NHS: Standards of Care and Commissioning
Earl Howe Excerpts(14 years, 3 months 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(14 years, 3 months 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(14 years, 3 months 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.
Health: Preventable Sight Loss
Earl Howe Excerpts(14 years, 3 months ago)
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Lord Low of Dalston
To ask Her Majesty’s Government what is their assessment of the level of preventable sight loss in the United Kingdom; and whether they will include that issue in the proposed Healthy Lives, Healthy People strategy.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government recognise that sight loss is a serious issue and that risks rise in an ageing population. The Health and Social Care Bill proposes that NHS sight testing will be the responsibility of the NHS Commissioning Board. The new public health system will help to prevent sight loss. We have proposed that Public Health England will design and fund some specific public health services, including diabetic retinopathy screening. We have also proposed that local authorities should have new responsibilities in relation to public health and health improvement.
Lord Low of Dalston
I thank the Minister for that response. However, given that half of the sight problems experienced by around 2 million people in the UK could be prevented by regular sight tests and early diagnosis and treatment, what plans do the Government have to communicate this important public health message to local commissioners, health and social care professionals and the public? Does the Minister agree with me that reducing such a high prevalence of avoidable sight loss through regular sight tests and better access to eye care services should be included in the public health outcomes framework, and that specific attention should be focused on minority ethnic groups who exhibit a particularly high incidence of some sight-threatening conditions?
Earl Howe
My Lords, I quite agree with the noble Lord that sight tests allow an invaluable opportunity to review all aspects of eye health, including investigations for signs of disease. The uptake of NHS sight tests is, I am glad to say, increasing. As regards messaging, the department has worked, and continues to work, with NHS Choices on the development of articles and videos to raise the profile of visual health and promote the importance of regular sight tests. Looking ahead, and as part of their new public health responsibilities, we propose that local authorities will have primary responsibility for the health improvement of their local populations. They could well choose, if they wished, to promote eye health and work to improve the wider aspects of health and lifestyle that contribute to improved eye health. We are currently consulting on the public health outcomes framework, as I am sure the noble Lord is aware. We are also consulting on the scope of the evidence base for public health and the interventions that will work best.
Lord Kennedy of Southwark
Does the noble Earl agree that one of the groups of people at risk of developing eyesight loss is people with diabetes? As part of the increased work to deal with diabetic retinopathy, should not everyone at risk have, in addition to their normal eyesight tests, annual eye screening? This service must not be cut but be expanded, as early detection and prevention is right for the patient, their family and ultimately the taxpayer, as thousands of pounds that would otherwise have to be spent on dealing with preventable complications will be saved.
Earl Howe
My Lords, the noble Lord makes some extremely important points. This is a good news story and very good progress has been made; more people with diabetes are being offered screening for retinopathy than ever before, and to higher standards. More people are being offered screening now than when the screening programme was announced in January 2003. At that time, 1.3 million people with diagnosed diabetes in England were being screened. The latest figures, for December 2010, show that 2.21 million people were offered screening.
Baroness Jolly
My Lords, given that sight loss will cost the economy £8 billion a year by 2013, will the Minister outline for the House the determining factors in extending free sight tests to all?
Earl Howe
My Lords, various categories of patients are eligible for free sight tests. Free tests are available under the NHS to a large number of people, including people aged 60 and over, children under 16 and people on low incomes. As I mentioned, the uptake of sight tests is increasing, which shows that people are continuing to get good access to NHS eye care services; but as regards an extension of the numbers, that will of course depend on available funding.
Lord Walton of Detchant
My Lords, does the Minister accept that one of the commonest causes of progressive visual failure in the elderly is macular degeneration? There are two forms: the dry form is currently not amenable to treatment, although research suggests that one day it may be; but the wet form can in many cases be arrested by expensive injections. Is he aware that some PCTs are allowing that particular form of treatment to be given only to one eye, allowing the other eye to deteriorate? Does he not agree that that—if he will forgive the pun—is an unfortunate and short-sighted policy?
Earl Howe
My Lords, the National Institute for Health and Clinical Excellence—NICE—has recommended treatment with Lucentis as a clinically effective and cost-effective use of NHS resources for patients with wet, age-related macular degeneration meeting specific clinical criteria. I am aware that, initially, the practice mentioned by the noble Lord was being reported, but I think that it is less true now. I will of course check whether what the noble Lord says continues to apply. I would just say that primary care trusts are legally required to make funding available to enable clinicians to prescribe Lucentis, which is the drug of choice for this, in line with guidance. The PCT allocations take account of expected growth in the drugs spending, including the impact of this type of technology.
Baroness Thornton
My Lords, last week the BBC programme “In Touch” asked the question, “Can the NHS cope with the demand for treatment for the UK’s most common cause of blindness?”—a question which follows on from the one asked by the noble Lord, Lord Walton of Detchant. The programme was made with the recently formed Macular Disease Society, which aims to raise awareness and money for both dry and wet macular disease. Will the noble Earl join me in welcoming the creation of this society, and will the Government ensure that the society is involved in the consultation process leading to the strategy for the early diagnosis and treatment of macular disease?
Earl Howe
My Lords, I join the noble Baroness in welcoming the formation of the Macular Disease Society, and I can assure her that my department will wish to engage closely with it; I think that it is a very positive development. Reducing avoidable sight loss is clearly an issue that we have to take seriously. The prevention of sight loss will be an aim of work undertaken across the new public health system, as I have indicated. At national level we are proposing that Public Health England will design some specific public health services including screening, as has been mentioned, and locally we propose new responsibilities for local authorities.
Lord Naseby
As financial resources are limited, is not avoidable sight loss an absolute public health priority? Is it not better to spend money on that than restricting small and large retailers further in terms of their display of tobacco in a market that is declining in any case?
Earl Howe
My Lords, I will simply say to my noble friend that public health clearly has an important contribution to make to reducing avoidable sight loss by addressing the obvious risk factors for sight loss, but also by delivering on our general public health outcomes, such as reducing smoking and obesity and diabetes, all of which are associated with the development of eye disease. The tobacco strategy has a direct bearing on this question.
