NHS: Global Health

Earl Howe Excerpts

Monday 20th December 2010 Lords Chamber

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

My Lords, I thank the noble Lord, Lord Crisp, for calling this debate and express my gratitude for his strong and continuing commitment to issues of global health. I found his speech extremely helpful and thought provoking.

The Government are deeply committed to issues of international development. In this year’s spending review we confirmed that, as well as protecting the NHS budget, we will keep our promise to spend 0.7 per cent of gross national income on aid from 2013, helping the billion people who live in extreme poverty around the world. We are equally committed to doing everything we can to meet the millennium development goals. In particular, we are taking bold action to tackle malaria and to improve reproductive, maternal and newborn health. In answer to the noble Baroness, Lady Thornton, we are currently reviewing the previous Government’s cross-Whitehall global health strategy to ensure its relevance and effectiveness in the coming years.

The noble Lord, Lord Crisp, has linked issues of development with those of the appropriate education of health professionals, which itself has enormous implications both for our nation’s health and for that of the rest of the world. As he knows, there are many aspects of the education of health professionals, encompassing pre- and post-registration training, as well as continued professional development. The responsibility for setting the standards required for professional pre-registration sits with the professional regulators. The higher education institutes then design training curricula to meet these standards in partnership with NHS service providers and the regulators. The Department of Health, along with the local NHS bodies that commission professional training, continues to work with the regulators and higher education institutes to ensure that their standards and curricula reflect the changing needs of patients and service delivery.

In terms of pre-registration education for doctors, we look to the General Medical Council for leadership. Its 2009 publication Tomorrow’s Doctors provides the framework that UK medical schools use to design detailed curricula and methods of assessment. I was glad to see the framework was well received by the authors of the recent Lancet Commission publication, Health Professionals for a New Century. The framework also highlights the importance of a global dimension. New graduates must be able to demonstrate awareness, from a global perspective, of the determinants of health and disease and of the variations in healthcare delivery and medical practice. Postgraduate medical training curricula are developed by the medical royal colleges for approval by the GMC. Most of the topics highlighted in this debate are covered in the foundation programme curriculum and core competence framework for doctors developed by the Academy of Medical Royal Colleges.

We have come a long way since the noble Lord wrote his report on medical training, Global Health Partnerships, in 2007. My noble friend Lord McColl is absolutely right that there is already significant good practice in the UK in terms of incorporating the global dimension into pre- and post-registration training. This is one part of the answer to the noble Lord, Lord Crisp, who asked me to consider what more might be done to support this type of activity. Medical students can study global health; they can spend a year studying international health as part of an intercalated degree or can choose to travel to developing countries for the elective component of their undergraduate training. There are also opportunities for post-registration medical doctors to spend part of their specialty training in developing countries, as part of the out-of-programme training and research arrangements. Here, I reassure my noble friend Lady Tonge and the noble Baroness, Lady Hollins, that, if prospectively approved, training of this type counts towards the certificate of completion of training. Details of this initiative are provided in the Gold Guide, a guide for postgraduate specialty training in the UK agreed by the four UK health departments for core and/or specialty training programmes. This sets out a clear process as a guide for post-graduate deans.

My noble friend Lord McColl—

[Lord Davies of Stamford]

I am extremely grateful to—

--- Later in debate ---

[Earl Howe]

Perhaps the noble Lord and I can speak after the debate.

My noble friend Lord McColl stressed the need for taking longer periods overseas and providing greater support for achieving the goals that we have all been talking about. Universities support medical student electives as long as the plans are carefully drawn up to ensure the best possible experience for them and, of course, for the host institution abroad. I emphasise to the noble Lord, Lord Patel, lest there be any doubt in his mind, that we strongly support the principle that trainees should have opportunities to gain experience overseas both for their own benefit and that of the host countries. Also, the noble Baroness, Lady Cox, was right to say that there are opportunities for postgraduate medical doctors to spend part of their specialty training in developing countries, as I have mentioned, and these can count towards clinical medical training.

In answer to my noble friend Lady Tonge, we take on board comments about reducing the level of bureaucracy in this process, and we welcome suggestions for improvement. However, we need to ensure both that service can continue to be delivered effectively in the NHS and that training overseas is appropriately recognised, supervised and assessed, which is not necessarily straightforward in every case.

