the development of GP commissioning is for consortia to play a central role in helping to reduce variation and drive up the quality of general practice. There will be strong incentives for GP consortia to want to tackle these variations, because with lower-quality primary care one achieves poorer outcomes for patients and one has greater pressure on more expensive secondary care services.
The noble Baroness, Lady Sherlock, questioned whether the Government were allowing enough time to see whether the changes would work. With the introduction of shadow bodies and early implementers, we are allowing almost three years to consult, to dry-run and to put our reforms into practice on the ground, so that by 2013 the new organisations will have had time to secure capability collectively. Therefore, it is wrong to say that the house is being demolished; in many senses, we are refashioning some parts of the existing edifice.
On that theme, the noble Baroness, Lady Pitkeathley, asked how consortia will be authorised, given their different states of readiness. The pathfinder programme is, I think, central to sharing learning across emerging consortia, and it is a crucial part of their development to take on full commissioning responsibilities. Consortia will not have statutory responsibility for commissioning until April 2013, so the intervening period will allow all consortia to be ready by that time.
We listened to an impassioned speech from the noble Lord, Lord Owen, who criticised the Health and Social Care Bill on a number of fronts. Time prevents me setting out a detailed set of counterarguments but perhaps I may just say to him that we have tabled amendments to the Bill that will put beyond doubt that competition will be on the basis of quality and not price. Far from challenging the principles of the NHS, we have consistently made it clear that we are absolutely committed to a comprehensive National Health Service which is free at the point of use and is based on need rather than ability to pay. Nothing in our plans changes that.
The noble Lord criticised the policy of “any willing provider”, or “any qualified provider” as we are now calling it, because we think that that is a better description of the policy. The noble Baroness, Lady Thornton, did the same. “Any qualified provider” is about empowering patients and carers, improving their outcomes and experience, enabling innovation, and freeing up clinicians to drive change and improve practice. Introducing a choice of any qualified provider will give patients more control. That is what all the research evidence tells us they want and increasingly expect from the NHS. Why should not someone with MS be able to choose the physiotherapist they want and be treated at the time and in the setting that best suits their need? Why should not a patient, at the end of their life, choose their hospice provider? Patients are already able to choose from any provider that meets NHS standards and prices when they are referred for a first out-patient appointment to a consultant-led team. That was an innovation brought in by the previous Government. “Any qualified provider” will extend that principle to more providers and more services, including social enterprises and charities, particularly in community care. For the life of me, I cannot see what is wrong with that. Money will follow the patient and the choices they make about where and by whom they are treated.
The noble Lord, Lord Owen, indicated his belief that the policies that the Government are advancing will damage clinical professionalism and remove the intimacy inherent in the doctor/patient relationship. I say to the noble Lord gently and with huge respect that I do not believe he has any basis whatever for suggesting that. I would argue, on the contrary, that clinically-led commissioning brings the design of services closer to patients.
Earl Howe
The department has sought legal advice on that point and the strong consensus is that the NHS, as we envisage it initially, will not be subject to EU competition law. It is not at the moment, as the noble Lord will know, although of course the situation can change over time. This is an interesting, and rather esoteric, area of debate but I do not think that it impacts—
Earl Howe
I mean that it becomes rather technical. However, I do not think that it impacts on the central point that I was seeking to make, which was to argue that the noble Lord’s contention that the doctor/patient relationship would be damaged does not stand up. To me, the principle of shared decision-making—“no decision about me without me”—will bring about an even closer partnership between clinicians and patients.
The noble Lord, Lord Patel, spoke about cancer services. GP consortia will be well placed to commission the majority of cancer services and GPs have a crucial role to play to achieve earlier diagnosis of cancer. As a first step in relation to cancer services, we will work with GP consortia and pathfinders to identify and provide the sort of data that they will find useful to commission cancer services effectively. We will provide GP consortia profiles of services and outcomes for their local populations—for example, cancer survival rates, the use of the two-week urgent referral pathway, uptake of screening and use of inpatient beds. We will be benchmarking the data against similar consortia so that they will know what needs tackling to improve outcomes in their areas. However, as the noble Lord will know, we have also earmarked a great deal of money to ensure that our plans for earlier diagnosis—giving GPs direct access to key diagnostic tests, for example—will assist in the process. He asked about cancer networks. They have had a crucial role in improving the quality of cancer treatment. I quite agree with him. They have helped commissioners, providers and patients to work together to plan and deliver high-quality cancer services. GP consortia will need commissioning support and cancer networks will be well placed to provide that. The department has said that next year there will be funding for cancer networks to support commissioning.