Public Bodies Bill [HL]
Earl Howe Excerpts(14 years, 3 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am grateful to noble Lords for providing us with a further opportunity to debate the future of these two bodies. As is clear, these amendments would have the effect of putting the Human Tissue Authority and the Human Fertilisation and Embryology Authority outside the scope of the Public Bodies Bill. The Government recognise that a number of your Lordships remain unconvinced of the merits of our plans to reform these arm’s-length bodies. The concerns that various speakers have raised are ones that we have debated previously and are therefore familiar. I hope, nevertheless, that I can address them.
To begin, I strongly feel that we cannot continue with the parallel systems of regulation that are currently running. There must be some scope for rationalisation and relieving the overall burden on those regulated. However, in looking to achieve that, I fully recognise the need to retain regulatory rigour and expertise in the fields of embryology and human tissue. I therefore offer further reassurance on those issues that have proved of most concern: the retention of expertise, public consultation and the potential savings offered by our proposals.
First, expertise will not be lost. It is envisaged that the expertise invested in individuals will follow functions —for instance, through staff transfers and establishing expert reference groups. There will be a carefully managed transition between regulators, which will ensure that key skills and knowledge are passed on to receiving organisations.
Secondly, there will be extensive consultation later in the summer on where functions are best transferred and, subsequently, on the orders to effect the transfers. We envisage that our consultation will cover two main areas. It will set out our proposals for the transfer of the regulation of treatment and research, and set out the options and considerations for other functions where there may be several different possible destinations, such as those related to the collection and sharing of information or policy decision-making. Let me be clear that these functions, which are required under the Human Fertilisation and Embryology Act and the Human Tissue Act, will continue. A number of your Lordships have voiced the fear that, for instance, the HFEA’s registers and databases will be dissipated or lost. That will not happen. The consultation document will set out a number of different options for how these functions might be delivered in the future, and we will listen to people’s views about this. I can reassure the House that, in considering how to transfer functions, we will want to maintain the best aspects of the current regulatory system and avoid action that might undermine them.
Thirdly, I turn to financial savings. Together, the budgets for the HFEA and the HTA total £13.6 million. Through the streamlining of regulatory functions, we envisage scope for savings in three areas. The first will be in grant-in-aid for reduced overall running costs. The second will be for the regulated bodies in licence fees. The third will be for those bodies in the preparation and demonstration of compliance with the regulatory system. A leading clinician licensed by the HFEA recently said:
“We pay over £100,000 per annum in fees to the HFEA. Since 80% of our work is NHS funded that means that over £80,000 of the money that the PCT pays for fertility treatments goes straight to the HFEA”.
That is money which in large measure could be saved and used to deliver healthcare to patients. The department will undertake more detailed analysis of current costs and potential savings to inform an impact assessment which will be developed as part of the consultation process, so the whole set of equations will be transparent.
Lord Harries of Pentregarth
I thank the Minister for giving way. In relation to that last point, when the impact assessment is made will it be possible not only to assess the impact of what the Government are proposing but that of simply telling the existing bodies that they have to cut costs by a certain amount, so that the one can be weighed against the other?
Earl Howe
My Lords, I do not think that I am chancing my arm by saying that that is my understanding of what the impact assessment ought to look like in that a typical impact assessment will have within it several alternatives so that it is possible to compare different options. I would be happy to come back to the noble and right reverend Lord with a definite answer on that but my understanding from previous impact assessments is that that kind of benchmarking ought to be possible.
The noble Baroness, Lady Thornton, has previously raised her concerns about where the ethical framework for any new arrangements will sit. Ethical safeguards, for example concerning the embryos and gametes 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 continue to remain firmly in place and will underpin the regulation of treatment and research as currently, by whoever is responsible for regulating. Where there are specific ethical issues surrounding new treatments, the department will consider how best to commission expert advice on an individual basis, as is currently being done for mitochondrial transfer, for example.
A number of noble Lords have shown interest in and support for the Government’s announcement last week, as part of the growth review, about streamlining research regulation and governance. The Government announced in the Plan for Growth on 23 March that they will create a health research regulatory agency to combine and streamline approvals for health research which are at present scattered across many organisations. As a first step, the Government will establish this year a special health authority with the National Research Ethics Service as its core. When established, the new agency will work closely with the Medicines and Healthcare Products Regulatory Agency to create a unified approval process and promote proportionate standards for compliance and inspection within a consistent national system of research governance.
This will reduce the regulatory burden on firms and improve the timeliness of decisions about clinical trials and hence the cost-effectiveness of their delivery in the UK, and has clear support from the Academy of Medical Sciences review of medical research regulation and governance.
In this context, it is important for me to remind the House of a key point. Here I refer particularly to the question posed by the noble and right reverend Lord, Lord Harries. The AMS report recognised at paragraph 9.5.1 that there are significant benefits in bringing all medical research regulation, including embryo research currently undertaken by the HFEA, within the remit of a single health research regulatory agency. Indeed, remarks made by Sir Michael Rawlins in the Guardian on 11 January firmly backed up that view. We agree with that proposition but again the consultation will invite views on it.
My noble friend Lord Willis expressed his fears about the Government adopting a piecemeal approach to reorganisation, as did some other noble Lords. I accept that our approach to the HFEA and the HTA may indeed seem rather complex. The powers of the Public Bodies Bill will enable us to transfer some of the functions of the HFEA and HTA to other bodies but they do not enable us to do everything that we have set out in the arm’s-length body review. In order to abolish the HFEA and HTA, or to transfer their research-related functions to any new research agency, we will require powers under future primary legislation.
It might help if I provided a rough outline of how and when we could take this forward. We intend publicly to consult on proposals to transfer all the HFEA and HTA functions to other bodies in the late summer of this year. During 2012-13, under the provisions of the Bill, we will prepare draft orders for formal consultation dealing with the transfer of functions, other than research functions. If appropriate, we would then be able to lay the orders before Parliament. This process would enable noble Lords and other interested parties to see, comment on and debate the proposals, as they progress.