Earlier this month, the Lancet Commission published a report, Health Professionals for a New Century. In response to some of its specific proposals, I should like to highlight the progress that has already been made in a number of areas. For example, the Department of Health is taking forward its technology-enhanced learning strategy to promote greater use of information technology for learning, harnessing and sharing global education resources. The Medical Training Initiative allows a small number of doctors from developing countries to work and train in the NHS before returning home. The National Leadership Council works with clinicians from all professions to develop their leadership skills and embed leadership across all undergraduate and postgraduate curricula. The Health Partnership Scheme, launched in November by my honourable friend in another place, Stephen O’Brien, will enable NHS professionals to share their skills with nurses and doctors in developing countries through teaching, training and practical assistance. We should also mention the report from the noble Baroness, Lady Deech, entitled, Women Doctors: Making a Difference. It makes recommendations on a range of issues that include improving access to mentoring and career advice, improved access to childcare, more flexible and part-time training, and encouraging women into leadership positions.

We must always look to improve the standards of medical education in this country. For this reason, as has been mentioned, we have today published Liberating the NHS: Developing the Healthcare Workforce, the consultation on the education and training aspects of the NHS White Paper, Equity and Excellence: Liberating the NHS. The White Paper signals a new approach to workforce planning, education and training by,

“giving employers greater autonomy and accountability for planning and developing the workforce”,

alongside greater professional ownership of the quality of education and training. The consultation will enable my department to do the second thing proposed by the noble Lord, Lord Crisp, which is to meet with relevant parties to consider the findings of the Lancet Commission report. With the changes set out in the NHS and public health White Papers, the system of healthcare in England is changing, and it is imperative that our system of education and training reflects that change.

The noble Baroness, Lady Hollins, asked whether curricula include global competences. They do, and in acknowledgement of the case presented by Medsin UK, a global health dimension is included in the 2009 GMC guidance, Tomorrow’s Doctors, which states that new graduates must be able to demonstrate,

“an awareness from a global perspective of the determinants of health and disease, and variations in healthcare, delivery and medical practice”.

In fact, most of the topics highlighted by the report of the noble Lord, Lord Crisp, which I mentioned, are covered in the foundation programme curriculum published this year. All topics are at least partly described in the core competences for doctors in the Academy of Medical Royal Colleges’ Common Competences Framework for Doctors, published last year.

The noble Lord, Lord Crisp, urged that we should find ways to give active support for doctors to take part in health partnership schemes. We agree that we need to support doctors and other health professionals to take part in that scheme and I can reassure him that the Department of Health is working closely with the Department for International Development on this initiative. I mentioned the partnership scheme earlier.

The noble Lord, Lord Butler, referred to the role of academic health science centres and I welcome the initiatives taken by the AHSCs, both in teaching and research, in global issues. They can contribute a huge amount but perhaps two things above all: the partnerships which they can and do form overseas and their ability to develop cultural competence in UK graduates.

My noble friend Lady Tonge referred to the need for ethical recruitment. She is absolutely right. She probably knows that the UK was the first country to produce international recruitment guidance based on ethical principles and the first to develop a robust code of practice for employers.

The noble Lord, Lord Crisp, made some extremely constructive and important points, as did all other speakers, for which I am very grateful. I shall make sure that these are taken into account during the consultation process.

In closing, I should like to take this opportunity to invite all interested parties to engage with the consultation to help us develop the recommendations made in the Lancet Commission report and to help shape the future system of education for health professionals.

NHS: Reorganisation

Earl Howe Excerpts

Thursday 16th December 2010 Lords Chamber

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

My Lords, I join other noble Lords in thanking the noble Lord, Lord Touhig, for calling this debate, which has been both wide-ranging and characterised by some extremely thoughtful and eloquent contributions. I welcome the opportunity to discuss these issues, which are so important to us all. Of course, being impressed by eloquence is not the same as being swayed by argument. It will not surprise your Lordships that I cannot identify with the criticisms of the Government’s policy voiced by several speakers. By and large, those criticisms are either misplaced or exaggerated and I hope to show why.

It is perhaps appropriate to start with the question posed by the noble Lord, Lord Hunt of Kings Heath, about why we are reforming the NHS. First, as good as the NHS is, in what is most important for patients and many health outcomes—for many cancers, respiratory disease and heart attacks—we lag behind. Secondly, in its current state, the NHS is unsustainable. We can no longer meet increasing demand by spending ever more money. In every western economy, cost pressures from healthcare exceed GDP growth. There is a basic challenge of affordability. Without reform, the NHS will quickly bend until it breaks.

We seek to address a good part of that challenge through the four pillars of the QIPP programme—quality, innovation, productivity and prevention. In many ways the White Paper is a vehicle for the QIPP reforms, squeezing the most out of every penny invested and creating a better-value and entrepreneurial NHS. Looking more particularly at the prevention agenda, our focus on public health through Public Health England will do as much to keep people healthy as the NHS does to make them well.