The noble Lord, Lord Touhig, asked about the commissioning of autism services. The health and well-being board will be the key vehicle by which commissioners and local authorities can work together, ensuring that services that cross health and social care can be effectively commissioned. The noble Lord raised a number of valid points about how these arrangements for autism services will work in practice. I suggest that I cover those in a detailed letter.
The noble Baroness, Lady Hollins, and my noble friend Lady Tyler questioned the ability of consortia to commission mental health. We recognise the need for GP commissioners to collaborate with their clinical colleagues and one of the key initiatives in mental health derives from the new joint commissioning panels set up in partnership between the Royal College of Psychiatrists, the Royal College of General Practitioners, the Association of Directors of Adult Social Services, and others. That collaboration works to promote integrated working across secondary and social care. The outcomes and lessons from this work will be made available to inform the implementation of the new commissioning arrangements.
My noble friend Lady Benjamin asked a number of questions about sickle cell. Again, I should like, if I may, to take full advice from my department about the points she raised and write to her.
Our reforms are ambitious and challenging but we have been heartened by the enthusiasm that we have found among clinicians, especially among those already taking increasing levels of responsibility through the new consortia. There are now 177 GP pathfinders involving more than 5,000 GP practices, covering more than 35 million people across England. I am confident that by empowering clinicians to innovate and deliver health services we can continue to address the healthcare needs of this country and move towards delivering outcomes that are indeed consistently among the best in the world.
Health: Neuromuscular Services
Earl Howe Excerpts(13 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am grateful to my noble friend Lady Thomas for raising extremely important issues and to other noble Lords who have contributed with such knowledge to the debate today. I join my noble friend in paying tribute to the Muscular Dystrophy Campaign, which has been such a powerful advocate for those affected by these lifelong and life-limiting conditions, and to the All-Party Parliamentary Group for Muscular Dystrophy, which has done so much to keep these important matters on the agenda. Although he is not in his place this afternoon, I cannot let the opportunity pass to remark that the noble Lord, Lord Walton of Detchant, is not only an active member of the all-party group but one of the founders of the Muscular Dystrophy Campaign in 1959. That really is a testament to both his commitment and his stamina.
The subject of the debate is, “What is the Government’s assessment of specialist neuromuscular services?”. For large parts of the country, I am afraid that the answer is clearly “not good enough”, and perhaps “poor” in some parts. We know that there are historic weaknesses, which noble Lords have drawn attention to during today’s debate. The urgency for change is all the greater because these failures have a massive impact on the lives of people with these conditions. There are around 5,500 emergency bed days a year for people with neuromuscular conditions, with all that that entails for them and their families.
The Health and Social Care Bill is clear that highly specialised services, as set out in the Specialised Services National Definitions Set, will in future be commissioned by the NHS Commissioning Board. This presents a real opportunity to streamline decision-making, funding, planning and commissioning of all specialised services, and to achieve greater consistency by doing it once through the Commissioning Board, rather than 10 times locally. I know that the all-party group received a progress report from staff in the specialised commissioning group on 9 March. I also understand that the all-party group and the Muscular Dystrophy Campaign liked what they heard about the excellent progress already made by the existing regional specialised commissioning groups and about how the national group’s work plan will prioritise neuromuscular disease in 2011-12.
The work plan will focus on the key issues for people with neuromuscular disease from service specifications to emergency admissions, and from access to services and workforce models to specialist equipment and non-invasive ventilation. Many of the subjects raised by noble Lords, such as hydrotherapy and physiotherapy and so on, will be embraced in that exercise. However, I think we need more. We need a high degree of integration across the care pathway to deliver more person-centred approaches to planning specialised services. People with conditions such as muscular dystrophy need more than just highly-specialised tertiary care; they need, and have every right to expect, the same community-based services that so many others enjoy. The ongoing care that is so important for supporting quality of life and keeping people out of hospital includes hydrotherapy and wheelchair services; speech and language therapy and respiratory support; and help with swallowing. These services need to be commissioned locally by those close to patients and their families. This is currently a job for primary care trusts, not the specialised commissioning teams. My noble friend Lady Thomas raised doubts, echoed by the noble Baronesses, Lady Wilkins and Lady Thornton, about the emphasis that GP consortia may place on these services. I absolutely accept that better co-ordination and better integration between commissioning teams and a more person-centred approach to planning across the whole care pathway rather than individual bits of it are all essential. Clearly, integrated planning between GP consortia and the NHS Commissioning Board will be vital, just as joint working between PCTs and specialised commissioning groups is today.