Without the inclusion of these bodies in Schedule 5, we would have to provide for the transfer of their functions entirely within future primary legislation. I simply say again, particularly to the noble Lord, Lord Warner, that not including these bodies would significantly increase the risk that the underlying ethical provisions of the Human Fertilisation and Embryology Act and the Human Tissue Act were reopened for debate.
Lord Willis of Knaresborough
Would it not be possible to include a new clause in the Health and Social Care Bill to set up the new medical research agency and leave to consultation and secondary legislation the details that would follow? That would at least give certainty to that organisation and, with a new Bill in the second part of the Parliament, put it into the parliamentary timetable much earlier than envisaged.
Earl Howe
In theory, my noble friend makes a constructive suggestion. We have considered that option and, I am afraid, rejected it on the grounds that the Health and Social Care Bill is big enough as it is, and contains a substantial programme of modernisation. It would be possible to Christmas-tree that Bill almost ad infinitum, and we have decided that that would not be helpful. With the Health and Social Care Bill, we seek to focus on the modernisation agenda, pure and simple. I am sorry to disappoint my noble friend, who makes a perfectly sound point, but I am afraid that we are not going to do that.
As I made clear earlier, I confirm to my noble friend that the CQC will have staff transferred into it. The intention is that expertise in staff and advice will follow the functions. Unfortunately, we cannot be definite about exactly which functions will be transferred to the CQC or elsewhere until after the summer consultation. If, standing here, I were to say exactly how that would work, I would be pre-empting the results of that consultation. I agree on the desirability of having clarity and certainty, and our aim is that there should be more clarity and certainty for HFEA and HTA staff after the consultation.
The noble Baroness, Lady Warwick, asked a number of detailed questions about the effect of our proposals on bodies regulated by the HTA and the way that its functions are performed. The case that she put eloquently was an argument in favour of keeping the HTA’s functions together. I understand her point of view; however, I reassure her that we will consult on the option of keeping the HTA’s functions together. We will not consult simply on one model, let alone pre-empt the results of the consultation.
Baroness Deech
Will that same option in the consultation apply to the HFEA, whereby its functions can be kept together?
Earl Howe
The direction of travel for the HFEA is one that we have mapped out. I am not aware that we are considering consulting on keeping the HFEA together. If I am incorrect about that, I will write to the noble Baroness. I understand why she wishes to press me on the point. However, I have not heard this option put forward, and it was not contained in the arm's-length bodies review.
I can assure the noble Baroness that the consultation will give an opportunity to all those with an interest to express their views on where would be the best place to transfer the functions, and on the merits of keeping functions together where appropriate. I recognise that the expertise of the HTA, and the extent to which this will be carried forward, is a key issue. The consultation that we plan will, as I mentioned, give an opportunity for interested parties to express their views on the point.
The noble Baroness, Lady Thornton, asked who would take over the role of competent authority for the EU tissue and organ directives from the HTA. That role will be considered for transfer to other bodies, as with other functions. It involves regulating according to quality and safety standards. We will consult on the most appropriate body for those functions to be transferred to.
My noble friend Lord Willis made clear his view that we should not split research functions. I can tell him that we envisage that the health research agency will cover what is now covered by the approval of research licences. In the context of human embryo research, the legislative requirements that the research is necessary or desirable, and that the use of embryos is necessary, will remain firmly in place. If that consideration includes an assessment of the research technique proposed, it will remain so in future.
The noble Baroness, Lady Thornton, and the noble and right reverend Lord, Lord Harries, asked how we would deal with the devolved Administrations. The intention of the proposals is to reduce both the cost of regulation and the bureaucracy for regulated establishments. It is important that a workable solution is found for the devolved Administrations, while recognising that the subject matter of the legislation is reserved. The Human Fertilisation and Embryology Act extends to the whole of the UK, and the Human Tissue Act extends to England, Wales and Northern Ireland. We hope to agree a way forward with the devolved Administrations that avoids any unnecessary duplication of effort in order to keep costs and bureaucracy for regulated establishments to a minimum. We have had constructive discussions already at official level, and these will continue. The CQC is at present an England-only body. If reserved functions were transferred to the CQC, we would extend its territorial remit in respect of those functions alone.
I will return to where I began. It is surely right that the Government and Parliament should look for opportunities to streamline regulatory mechanisms, as long as this is done in a way that preserves the legal functions, and the ethical underpinning of those functions that Parliament has put in place. The Bill provides us with the means to do that in respect of the HFEA and the HTA. In view of the Government's broader concessions on the Bill, and our intentions to consult widely on the proposed transfers of functions and to protect existing ethical and legislative safeguards, I hope that noble Lords will not press their amendments.
Baroness Thornton
I thank the Minister for another detailed response. I also thank the noble Lord, Lord Willis, the noble Baroness, Lady Deech, the noble and right reverend Lord, Lord Harries, and my noble friends Lady Warwick and Lord Warner. I counted 17 to 20 questions that the Minister was asked. He gave us a great deal of information, some of which was useful and very interesting. However, I do not think that he answered all the questions.
The Minister raised the issue of us not being convinced. We are not being perversely unconvinced. The problem is that there are still too many unknowns about this part of the Bill. Extensive consultation in the summer, to which the noble Earl has referred on many occasions, is after the decision has been taken and after the powers have been taken.
For example, the Minister was pressed on the concern about registers and databases. His answer was that the decision would be part of the consultation, that they would not be dissipated and that there would be options put in the consultation. That is not a satisfactory answer at this point. The same goes for the impact assessment, which will be carried out in the context that the Government will have already taken the powers to do what they want to do.
On the ethical issues that I raised, the Minister suggested that those would go with whoever it seemed appropriate to be the responsible body. Frankly, at this stage of the Bill, an answer that has “whoever” in it is not satisfactory. There is widespread agreement that the medical research agency proposals sound promising, but that simply underlines the point that we should not proceed with including these two bodies in the Bill at this point.