Although some see the reforms as a big step—I do not disguise the fact that there will be some big changes—they amount in several other respects to a series of small steps. GP-led commissioning builds on the experience gained from previous reforms, particularly practice-based commissioning and GP fundholding. Our any willing provider policy is an extension of the choice agenda initiated by the previous Government. Without lowering the quality bar—I say that particularly to the noble Lord, Lord Touhig—we are completing the rollout of foundation trusts, only this time with robust arrangements for provider failure. The reforms resolve and bring coherence to a series of sometimes disjointed measures rolled out under the previous Administration. Our aim in doing this is very clear: it is to transform the health service into a sustainable system with outcomes as good as any in the world.

Noble Lords need to ask themselves what the alternative would be. Without reform, the alternative is to salami-slice the health service as it is now, with obvious risk and detriment to patients. We know that the previous Administration put aside £1.7 billion for NHS reorganisation of some sort. We will never know what precisely they would have done, but if it was not something similar to our proposals then I wonder what it was.

The other vital strand to the new NHS—again, this was a clear ambition of the previous Administration—is the genuine integration of health and social care, which was mentioned by a number of noble Lords, including the noble Baroness, Lady Sherlock, and the noble Lords, Lord Turnberg and Lord Beecham. We are putting a lot of money into integrated care. I say to the noble Baroness, Lady Sherlock, that the involvement of social care in commissioning will be a key role of the health and well-being boards and the related joint strategic needs assessments that will need to be undertaken by consortia and local authorities working together. What she will see, based on those joint strategic needs assessments, will be better, more integrated health and social care services for patients.

The Government’s response to the White Paper consultations was also published yesterday. This sets out the legislative framework and next steps for the White Paper as we move towards publishing a health and social care Bill in the new year. I wish to pick out two or three issues from this. First, as regards commissioning, the best decisions are those taken closest to those whom they affect. Unfortunately, time prevents me from expatiating on the excellent theme of the noble Lord, Lord Mawson. However, GP-led commissioning will place decisions about the future design of local health services in the hands of clinicians—GPs and their colleagues across the NHS and social care working together. These are people who see their patients and service users every day.

Last week, in response to the consultation, we announced the first 52 in a rolling programme of GP consortia pathfinders. These are in essence the pilots to which the noble Baroness, Lady Williams, urged us to direct our efforts. This first batch involves more than 1,800 GP practices and covers a quarter of the population—some 12.8 million people. The noble Lord, Lord Turnberg, doubted whether integrated care was truly achievable. I visited a pathfinder last week in Nottinghamshire and came away completely inspired by what I saw there in terms of joint working, creative thinking and the breaking down of professional barriers. Noble Lords who have thus far viewed the Government’s proposals solely from the printed word should consider experiencing what is actually happening on the ground. Pathfinders will enable emerging consortia to become more involved more quickly in commissioning. They will explore the issues involved in effective implementation before consortia take on their statutory duties in 2012-13.

The noble Lords, Lord Hunt and Lord Touhig, and others somewhat poured cold water on the whole concept of GP-led commissioning. However, it will remove the current disconnect between clinical decision-making and financial decision-making by putting both in the same place. Those who question the wisdom of that approach should speak to some of the pathfinder GPs. They do not see themselves as being presented with a problem; they see themselves as being able at long last to manage budgets in a way that will change services and bring maximum benefit to all their patients without “the system” getting in their way. The brutal truth is that a budget that is subject to the kind of managerialism referred to by my noble friend Lord Alderdice risks depriving some patients of the care that they need. To those who question the enthusiasm of GPs, I say that the first application for becoming a pathfinder was oversubscribed. More will be coming on stream. By the middle of 2011, we believe that the vast majority of GP practices will be members of pathfinder consortia.

At the centre of everything should be the patient. The noble Baroness, Lady Masham, was right in her general point, although I did not agree with everything that she said subsequently. The NHS should be accountable to the people whom it serves. Patients and the public should have a say in how local NHS services are shaped and should be able to hold them to account in a meaningful way. Beyond a straightforward legal duty for NHS organisations to consult the public, the new local patient champion, HealthWatch, will ensure that people’s voices are heard and acted on. It will be supported by a new national patient voice, HealthWatch England—a short step from what we have at the moment with local LINks, but an absolutely crucial one. The patient voice will also be vital for the new health and well-being boards, which will join up the local NHS, public health and social care. The fact that these boards will be based in local authorities will, of itself, inject a high degree of local democratic accountability into commissioning.

The noble Lord, Lord Touhig, and others referred to the trend towards competition, arguing that there is little evidence of its benefits. As we set out in the White Paper, choice and competition can be powerful drivers for quality and efficiency and can force providers to develop services that genuinely meet patients’ needs and preferences. However, we do not want to introduce the choice of any willing provider for its own sake. That makes sense only where it is likely to deliver real benefits. Competition should not be at the expense of co-operation and there is no reason why it should be. There will still be a duty in the health Bill for NHS organisations to co-operate in patients’ interests.