The best answer that I can give on this is to refer to the strength and accountability mechanisms that we plan to put in place. They include the role of health and well-being boards at local authority level; the joint strategic needs assessment and joint health and well-being strategies, which will inform and guide local commissioning decisions; the overarching commissioning outcomes framework, by which consortia will be held to account; the place of the patient experience within that framework; the transparency of consortia performance; and the role of HealthWatch, which will act as the local voice of patients and the public and which will be in prime position to feed in grassroots opinion and experience to local planning, not least through its membership of the health and well-being boards. Once again, the points raised by the noble Baroness, Lady Brinton, on access to physiotherapy services and the noble Lord, Lord Luce, on hydrotherapy pools are things which, I have no doubt, will come into the compass of the health and well-being boards.
A consistent message which I have heard and which my noble friend reiterated today is that clear guidelines from NICE to cover muscular dystrophy, home ventilation and respiratory support would improve matters immeasurably. I hope that noble Lords will understand that it is not for me to direct NICE—its strength lies in its independence from government and I am not going to compromise that—but the new system will see quality standards commissioned from NICE by the NHS Commissioning Board. It will want to have quality standards for those topics that will help it to meet its outcome goals. Because of the focus on outcomes, a new approach for topic selection is being developed, overseen by the National Quality Board, which will allow stakeholders to comment and suggest topics. NICE welcomes that engagement from voluntary and patient groups, not only in the strategic sense but also on matters of detail.
I have already paid tribute to the Muscular Dystrophy Campaign for its achievements and to the all-party group. I am afraid that I must break some bad news: their work is not yet done. The NHS is changing—there is a great deal of work to be done to make it more responsive to patients and their families, and it cannot do this alone. GP consortia will need advice and guidance as they take the reins; NICE is already talking with the neurological leadership group on how it can develop stronger clinical advice; and the National Quality Board is working on a broad library of quality standards for NHS care. These are opportunities for the Muscular Dystrophy Campaign and others to feed in their accumulated knowledge and expertise, either directly or through the Neurological Leadership Alliance.
My noble friend Lady Jolly and the noble Baroness, Lady Thornton, asked about research. The Medical Research Council is, of course, independent of government. We have ensured that its budget for the period of the comprehensive spending review remains intact; its resource expenditure can be maintained in real terms. However, it remains the case that the selection of projects for MRC research funding is determined through peer review.
The noble Baroness, Lady Wilkins, asked about the sub-national structures of the NHS Commissioning Board and how the capacity and capability of services will be sustained during the transition. I fear that much of this falls into the category of work in progress. It is definitely not only on the radar of the department but is the subject of active work as I speak. A priority during the transition period will be to ensure that key capacity and capability are sustained through to April 2013 in order to support delivery. As the noble Baroness may know, the Government are proposing a managed consolidation of PCT capacity in order to create transition clusters. These will be administrative mergers similar to those that have already taken place in London and the north-east.
My noble friend Lady Thomas asked whether NICE should conduct a detailed review of its guidance, particularly as it relates to Duchenne muscular dystrophy. I spoke to the noble Lord, Lord Walton, about this the other day and encouraged him to feed in this view to NICE directly. I well understand why the request has been made.
My noble friend Lady Thomas also asked about quality standards. For the NHS, the new system will see quality standards commissioned from NICE by the NHS Commissioning Board. It will want to have quality standards for those topics that will help it to meet its national outcome goals. The remarks I have made about the process of feeding in to NICE apply equally there as well.
The noble Lord, Lord Luce, asked about training for GPs to deal with specialised services. As he knows, the Department of Health does not specify the content of training curricula; that is determined by regulatory requirements and the needs of the service. Comprehensive information to support clinical decision-making is included on NHS Evidence, the new single web-based portal hosted by NICE which provides all health and social care professionals with authoritative clinical and non-clinical evidence and best practice. NHS Evidence provides access to a range of information, including primary research literature, practical implementation tools, guidelines and policy documents. It is improving all the time and is widely used.