The Minister has said several times that it is a complex process. We agree, and indeed the noble Lord, Lord Willis, made an extremely good suggestion about one way to simplify the process by using forthcoming legislation. Having been the Minister responsible for several Bills that might have been called Christmas-tree Bills, I am not sure that he does not have a very good point.
That begs the question: what is the hurry? If streamlining can be achieved without powers being taken in this Bill, money can be saved—as several noble Lords have said—without taking such powers, and a much larger discussion will be taking place as we move forward. It seems to me that those points remain outstanding.
At this point in our consideration, I do not think that we have reached a satisfactory and conclusive point in our discussions about the HFEA and HTA. I hope that we can resolve and clarify the remaining and outstanding uncertainties on this issue before Third Reading, and I very much welcome the fact that the Minister has said that he will be responding to certain points. I am sure that he is prepared to continue those discussions and I hope that we can resolve them before Third Reading. Otherwise, I fear that we may have to return to this issue. I beg leave to withdraw the amendment.
NHS: Reorganisation
Earl Howe Excerpts(14 years, 3 months ago)
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Baroness Williams of Crosby
To ask Her Majesty’s Government what is their latest estimate of the cost of the reorganisation of the National Health Service and what proportion of that is due to redundancy and early retirement.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government published an impact assessment alongside the Health and Social Care Bill. This estimated the costs of the transition at £1.4 billion. Just over £1 billion was estimated to be as a result of redundancy. The £1 billion has not been split into redundancy and early retirement as these decisions will be made at a local level. The proposed reforms will save £1.7 billion per year from 2014-15 onwards.
Baroness Williams of Crosby
I thank my noble friend for that Answer, but I am aware that the National Audit Office, on the basis of its own surveys, has indicated a considerably higher figure. In an important article written by the professor of medical health at the Manchester Business School, the estimates are between £2 billion and £3 billion. Could my noble friend tell us the cost of the redundancies that have arisen from PCTs being brought to an end and people moving into the new consortia, and whether that figure is part of the figure that he has given to the House?
Earl Howe
My Lords, I would do best to refer my noble friend to the impact assessment, which provides a detailed breakdown of the figures that I have just given. I acknowledge that we have had to make assumptions in drawing up the impact assessment. Those can be challenged, and I am aware of the figures that my noble friend has referred to. But I do not believe that changing the figures—and they are bound to change in the nature of the exercise—will make a significant difference to the overall cost. The assumptions made in the modelling are based on the best available evidence that we have at the moment.
Baroness Thornton
Among many others, the Conservative MP Sarah Wollaston recently argued in the Daily Telegraph:
“I cannot see that it makes sense to foot the bill for redundancies for the entire middle layer of NHS management only to be re-employing many of them within a couple of years”.
As the Minister has said, the Government’s assessment of the redundancies varies between 600 and 1,200. Can I tempt the Minister to give us his best guess of how many of those redundant managers will be re-employed within the NHS within two years? Indeed, does the Minister think that this is an acceptable use of taxpayers’ money?
Earl Howe
We expect that about 60 per cent of management and administrative staff currently employed in PCTs and strategic health authorities will transfer to the new GP consortia or the NHS commissioning board. Those are straight transfers. As for those who leave the service, we have included claw-back arrangements in the redundancy scheme so that, if any employee returns to work for the NHS in England within six months, they will be required to repay any unexpired element of their compensation.
Lord Walton of Detchant
Does the Minister accept that many members of the administrative staff of the NHS are acting as if the Bill were already in law? For instance, staff in the PCTs are melting away. It is crucially important that those who will be required to help to administer the GP consortia should be kept on. Equally, now that the Government accept that the NHS commissioning board will require some regional infrastructure to commission highly specialised services, what action are the Government taking to ensure that the experienced and dedicated staff involved in the regional strategic authorities who carry out those commissioning tasks will be kept on?
Earl Howe
I am very grateful for the noble Lord’s question, because it gives me the opportunity to pay tribute to the skill and dedication of our managers and administrators in PCTs and strategic health authorities, whose skills we will most certainly need once the modernisation plans have been completed. We are clear that those who are able to provide these skills and can give us continuity into the new system are people we want to keep. We are encouraging them to stay and hope that they will. We are encouraging also the pathfinder consortia to engage with the PCTs to enable that to happen.
Baroness Gardner of Parkes
Following the question from the noble Baroness, Lady Thornton, could I ask my noble friend more about this transfer? Does he recall that, in previous reorganisations of the health service, large numbers of people claimed redundancy payments and then got very favourable jobs afterwards? Does he not think that the six months that he mentioned as the claw-back period is probably not enough at a time when the health service is very stretched? Also, will he consider what the noble Lord, Lord Walton, said about reorganising some of those posts now to avoid that situation?
Earl Howe
My Lords, we are beginning to reorganise the system. Under current rules, we are enabled to do so. I understand my noble friend’s particular point about the claw-back arrangements but there is perhaps a countervailing argument over what is fair and unfair in redundancy arrangements. In that sense, one cannot push the issue too far. Having said that, we are on track with the retirement scheme. We are seeing a deliberate and carefully managed process of reducing staff numbers at primary care trust level, leading up to the clustering of primary care trusts, which I am sure my noble friend knows about.
Lord Patel
Can the Minister say whether the Government have made any assessment of the transaction costs of the reform?
Earl Howe
I can tell the noble Lord, as I did before this Question began, that the transaction costs are not in my brief. However, we are in a different world now from the one we were in 10 or 15 years ago. We have a payment-by-results system which is well established. It is important to understand that the modernisation programme is not about competitive tendering, because it will streamline the whole process whereby providers to the health service will be enabled to offer their services to patients. It is not dependent on competitive tendering and the transaction costs should reflect that beneficially.
Health: Visitor Service
Earl Howe Excerpts(14 years, 3 months ago)
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Lord Northbourne
To ask Her Majesty’s Government whether their proposed development of the Health Visitor service will be targeted at those families in greatest need.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the health visitor implementation plan, published last month, confirms our intention to recruit an extra 4,200 health visitors and sets out the enhanced offer to families that the increased workforce will bring. The new model ensures a universal service for all, a rapid response from the health visitor team when parents need specific expert help and ongoing support to deal with more complex needs over time, including services from Sure Start children’s centres, other community services and, where appropriate, the Family Nurse Partnership.