The noble Baronesses, Lady Williams and Lady Finlay, and, indeed, the noble Lord, Lord Rea, with his arboricultural hat on, suggested that we keep PCTs and simply populate them differently. Let me say why that would not have delivered the outcomes that we want. PCTs are administrative units. The way in which they are configured bears no automatic relationship to the way in which clinicians want to deliver services, and clinicians feel no sense of ownership of them. The pathfinder consortium that I visited in Nottinghamshire last week is configured in a way that takes account of patient flows between primary and secondary care, is logical in terms of how health and social care services are best integrated and works on the ground in terms of close professional relationships. Doctors and other health professionals have designed it; they own it and they believe in it. That is the difference.

The noble Lord, Lord Touhig, referred to fundholding, which I agree was not a successful enterprise in some respects, although it had some valuable lessons which we are now picking up on. Fundholding had a conflict of interests because, as the noble Lord said, underspends of the commissioning budgets tended to go to the practice involved. This will not be the case for GP consortia. The only way in which GPs will be able to benefit is if they can improve outcomes for patients.

The noble Lord, Lord Turnberg, and the noble Lord, Lord Touhig, referred to the risk of recreating or accentuating the postcode lottery. Perhaps I may say that the prime purpose of the National Health Service commissioning board will be to inject two main things, consistency and quality, into commissioning. The NHS commissioning board, supported by NICE, will develop a commissioning outcomes framework so that there is clear, publicly available information on the quality of healthcare services commissioned by consortia. It will include measures to reflect a consortium’s duties to promote equality and to assess progress in reducing health inequalities.

The noble Baroness, Lady Finlay, and the noble Lords, Lord Touhig, Lord Patel and Lord Beecham, criticised the injection of competition and choice into local health economies and expressed fears about cherry-picking. In the new system, the NHS board and Monitor will develop packages of services and tariffs for services, taking account of the need for individual providers or partnerships of providers to deliver integrated care. Monitor will have a duty to ensure that competition, where it is appropriate, functions effectively, which means developing systems where providers cannot cherry-pick the easiest patient groups.

The noble Lord, Lord Hunt of Kings Heath, and others raised various issues concerning accountability and governance. I suspect that we will get into the weeds of this when the health and social care Bill reaches your Lordships’ House, as there is no time to do so today. We think that consortia should be free to define their own governance processes but within a broad framework that will be set out in the legislation. Noble Lords will have to wait to see what that legislation says but I can tell the House that the NHS commissioning board will have a role in establishing consortia and, in doing so, it will seek to ensure that consortia have the systems in place to fulfil their statutory functions in a proper way that takes account of the stewardship of public money.

My noble friend Lord Rodgers of Quarry Bank asked whether there will be a regional role for the NHS commissioning board. It will be for the board itself to decide how it designs the most effective and cost-effective operating model. The board will determine the optimal configuration of its sub-structures with the freedom to adapt over time.

The noble Lord, Lord Kakkar, spoke, as he always does, about education and training, particularly their impact on research and academic medicine. We shall shortly be publishing a consultation document on future arrangements for education and training, which I hope will begin to answer his questions. The noble Lord talked about the importance of research. As Research Minister, I am enthusiastically on his side on that score. Supporting and promoting research and development will be a core function of the future Department of Health, and the Government remain committed to providing the right environment for innovation to flourish. I think that the increased funding for health research in the recent spending review gives us a strong platform to fulfil that ambition.

The noble Baroness, Lady Masham, asked about the position of the 10 specialised commissioning groups, and the noble Earl, Lord Listowel, referred in particular to specialist mental health services. The new NHS commissioning board will commission national and regional specialised services. The consultation has highlighted the need for criteria to be developed to determine which services should be commissioned by the board or by a lead consortium across a population. We will consider the best way to keep the specialised services portfolio under regular review and, as Minister for specialised services, I can tell the House that I will keep a close personal eye on those issues.

The noble Baroness, Lady Masham, doubted whether the HealthWatch model was the way to proceed and she referred to the constant reinvention of patient and public involvement. While local HealthWatch organisations will retain the current functions of LINks, they will also gain additional functions, providing advice and signposting, as well as advocacy, for NHS complaints. We are continuing to work with LINks to build on the valuable work that volunteers have taken forward. As I mentioned, HealthWatch England will be established as a national consumer champion both to give patients and the public a voice at a national level and to provide advice and support for the new local HealthWatch organisations.

The noble Baroness, in her criticism, was doubtful that the local LINks and HealthWatch, as they are to become, will be up to the job. The Command Paper sets out that, while HealthWatch should have an advocacy role, which is one of the roles that we envisage for it, this will not have to be through its own staff. Local authorities will have the flexibility to commission services from other providers, which could include citizens advice bureaux, for example. We have done this. We have created that flexibility, as we recognised the expertise that is required in advocacy services.