My noble friend Lady Brinton asked whether we would think about producing simple guidance for GPs to commission services for specialist conditions. I am happy to feed that suggestion into the NHS Commissioning Board, whose responsibility it will be.
The noble Baroness, Lady Wilkins, asked whether the department might publicise updates on the work plan to the NHS. I shall write to her about that.
I am grateful to my noble friend for the opportunity to discuss these important issues and I thank all noble Lords who have made contributions. We know there is much to do to improve the care of those with neuromuscular and other long-term conditions. At the same time, I am confident that by modernising the National Health Service we will improve the lives of patients with these conditions across the country.
Health: Polymyalgia Rheumatica and Giant Cell Arteritis
Earl Howe Excerpts(13 years, 1 month ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am grateful to the noble Lord, Lord Wills, as I am sure are all noble Lords, for raising the need for early diagnosis of polymyalgia rheumatica and giant cell arteritis and for making clear the serious results that can follow should the diagnosis be missed or appropriate treatment delayed.
In addressing his question, perhaps I may start with what may be the most obvious and important issue: namely, what is out there for clinicians in terms of commissioning support and training. As the noble Lord will be aware, there is already excellent guidance available on these related medical conditions, both for healthcare professionals and for patients. The British Society for Rheumatology, with partner organisations, has recently published clinical guidelines for both conditions. The society has an active strategy for disseminating these guidelines widely among healthcare professionals, including GPs. Summary information for GPs is available from Patient UK and from clinical knowledge summaries.
I am advised that the importance of prompt diagnosis of giant cell arteritis is underlined in both the undergraduate medical curriculum and in post-graduate training for GPs and relevant hospital specialists. Both NHS Direct and Patient UK carry information for patients.
This of course underlines that it is not the Government who improve the quality of patient care; it is clinicians. The role of government is to provide a framework that enables clinicians to get on with it, as the noble Lord, Lord Darzi, eloquently articulated in his publication in 2008, High Quality Care for All. Now, with the Health and Social Care Bill, we are breathing life into that framework. I genuinely believe that this will enable clinically led quality improvement of the kind that the noble Lord is seeking for the care of polymyalgia rheumatica and giant cell arteritis as much as it will for other conditions.
Commissioners of healthcare are faced with a complex task. Determining the relative priorities between different clinical conditions requires a difficult and largely technical balance between a number of factors, including the strength of the evidence base, the size of the population affected, the impact of the disease if not properly treated, the disparity between current standards of provision and best practice. The commissioners also need to take into account their duties to promote patient choice, to promote public health and well-being and to tackle inequalities in health outcomes. It is a complex set of interlocking tasks that, again, cannot be managed from the centre.
What we can and should do from the centre is to set broad expectations for the NHS. In the national outcomes framework published in December, my right honourable friend the Secretary of State for Health made clear that we would hold the NHS to account against five broad health outcomes: reducing premature mortality; improving the quality of life of people with long-term conditions; helping people to recover quickly from episodes of illness; improving their overall experience of healthcare services—
Earl Howe
My Lords, the last of the five health outcomes that I was listing is delivering safe care. Within these five domains we have signalled a number of major improvement areas where evidence suggests the need to improve current performance in the NHS. The national commissioning board will support the NHS in achieving these improvements in various ways, through setting tariffs and other financial incentives, such as commissioning guidance and setting a lower level commissioning outcomes framework against which local commissioners will be held to account. But below this level, it will be for local commissioning consortia to determine exactly which service improvements they need to prioritise to best improve the health outcomes for their populations. They will, of course, be working within health and well-being strategies agreed with local government partners on the basis of a joint strategic needs assessment. They will be accountable to the local HealthWatch and nationally to the commissioning board for the outcomes they achieve.
I turn to the specific suggestions of the noble Lord, Lord Wills. The first of his suggestions was that we should add blindness due to giant cell arteritis to the list of never events which, if they occur in the NHS, would result in contractual penalties. The noble Lord was kind enough to alert me in advance to this suggestion and we have considered it carefully. I am very sympathetic to its underlying intention. However, I am not convinced that it would be feasible. I say that because to qualify as a never event, an incident—in this case, a failure to diagnose giant cell arteritis—must meet a number of criteria. In particular, the incident must be easily defined and identified, and it must be largely preventable if the appropriate guidance is followed. The problem is that the differential diagnosis of giant cell arteritis is not straightforward and would require a detailed case note review to establish whether a clinician was culpable for missing it in a particular instance. I am afraid that the proposed addition falls outside the criteria.