Lord Northbourne
I am most grateful to the Minister for that encouraging Answer; it sounds very good indeed. Is he aware, though, that some of the families in the greatest need are very hard to contact, sometimes simply because they are embarrassed by their inability to parent and sometimes because they are afraid that the local authorities, if they hear about it, will take their children away? Is he also aware that there is a strange geographical distribution of the supply of health visitors, which as it stands has nothing to do with need? Will he assure the House that these issues will be addressed in the new plan?
Earl Howe
My Lords, the noble Lord is undoubtedly right that in many areas the current health visitor workforce is very stretched. They are there as a universal service but, at the same time, they try to target their efforts to families in the greatest need. Some struggle to do so, which is why we have set this ambitious programme of recruitment over three to four years. It is a very tough target—I do not disguise that from the noble Lord—but we think that it is necessary if we are to focus on the needs of the most disadvantaged families.
Baroness Gardner of Parkes
Is the Minister aware that many people apparently now view health visitors with suspicion as agents of the state? They are frightened, as the noble Lord has said, of the child being taken away. Does the Minister therefore think that one great answer is the system of adoption whereby children can be fostered by someone who could adopt them if, for example, the drug addict mother does not overcome her addiction, but which also leaves open the possibility of the child returning to the mother? That gives the mother an opportunity to recover. It is a very good scheme and it is in operation in some parts of the country. Would it not be a help in addiction cases?
Earl Howe
My noble friend makes a good point. The kind of intensive interventions that she is referring to are very much the domain of the family nurse partnerships, which are there to assist and support those families with the greatest needs, particularly single mothers, families where there is addiction and so on, and try to keep the family together. With regard to the health visitors, however, I take her point that there is suspicion out there. It comes down to creating a relationship of trust with a named health visitor, and we have seen the success of that over the past few years. The results of the assessments have been very positive.
Lord Hughes of Woodside
My Lords, when health visitors were attached to local authority services, co-operation between the different arms of local authorities was much easier. In many cases, health visitors are now attached to general practice services. Can the noble Earl assure me that there will be the widest possible consultation to make sure that health visitors can reach out to the community at large, which would be very valuable in terms of public health?
Earl Howe
My Lords, the noble Lord makes an extremely good point. The health visitor initiative is very much part of our public health drive. Local authorities will have an important part to play in commissioning services in the future. However, at the start of this big programme of recruitment, it is very important to have a concerted national drive. That is why we have said that it will be the responsibility initially of the National Health Service Commissioning Board to push this agenda forward. Thereafter, we will see much more local commissioning as the programme moves on.
The Lord Bishop of Wakefield
My Lords, given that the Department of Health accepts that the family nurse partnerships—to which the Minister has referred—have been shown through an international report to have a great effect in minimising the maltreatment of children, are there plans to introduce them across the board alongside the implementation plan for health visitors?
Earl Howe
The right reverend Prelate draws attention to a very important area. Family Nurse Partnership is essentially a preventive programme for vulnerable young first-time mothers. It complements and supports the work of health visitors, providing intensive care. We are committed to expanding the Family Nurse Partnership Programme for those families and doubling the number of places on the programme by 2015.
Baroness Jolly
My Lords, this is a really large programme. Will the noble Earl clarify whether, if these posts are filled from within the NHS, those posts will in turn be backfilled?
Earl Howe
My Lords, we hope to recruit nurses and midwives for upskilling from a variety of sources. Some will come out of retirement, we hope, while others will, we trust, come from the acute sector. As my noble friend knows, the trend for a long time has been to try to get care increasingly out of acute settings and into the community. I think that we will see that transfer of skills taking place from a variety of sources.
The Earl of Listowel
My Lords, given the important and welcome drive to recruit health visitors, will the Minister consider hosting a meeting for health visitors and Members of the House of Lords so that we can understand this issue better and support this work as far as we can?
Earl Howe
My Lords, I draw the noble Earl’s attention to the document which my department published last month, Health Visitor Implementation Plan 2011-15: A Call to Action, which sets out how we are going to work with partners to deliver our ambition, including, very significantly, the Sure Start children’s centres which play an important role in our agenda. However, I will take the noble Earl’s idea back with me and be in touch with him about it.
Baroness Ritchie of Brompton
My Lords, what work is being done to improve the training of health visitors to enable them to identify the mental health needs of new mothers, which can impact very negatively on the emotional attachment between mother and child?
Earl Howe
My noble friend identifies an extremely important area of the health visitors’ remit—to put their finger on where there are problems and therefore to alert members of the multidisciplinary team to address those problems where necessary. The issues to which she refers are very much a part of health visitors’ training.
Health: Sickle-Cell Disease
Earl Howe Excerpts(14 years, 3 months ago)
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Baroness Benjamin
To ask Her Majesty’s Government what measures are in place to ensure that paramedics and ambulance crews across the country are adequately trained in the diagnosis and treatment of those with sickle-cell disease.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, addressing the training needs of health professionals working with patients with sickle-cell disease is the responsibility of the appropriate regulatory body. They set standards for the preregistration training, approve the education institutions that provide training and determine the curricula. Where a health profession is not regulated, it is the duty of the employer to make sure that the individual has the appropriate level of training to perform the duties required of them.
Baroness Benjamin
I thank my noble friend for that Answer. I am sure he is aware that sickle-cell disease is now the fastest growing genetic blood disorder in England. Some 300 babies are born with the condition every year and yet there are many misunderstandings about diagnosing a sickle-cell crisis. Is my noble friend aware of the recent tragic death of a young girl who died of a sickle-cell crisis? Apparently, during the crisis, she had soiled herself and, allegedly, the emergency crew who came to her home refused to treat her and to take her to hospital because of the messy state in which they found her. Does my noble friend agree with me that this underlines the urgent need for training, not just for paramedics but for all emergency crews, so that that never happens again? Will he assure the House that best practice standards and guidelines with regard to sickle-cell disease are enforced right across the NHS? I declare an interest as a patron of the Sickle Cell Society.