The noble Lord, Lord Kakkar, asked what arrangements there were for the sustained development of clinical leaders. Clinicians with leadership skills are central to our efforts to deliver better outcomes for patients and a critical part of successful commissioning. The National Leadership Council’s commissioning work scheme will provide targeted development for GPs who wish to lead consortia. Its work will ensure that, with the advent of consortia in 2013, there will be a suitably skilled group of individuals prepared to lead these organisations.

The noble Lord, Lord Turnberg, spoke about the role of NICE. There is no time for me to reply in detail, except to say that on this subject he was 100 per cent wrong. I will write to reassure him. He also asked about the likely number of GP-led consortia, as did the noble Lord, Lord Beecham. We are intending this to be a bottom-up process, so we have no set expectations of how many consortia there may be. There are, as I mentioned, 52 pathfinders, which we announced the other day, covering 25 per cent of the population. What we will see emerging is the pathfinders exploring the issues involved, including which services are best commissioned at which level.

The noble Lord, Lord Patel, asked what the key essential services will be and how we will make sure that they are available. We will set out the definition of essential services in the health Bill, but broadly a service will be defined as essential if the commissioner could not turn to a suitable alternative service for patients if the incumbent provider stopped offering it. Monitor will be responsible for the process of identifying essential services and ensuring that they are protected, working closely with the board, consortia and other stakeholders.

As the noble Baroness, Lady Sherlock, suggested, we will return to these issues. The Government are committed to the values of the National Health Service: healthcare for all, free at the point of need. In view of all the talk about privatisation, that needs stating. But we are equally committed to doing everything possible to ensure that the quality of that healthcare, as measured by clinical outcomes, is as good as it is possible to be. I believe that our reforms will enable us to achieve exactly that.

Hospices and Palliative Care Services

Earl Howe Excerpts

Wednesday 15th December 2010 Lords Chamber

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

My Lords, I begin by thanking my noble friend for tabling this Question for debate and introducing the subject so ably. I very much recognise the considerable knowledge that he brings to this subject, not least as a result of his past chairmanship of St John’s Hospice in London.

Thanks to the dedicated work of hospices, many people do die well: where they choose, with the people they love, and with all the medical, psychological and spiritual care they need. The Government are committed to supporting the work of hospices. We have confirmed the £40 million hospice capital grant for 2010-11, allocated under the end-of-life care strategy, supporting 123 projects in 116 hospices. More generally, we are determined that care should be compassionate and appropriate and that it should support personal choice. We will do that by putting patients, their families and carers at the heart of everything we do.

The end-of-life care strategy aims to improve care for all adults approaching the end of their lives, whatever their diagnosis and wherever they are, including enabling more people to be cared for and to die at home if they so wish. However, while many people receive excellent care, others do not. There are still variations in people’s experience by region, by age and, as my noble friend Lord Cavendish, pointed out, by disease, with greater emphasis given to people with certain conditions, particularly cancer. We can and must do better. We are taking forward a number of initiatives to improve end-of-life care services for everyone.

The issue of funding was introduced by many noble Lords, not least the noble Lord, Lord Faulkner of Worcester. I agree with much of what he said. End-of-life care needs a long-term system of sustainable funding. We committed, in the coalition agreement, to a per-patient funding model for palliative care. I listened with care to what the noble Baroness, Lady Finlay, said in that connection and I am grateful to her for the points that she made. My right honourable friend the Secretary of State for Health has asked Tom Hughes-Hallett, chief executive of Marie Curie Cancer Care, to chair an independent review of palliative care funding. I am sure that he will wish to take account of the experience and expertise of the noble Baroness in this area.

The review, covering services for both adults and children, is looking at options to make sure that the funding of hospices and other palliative care providers is fair. It will make recommendations for a funding system that will cover care provided by the NHS, a hospice or any appropriate provider, which encourages more community-based care so people can remain in their own homes, if they wish. It will be fair and transparent to all organisations involved in end-of-life care. The review is making good progress and I know that many in the hospice movement including, as my noble friend Lord Howard will be pleased to know, Help the Hospices, have provided evidence to inform its work.

The review’s interim report, published on 3 December, sets out a definition of dedicated palliative care and initial thoughts on a national funding system, stressing the importance of 24/7 community services. I look forward to receiving the final report and its detailed recommendations for funding in the summer. Of course, the funding review comes with a caveat that it has to be affordable within the constraints of the current financial climate.

Beyond sustainable funding, we need to consider how we will deliver end-of-life services. The NHS operating framework, published today, emphasises the importance of implementing the end of life care strategy and of developing round-the-clock, community-based services. The best services already know that good end-of-life care is not only more effective, but can be less expensive than poor care. A recent National Audit Office report found that in a typical PCT, around 40 per cent of the people who died in hospital had no medical need to be there. They could have been cared for at home or in their care home if the community-based support had been in place to support them and their family or carers.