The noble Lord has also suggested that there is a need for NICE guidance. He will be pleased to hear that NICE is indeed considering, through its topic selection process, a potential short clinical guideline on the safe and effective use of steroids in the management of polymyalgia rheumatica and giant cell arteritis. As he will know, NICE has limited capacity for the development of guidance and there are many competing demands on its resources. While it would not be appropriate for me to circumvent the established process for identifying priorities, I can reassure him that the need for guidance in this area is being carefully considered. He also suggested that I refer to the issues of giant cell arteritis in a landmark speech. I fear that he may have somewhat exaggerated the impact that a few words of mine are likely to have on the knowledge and skills of thousands of GPs across the country, but I am always willing to take up suggestions of this kind, where possible, and if I can give honourable mention to this specific condition in a speech I will certainly endeavour to do so.
Finally, the noble Lord suggested that we should use one of the Department of Health’s regular channels of communication with the NHS to raise the profile of these two conditions—perhaps via the regular bulletin to GPs and practice staff. The department has a variety of means for communicating directly with NHS professionals. I am happy to consider that idea. In general, the modes of communication tend to be used mainly for the most urgent or significant public health messages, and it would not be appropriate for the department to seek to give advice on clinical issues for NICE or the various professional organisations. However, it would be possible in theory to use the GP bulletin to draw attention to professional guidance in this area, such as the excellent clinical guidelines developed by the British Society for Rheumatology and its partners. The department is already discussing with the society whether it would see this as a useful addition to its own means of dissemination.
We need to come back to a fundamental point. A liberated NHS should not wait for permission from Ministers to do anything. It should instead be listening directly to patients and their advocates—here, I include the noble Lord among the champions of these particular groups of patients. That is what the NHS will increasingly be doing.
The noble Lord asked me—he repeated the figure several times—whether the department accepted the estimate of 3,000 people a year going blind as a result of failure to diagnose giant cell arteritis. I made informal inquiries before the debate and, although he is absolutely right in all that he said about the devastating effects of this condition, I have been unable to verify the figure of 3,000 people, and experts whom we have consulted think that the true figure is quite a bit lower than that. I would be interested in any further information that the noble Lord has on that issue, and indeed on his statements around the failure by doctors to diagnose giant cell arteritis.
My advice is that the vast majority of GPs are already aware of the serious consequences of failure to diagnose giant cell arteritis, and I have already referred to the aspects of their training relating to that. It is a relatively rare condition; the average GP might see one case every two years. Picking up the occasional case of giant cell arteritis among many less serious conditions with superficially similar symptoms is therefore not straightforward. However, I believe that the great majority of GPs are sensitive to the need to pick up this serious condition.
The noble Baroness, Lady Thornton, asked me about research. As she well knows, there is a transparent process for determining research priorities, and I am sure that the professional organisations for rheumatological conditions will be familiar with the steps that they need to take, either in relation to research funding through the MRC or indeed, as regards clinical research, through the Department of Health.
My noble friend Lord Black referred in powerful terms to the adverse effect of steroids as treatment. He may like to know, if he does not already, that the standard guidance to GPs makes it clear that any dose of steroids should be progressively reduced over a fairly short period, so it is alarming to hear the experience that he recounted. He also said that GPs should warn patients of the adverse effect of drugs. I agree absolutely that that is a fundamental responsibility for all doctors, especially if drugs have potentially severe side effects. My noble friend Lord Alderdice pointed out the need to keep a focus on temporal arteritis, which should not be muddled up with polymyalgia rheumatica. That is clearly an issue for the professions, although he makes a valuable point. I undertake to draw his suggestions to the attention of the Royal College of General Practitioners.
My noble friend Lady Brinton suggested applying NICE rheumatoid arthritis guidelines to polymyalgia rheumatica. As many of the issues are the same I would be reluctant to tell NICE how to do its job. It is perhaps better to await the outcome of the topic selection process, which is already looking at PMR. The noble Baroness, Lady Bakewell, who is not in her place, spoke powerfully about ageism. I agree that any form of ageism is unacceptable. It is vital that education and training for GPs should address this issue and emphasise the specific signs for these diseases that are particularly prevalent in older people.
My time is up but I shall address the final question put to me by the noble Lord, Lord Wills, who asked whether I would agree to meet him to discuss these issues further. I would, of course, be happy to do so.