Earl Howe
My Lords, I am aware of the tragic case to which my noble friend refers, which is of course the subject of an investigation at the moment. The facts, as I am aware of them, suggest that the failings that occurred in that case were more to do with poor practice than a lack of training, although we will see what emerges from the inquiry. However, I can tell her that there is national guidance on the symptoms and emergency treatment of people with sickle-cell disease, published by the Joint Royal Colleges Ambulance Liaison Committee. All ambulance crew staff receive training in the assessment and management of patients with sickle-cell conditions in line with those guidelines and further national guidance was issued to staff in 2009. It is regularly updated and it is taken very seriously.
Lord Foulkes of Cumnock
Do both of the Minister’s replies apply also to Scotland?
Lord Colwyn
My Lords, I declare an interest as chairman of the All-Party Parliamentary Group on Emergency Ambulance and Paramedic Services. The College of Paramedics is very aware of the skills levels of ambulance staff. Will the Minister consider the use of badges to identify staff according to their registration status, so that all concerned parties are enabled to make reasonable assumptions about their abilities as regards treatment and overall incident management?
Earl Howe
My Lords, I am aware of the suggestion to which my noble friend refers. The wearing of badges is very much a matter for local determination. Clearly, it is desirable that there should be consistency across the country. I understand that there is a regular meeting of the chief executives of ambulance trusts under the chairmanship of Peter Bradley, the London Ambulance Service chief executive. I suggest to my noble friend that the proposal is put to Mr Bradley as one that the joint chief executives could look at.
Lord Hughes of Woodside
My Lords, does the Minister accept that it is not simply the health service that needs education about sickle cell but also vulnerable communities themselves that need a great deal of education and knowledge to help them?
Earl Howe
The noble Lord is quite right. One of the successes in recent years has been the universal screening programme for sickle cell that has certainly raised awareness among all communities about this devastating condition. The screening programme alerts healthcare professionals to the needs of children with the disease and also enables them to provide the necessary support for families.
Baroness Gardner of Parkes
Do people who have sickle-cell disease carry any form of card or identification as people with various other conditions do? As a dentist, I know that the definitive test is a blood test. Patients told you they had it, but no one expected you to pick it out in some person coming in the door. I wonder whether there might be a case for having some kind of identification.
Lord Touhig
One in 10 children diagnosed with sickle-cell disease will suffer a stroke. Unfortunately, a number will die. Those who do not will go on to have further strokes leading to disabilities and cognitive loss. The Minister talked about a screening programme. Do the Government have in mind any plans to get greater public awareness of sickle-cell disease by a public education programme right across the board among all groups in society?
Earl Howe
There are several initiatives in train that should raise public awareness. We have asked NICE to produce a short clinical guideline. The National Haemoglobinopathy Registry is being launched. It was a key recommendation of the NCEPOD report a couple of years ago. We are funding many more training posts for registrars, nurse consultants and clinical scientists, and we are developing a special competence framework for nurses. As for raising awareness generally among the public, patient groups have an important part to play there in conjunction with specialist clinicians.
Public Bodies Bill [HL]
Earl Howe Excerpts(14 years, 3 months ago)
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Lord Patel
My Lords, I think I have lost my thread, but I have said what I wanted to say.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by expressing my thanks to all noble Lords for the opportunity to debate these amendments. As the noble Baroness, Lady Thornton, pointed out at the beginning of her remarks, following the Government’s concession in withdrawing Schedule 7 in its entirety, these amendments would have the effect of putting the Human Tissue Authority and Human Fertilisation and Embryology Authority out of scope of the Bill.
Our starting point in approaching these issues is a clear objective to streamline the process of regulation and, consequently, reduce costs and the administrative burden on establishments while continuing to offer the necessary protection for the public. The Bill presents us with an opportunity to achieve that. Our aim is to streamline healthcare and medical research regulation and so reduce bureaucracy. That approach is supported by leading assisted reproduction clinicians and their professional bodies and by the Academy of Medical Sciences.
The scope for streamlining is clear. We estimate that around 80 per cent of the centres currently licensed by the HFEA are also either regulated by the Care Quality Commission or are in premises that the commission regulates. Some 60 per cent of the centres licensed by the HTA are similarly covered by the CQC. It therefore seems unsustainable to continue to have these regulatory systems running in parallel. The question posed by my noble friend Lord Newton of Braintree as to whether the CQC wants to take on this work can best be answered by reference to the regulatory activity that it already performs. In any event, as regards the pace at which we take this, we intend to develop arrangements for the transfer of functions in consultation with the CQC over the next few years, and no transfer of functions will take place until that process is complete. However, the Government recognise that there are number of noble Lords with concerns about the proposal to transfer the functions of these two bodies, and not for a minute would I wish to minimise the nature of those concerns.
Let me be clear—both the HFEA and the HTA are models of regulatory authority that were right for the times in which they were created and which have done an admirable job in meeting the demands placed on them. However, as my noble and learned friend Lord Mackay of Clashfern pointed out, times change, and most pertinently so has the way in which we regulate the delivery of healthcare. With the establishment of the CQC along with the possibility—and I put it no stronger than that at the moment—of the creation of a new regulatory body for medical research, alternative structures are becoming available to ensure a more joined-up system. This provides, as I have said, the opportunity to streamline the process of regulation and reduce costs.
The powers in Clause 5 would allow us to achieve that without disturbing the underlying legislation, which captures the ethical safeguards that Parliament has so carefully set in place. Any future proposals to abolish these two bodies will be provided for in future primary legislation. I am happy to reiterate my assurance that there is no intention to revisit the provisions in either the Human Tissue Act or the Human Fertilisation and Embryology Act that provide the important ethical safeguards necessary to maintain public confidence in these sensitive areas. I would say to my noble friend Lord Willis and to the noble and learned Baroness, Lady Butler-Sloss, and the noble Baroness, Lady Deech, that means that future arrangements to regulate tissue and embryos must adhere strictly to the provisions of the two relevant Acts.