We want services that enable people to have more control over the care they receive when they are dying. As one way of achieving this, our intention is for people to be able to add their end-of-life care plans to their own summary care record. We need to develop the services that allow people to die in a place and in a manner of their choosing. I recognise that this is not easy. Nor can it be done overnight. There is a great deal of work to do. In 2013 therefore, we shall review our progress and see how close we are to giving people the control that they clearly wish for.

We need more imagination, more radicalism, more courage in commissioning. We need to shift the landscape of end-of-life care in favour of the service user. The best commissioners are already challenging old conventions, finding new ways of designing services, and new ways of bringing hospices and other community organisations together to meet patients’ needs. Soon, new GP consortia will commission services. GP-led commissioning has clear advantages over the current model for end-of-life care. GPs have a better understanding of patient needs and better connections within the local community. They know what is available locally to support patients at the end of their lives. I firmly believe GP consortia will be advocates of hospices, not their enemy. But hospices themselves should be proactive. They should talk with their local GPs. They should also talk with their local authorities, which will play an increasingly important role in co-ordinating care, as we move toward joint-commissioning and planning through health and well-being boards.

My noble friend Lord Bridgeman dwelt with some emphasis on funding. The Department of Health is providing £286 million of additional funding to support implementation of the end-of-life care strategy over the two years 2009-11. A huge amount of money is being spent on end-of-life and palliative care. We know that it is often not used as it should be. That is why the palliative care funding review is looking at how we can better deploy the resources that we currently provide.

My noble friend Lord Bridgeman and others were right to highlight the particular issues surrounding palliative care for children. The Coalition: Our Programme for Government, states that the Government will provide,

“£10 million a year beyond 2011 from within the budget of the Department of Health to support children’s hospices in their vital work”.

As I have already mentioned, the children’s palliative care services are being specifically considered by the palliative care funding review.

My noble friend Lord Bridgeman also asked me about 24/7 community services. The end-of-life care strategy encourages commissioners and providers to develop 24/7 community-based services for medical, nursing and personal care which people need to enable this to happen. The funding review has already highlighted the importance of treating 24/7 community services as a priority.

The noble Lord, Lord Faulkner, asked about future funding. I have already referred to our intention to introduce a per-patient funding system. More generally, the strategy makes clear the responsibilities of the NHS to ensure adequate support for hospices, including through stronger commissioning and adhering to the principles of the compact code of good practice. That should mean more funding stability, including longer-term contracts, for hospices. My noble friend Lord Howard referred, quite rightly, to the cost-effectiveness of palliative care. The new health and well-being boards will follow on from the current commissioning arrangements that are already directed at end-of-life care because improving quality and improving productivity are, effectively, the same things.

The noble Lord, Lord Patel, asked me about commissioning in the future and the noble Baroness, Lady Thornton, questioned the Government’s commitment in this area. The NHS commissioning board will determine how best to deliver high-quality services, including end-of-life care, by working with GP commissioning consortia and making use of the various tools and levers it will have available. The board will commission NICE to develop quality standards to define the quality of care necessary to deliver the desired outcomes and use those standards to produce a commissioning outcomes framework. That framework will then be used to hold GP consortia to account. NICE has already begun the process to develop an end-of-life quality standard and we look forward to seeing the fruits of that work.

My noble friend Lord Bridgeman asked about the extent to which choice will be embedded in the system. We recognise how important it is to give people choice over the care that they get when they are dying and the place in which they receive that care but, as I have mentioned, we also recognise that it is not an easy task and cannot be done overnight. We need to do a lot of work and, as I have mentioned, we will be reviewing progress in 2013 so as to be sure of what we are capable of committing ourselves to on the issue of choice.

My noble friends Lord Patten and Lord Cavendish and the right reverend Prelate stressed the importance of spiritual care. The end-of-life strategy recognised that each person has spiritual, religious or emotional needs and that spiritual care is an important, integral part of the care given to people at the end of their life and to their carers and families. The department has produced a set of quality markers for end-of-life care and in the strategy’s second annual report, published in August, we said that we would consult on the effectiveness of the quality markers and revise them. Those will include spiritual care and consultation will begin in the new year.

My noble friend Lord Bridgeman referred to the importance of training and education. The department has taken forward a number of initiatives to develop the workforce, including: the development of core competences and principles; publishing an e-learning package on end-of-life care, which is free to access for health and social care staff, and supporting communication skills so there is a lot going on in this area.

To conclude, my noble friend Lord Cavendish referred to hospices as places where patients receive the best kind of care and I would not wish to disagree with him. Having said that, surveys consistently show that up to 75 per cent of people would prefer to die at home but at present only about 20 per cent do so, with a further 17 per cent dying in a care home. It is about choice; however, I take note of the powerful points that he made. Lest any noble Lord should think otherwise, the Government remain committed to delivering good- quality end-of-life and palliative care services and we believe that the action we are taking will improve the quality and range of options available to those in England at the end of their lives, including the many who receive such excellent care from hospices.

Autism

Earl Howe Excerpts

Tuesday 7th December 2010 Lords Chamber

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

My Lords, yes, I believe that the planning guidance will be effective in delivering the strategy for adults with autism. This guidance has been developed with advice from health and social care professionals, people with autism and their carers and the voluntary groups representing them. Only by such a transparent, mutual approach can we achieve the vision that the Government have set out for adults with autism: fulfilling and rewarding lives within a society that accepts and understands them.

[Lord Touhig]

I thank the Minister for that reply. I am sure he agrees that, when planning services, it is important to know what services are needed and how many people need them. I do not know whether the Minister is aware of the National Audit Office report which has revealed that 80 per cent of councils have no idea how many people with autistic spectrum disorders live in their areas. Will the Minister therefore agree to meet our colleague, the noble Baroness, Lady Browning, myself and members of the National Autistic Society to discuss ways in which we can ensure that local authorities meet their statutory duties towards people with autism?

[Earl Howe]

My Lords, I should be very happy to meet the noble Lord to discuss those issues. Although we do not have definitive figures for the number of people with autism in England, we have commissioned a study into the prevalence of autism among adults to inform strategic planning at central and local levels to benefit adults with autism as they access public services. We have commissioned that study from the University of Leicester and it is due to report by March 2011.

[Baroness Browning]

Can my noble friend confirm that part of the strategy will entitle people on the autistic spectrum to an assessment if they have an IQ of over 70? For many years, Department of Health circulars have given them this entitlement but they have been ignored in most parts of the country by social services departments. How will my noble friend ensure that this new strategy is properly implemented and that people with IQs of over 70 get the assessment to which they are entitled?

[Earl Howe]

My Lords, I am very grateful to my noble friend for raising that issue. I can reassure her that under Section 47(1) of the National Health Service and Community Care Act 1990 local authorities have a duty to assess a person who may be in need of community care services. This duty applies to people with autism. The revised Fair Access to Care Services guidance already makes it clear that an assessment of eligibility for care services cannot be denied on the grounds of a person’s IQ. We intend to reiterate this very clearly in the autism statutory guidance.

[Baroness Pitkeathley]

My Lords, does the Minister agree that delivering the vision for people with autism and their families is, in many cases, dependent on local authority resources? Has he any anxiety about that, especially as many of the services are delivered in the voluntary and community sector, which is already reporting major cuts to its grants?

[Earl Howe]

My Lords, clearly, local government grants will come under pressure over the coming years. To my mind, that makes it even more important that decisions about priorities are taken at a local level and the joint strategic needs assessment is, of course, the tool which will enable local authorities to decide on their priorities locally.

[Lord Low of Dalston]

My Lords, training for awareness of autistic spectrum disorder among frontline professionals is key to improving services. Following the publication of the guidance, when does the Minister expect that all lead professionals involved in commissioning community care assessments and GPs will have received autism training?

[Earl Howe]

My Lords, the statutory guidance that already exists—it has been revised in light of the response to the consultation—makes it explicitly clear that in addition to general autism awareness-raising training for staff, local areas should develop or provide specialist training for those in key roles who have a direct impact on access to services for adults with autism, such as GPs, community care assessors and commissioners and service planners.

[Baroness Thornton]

My Lords, I congratulate the Minister on continuing to make progress in this matter. As he will know, commissioning for autism services requires expert knowledge and, as my noble friend said, a recent National Audit Office survey found that 80 per cent of GPs said that they needed more training in autism awareness. Can the Minister outline whether any progress is being made to change that situation because, if it applies to GPs, it probably applies to other health workers? Is the Minister also supportive of the call from the National Autistic Society for NICE guidelines and for the inclusion of autism as one of the future quality standards currently under consideration by the National Quality Board?

[Earl Howe]

My Lords, we cannot mandate to NICE what quality standards are produced. However, the case for developing a quality standard for autism will be considered as part of work to commission a comprehensive library of such standards from NICE in line with our plans in the White Paper. NICE is already developing clinical guidelines on diagnostic pathways for autism, including one for children and young people with autism. That is scheduled to be published in September next year. On training, I cannot really add much to what I have already said to the noble Lord, Lord Low, but it is very high on the agenda.

[Baroness Hollins]

My Lords, in respect of the training of medical students to be able to provide, in their future careers, adequate and reasonable adjustments for people with autism, what does the Minister think can be done to develop sufficiently existing equality and diversity training so that there will be adequate understanding and adequate adjustments will be made?