Noble Lords have raised particular concerns about the need to preserve the expertise these bodies have built up in the ethically sensitive subjects they deal with and the need to preserve the confidence of both professionals and the public in the way that these regulatory functions are carried out. The Government recognise the genuine nature of these concerns and we are determined that changes will not be at the expense of regulatory rigour or expertise.
I say to my noble friend Lord Willis that expertise will not be lost. It is envisaged that expertise will follow functions; for instance, through staff transfers and expert reference groups. Noble Lords have questioned the capacity of the CQC to assume these responsibilities. It will be given the capacity and the resources to carry out any widened functions. The CQC already has a proven track record of taking on the oversight of a specialist area. It took on the Mental Health Act Commission functions and I believe has successfully maintained oversight and focus on that area.
The noble Baroness, Lady Thornton, expressed concern that our whole approach in this area seemed unnecessarily complex. The powers that we are debating today will enable us to transfer some of the functions of the HFEA and HTA to other bodies but they do not enable us to do everything that we have set out in the ALB review. In order to abolish the HFEA and HTA or to transfer their research-related functions to any new research agency we will require powers under future primary legislation.
It may help if I try to provide a rough outline as to how and when we expect things to happen. We intend publically to consult on proposals to transfer all of the HFEA and HTA functions to other bodies in the late summer of 2011. Then during 2012-13 we would prepare draft orders for formal consultation under the provisions of this Bill dealing with the transfer of functions other than research functions. If appropriate we would then be able to lay the orders before Parliament. The process would enable noble Lords and other interested parties to see, comment on and debate the proposals as they progress. In order to avoid the piecemeal transfer of functions we would intend to ensure that the timetables for necessary future primary legislation and the commencement date of orders made under this Bill are aligned so that they come into force at the same time.
Without the inclusion of these bodies in Schedule 5 to the Public Bodies Bill we would have to provide for the transfer of their functions entirely within future primary legislation and this would significantly increase the risk that the underlying ethical provisions of the Human Fertilisation and Embryology Act and the Human Tissue Act could be reopened for debate and would afford less time for consideration and comment than the progressive approach which I have just outlined. I seek to impress upon noble Lords that that is a very powerful reason for wishing to grant the Government the powers we are seeking as regards these two bodies.
The noble Lord, Lord Warner, indicated that, in his view, the report by the Academy of Medical Sciences does not give sufficient backing to the idea that embryo research should be covered by the new research regulator. I would simply point him, if I may, towards paragraph 9.5.1 of the report which explicitly refers to the new body, if it is set up, having responsibility,
“for ‘specialist’ approvals and licences within the HRA around data, tissue and embryos, gene therapy and exposure to radiation”.
I think, as I read that, it was very much in the minds of the authors of the report that the research functions of the HFEA should be brought within the scope of a health research regulatory agency.
The noble and learned Baroness, Lady Butler-Sloss, expressed her worries about the information functions of the HFEA and the absence of a clear plan by the Government for what should happen to those functions. She is right, we have not fully made up our minds about where those functions should best sit, but that is one of the main reasons why we wish to consult on this. We need to ask the public and interested parties where these functions should sit, and there will be an impact assessment with the consultation.
My noble friend Lord Willis asked about the possibility of setting up a single research agency without primary legislation. He is technically right; we could do that. I should emphasise that we have not decided whether to accept the AMS recommendation to establish a single research agency—we think that there are merits in the proposal and we will be making an announcement shortly—but if we were to propose setting up such an agency we could do so initially by creating a special health authority. However, we could not legally transfer the research-related functions of either the HTA or the HFEA to that body. We could not make a transfer of functions to a special health authority without amending the 2006 Act.
The case was simply put by my noble and learned friend Lord Mackay of Clashfern. Essentially, we are asking the Committee to agree to grant the Government permission to consult on these matters. I hope that the noble Baroness will not seek to press her amendment today but instead will consider that a good purpose will be served by reflecting on the comments that I have made in response. In view of our concessions—
Lord Warner
I am sorry to interrupt the Minister. I have been listening intently to what he has said. I am extremely confused about the order in which things are going to be done. As I understood what he was saying, we are going to get a series of orders that transfer functions through a process of consultation, which I welcome, but we may or may not know at that point what the Government are going to do about setting up a health research agency, either by statute or otherwise. As I understood him, we could be in the position of being asked to agree those orders before we know what the final endgame is. It would be helpful if, before the next stage of the Bill, the Minister could set this out more clearly for us in writing so that we can understand the sequence. I found it rather difficult to understand.
Earl Howe
I must apologise to the Committee if I was not sufficiently clear and I will be happy to write to those who have participated in this debate to make the position clearer. I was seeking to say that we do not wish to take a disjointed, piecemeal approach. There is a natural flow of process that, if Parliament agrees, can lead us to a position where we are able in one move, so to speak, to transfer the various functions more or less simultaneously—although I would not wish to undertake that the whole thing would be done on the same day—so as to arrive at that point.
In our view it is desirable to consult during the late summer of this year. We will then set about the process of designing statutory instruments based on that consultation and go out to consultation on them. All being well, we will then introduce a second-Session health Bill that will have within it the provisions to establish a single research regulator, assuming that that is what we decide to do. Therefore, the whole process should work in a seamless way. However, I shall be very happy to write to noble Lords setting that out.
I return to the point at which I left off, which is to express the hope that the noble Baroness will not press her amendment this evening. I hope that she will accept our assurance that we have a clear intention to consult on the proposed transfers of functions and that she will be willing to withdraw the amendment.
Baroness Thornton
My Lords, I thank everybody who has contributed to this debate. I knew that it would be an interesting debate and a long one. I have been told by my noble friend that I have to be brief, as the Committee still has a lot of things to get through and the rest of us can go home when we have finished this. As I say, I thank all those who have taken part in this debate. The remarks of the noble and learned Baroness, Lady Butler-Sloss, were forensic and, as usual, very helpful. The noble Lord, Lord Walton of Detchant, spoke with great wisdom and knowledge about both the HFEA and the HTA. The noble Lord, Lord Newton, spoke wisely about the CQC. Having been one of the architects of the CQC in the previous Government, I wish to put on record that I very much admire the work that it does. However, it is being asked to do a great deal more, which worries me.
I am pleased that the noble Baroness, Lady Deech, continues to support us as we work towards resolving this matter. The noble and learned Lord, Lord Mackay of Clashfern, my noble friend Lord Winston and the noble Lord, Lord Patel—a trio of very distinguished professionals in their respective ways—said that, although progress has been made, the most important thing is to make more progress. I am not a scientist but in a way the scientists and the experts got us into trouble on both these issues and that led to the creation of the HFEA and the HTA, as imperfect as they might be. Those bodies were established to tackle the need to regulate and to restore public confidence. That is where we came in, as it were. It seems to me that challenges and problems still exist in terms of public confidence, to which I will return in a moment.
I accept that if we need to move to a more overarching medical research body, we need to go through a proper process. I am not convinced that the powers granted to the Government in this Bill are the way to do that or that what looks like a rather complex and very piecemeal process is the right way forward. However, I am grateful to the Minister for explaining this in great detail.
I am worried. A floating ethical framework sprang into my mind because I could not see where the ethical framework of what is being proposed will sit. If we cannot see where it will sit, what hope is there for the public? It seems to me that that is where the Government need to start. It is not a question of having a mechanical process and saying, “We will put this bit here and that bit somewhere else and have a regulation that will make sure that the research goes somewhere else”, because if we cannot understand where the ethics sit we are in very serious trouble.
The Minister has given us a great deal to think about and I am grateful to him for his detailed answer. I will read the record and I look forward to receiving his letter. We will need to think about what he had to say and discuss it further before Report. I will not press the amendment now, so I beg leave to withdraw it.
Health: Care and Compassion?
Earl Howe Excerpts(14 years, 4 months ago)
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Lord Touhig
To ask Her Majesty’s Government what action they plan to take in response to the Parliamentary and Health Service Ombudsman’s report Care and Compassion?.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the department has asked the Care Quality Commission to conduct a series of unannounced inspections on NHS trusts, and will report on its findings. The department wrote to NHS chairs on 15 February to raise awareness of this report and to ask them to assure themselves that their own organisations were up to standard. Similarly, the chief nursing officer also raised the report findings at her February meeting with strategic health authority directors of nursing.
Lord Touhig
I thank the Minister for his Answer, which is very helpful. We in this country are blessed with a National Health Service staffed by very dedicated and committed people but, as this report highlights, there are instances of neglect and a lack of care for the elderly. The best way to prevent cases like the 10 listed here happening again is to ensure that everyone in the National Health Service, if possible, reads the report. It is available online at www.ombudsman.org.uk, but can the Government find ways to help to distribute the report so that everyone working in the health service can read it?
Earl Howe
My Lords, I understand and applaud the noble Lord’s reason for making that suggestion. I will overlook the issue of cost, but I am not sure that his idea would necessarily have the desired impact. What is needed here is for local leaders to take charge. That is why the chief executive wrote to every chairman and chairwoman in the NHS asking them to share the report with every member of their board, so that they can examine the services in their particular organisation and assure themselves that these situations are not happening on their watch. Nevertheless, I am certain that boards around the country will wish to take heed of the noble Lord’s suggestion.
Baroness Knight of Collingtree
Does the Minister recall the number of legitimate complaints that were made during the period of office of the previous Government about bad treatment within the health service? Nothing was done with urgency. Will he recognise that when there are legitimate complaints, delay causes deaths and great suffering? When there are such complaints, they should be dealt with speedily and deeply.
Earl Howe
My Lords, I am sure the whole House will recognise the contribution that my noble friend has made to raising awareness of these very troubling issues, and I pay tribute to her. She is right, which is why our proposals for the NHS place a great deal of emphasis on strengthening accountability at every link in the chain, so that the complaints that she has referred to are dealt with speedily and someone is held accountable for what has happened.
Baroness Emerton
My Lords, will the Minister please say whether it is the Government’s intention to respond to the previous Prime Minister’s commission on nursing, which reported in March 2010? There were 21 commissioners, and I declare an interest as one of them. The report made 20 recommendations, 17 of which relate directly to the ombudsman’s report and, if implemented, would go some way to curing some of the types of incidents that were reported. There is a great need on the part of both the employers and the employees, and it was good to hear the Minister say that a letter has gone to the employers. Would it be possible to have an answer to the commission so that we could see the implementation of some of these recommendations? I am ashamed to be named a nurse when such dreadful care and lack of supervision have been identified. We have a responsibility here. I ask the Minister to look at the supervision of untrained staff and the regulation of assistant nurses.
Earl Howe
My Lords, I will look and see where we are on a formal reply to the commission’s report. Again, I pay tribute to the noble Baroness for her work in leading the nursing profession. She is absolutely right that strong nursing leadership at every level, from ward to board, is essential to ensure high-quality care. Ward managers make a critical difference, matrons provide strong leadership on wards and all nurses, I believe, must aspire to continuous quality improvement. That is why we expect directors of nursing to review this report with a view to addressing any areas of improvement in their own organisations.
Baroness Royall of Blaisdon
My Lords, we warmly welcome this report and the actions that the Government are going to take upon it. However, how will a fully competitive market in healthcare ensure that older people are looked after properly, with care and compassion?
Earl Howe
Perhaps I may elaborate on an answer I gave earlier about our reform proposals, which have at their heart the strengthening of accountability. There will be accountability: for outcomes, through the outcomes framework, to ensure that NHS providers focus first and foremost on quality; through GP commissioning, which will bring commissioning closer to patients and ensure that it is clinically informed; and in strengthened local accountability, not only through the health and well-being boards in local authorities but via the public, through Health Watch, which will ensure that the NHS focuses on what is important to patients and citizens.