[Earl Howe]

The noble Baroness raises a very important point. We know from general practitioners that they feel an absence of knowledge and training in this area. We are talking to the royal colleges about this.

[Baroness Hussein-Ece]

My Lords, how will the Minister ensure that the guidance ties in with the reforms to the NHS, for example, ensuring that the NHS bodies have due regard to any quality standards on autism that will be produced by NICE?

[Earl Howe]

My Lords, when the National Health Service commissioning board is established, it will have a duty to promote quality in the NHS. One way of doing that will be to utilise the quality standards produced by NICE, to produce commissioning guidance based on those quality standards and, in that way, to promote consistency of commissioning across the health and social care sector.

Health: Passive Smoking

Earl Howe Excerpts

Tuesday 30th November 2010 Lords Chamber

[Lord Faulkner of Worcester]

To ask Her Majesty’s Government what is their response to the report by the World Health Organisation (WHO) that passive smoking annually kills 600,000 people worldwide, and to the recommendation that the WHO Framework Convention on Tobacco Control be immediately enforced.

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

My Lords, the report from the World Health Organisation sets out the significant harms to health from exposure to second-hand smoke. The United Kingdom is a strong supporter of the FCTC and has worked hard to implement it since ratification of the treaty in 2004. Today, we exceed our treaty obligations in this area through the effective and popular smoke-free legislation. Tackling tobacco will be a key element in the Government’s new public health White Paper.

[Lord Faulkner of Worcester]

My Lords, I thank the Minister for that very positive and welcome reply, which is particularly interesting in view of the interview given by the Secretary of State, Mr Andrew Lansley, on the “Today” programme this morning, in which he had some interesting things to say about packaging. Would the Minister comment on that? Does he agree with Mr Lansley’s assertion that “the visibility of cigarettes … constantly tends to reinforce smoking, but it also leads to initiation of smoking amongst young people”? Can he confirm that it is necessary for the United Kingdom, in order to comply with Article 13 of the framework convention, to proceed with restrictions on tobacco display and the banning of vending machines?

[Earl Howe]

My Lords, the noble Lord is correct that plain packaging is an idea that we are considering, which would require tobacco products to have standardised plain packaging so that only basic information and health and picture warnings were visible. The Government are going to look at whether the plain packaging of tobacco products could be an effective way to reduce the number of young people who take up smoking and to help those who are trying to quit, but the decision will depend on the strength of the evidence, which we are going to have to look at.

On tobacco displays, the Government are currently considering options around the display of tobacco in shops. We recognise the need to take action both to reduce tobacco consumption and to reduce burdens on businesses. No decisions have yet been made on that.

The noble Lord will know that the issue of vending machines is currently subject to a legal challenge. We await the judgment from the court before making any further announcements.

--- Later in debate ---

[Lord Alderdice]

My Lords, on Her Majesty’s Government’s commitment after ratification in 2004 to produce a five-year implementation report, I note that the WHO website gives no indication that the report due on 16 March this year was in fact forwarded to the WHO. Will my noble friend confirm whether the report has been forwarded?

In addition, given the enormous amount of smuggled tobacco—accounting for some half of hand-rolled tobacco and 10 per cent of cigarette tobacco in the United Kingdom—what has happened to our commitment under Article 15 to deal with illicit tobacco and, indeed, to the protocol mentioned in the commitment in the Uruguay meeting of earlier this month to ensure that, by 2012, others will also fulfil their responsibilities?

[Earl Howe]

In answer to my noble friend’s first question, yes, the report has been forwarded to the WHO.

On illicit trade, HMRC leads on tackling the availability of illicit tobacco and has carried out—as I am sure my noble friend knows—a great deal of activity to tackle that market through its overseas network of fiscal crime liaison officers, as well as through activity at the border and inland detection work. HMRC also works closely with local authority trading standards officers. Those efforts have led to a decline in the market share of illicit cigarettes from 21 per cent in 2000 to 11 per cent, according to the latest available figures. However, he is right that hand-rolling tobacco in particular remains a problem.

[Lord Patel]

Does the Minister agree that the current packaging of cigarettes is used as a form of marketing by the tobacco industry?

[Earl Howe]

My Lords, that is the very question that we want to look at. Of course, tobacco companies regard their brands as a form of marketing and they attach value to the intellectual property that they consider to be in those brands. However, the issue from a public health perspective is whether the design of a pack actually entices non-smokers to take up smoking or indeed deters smokers from giving up. That is the question that we will examine.

[Lord Naseby]

Is my noble friend aware that the oldest member of Surrey County Cricket Club last year claimed that his longevity was due to a combination of smoking fags and good sex?

[Lord Naseby]

Well, that was not his view.

Furthermore, in relation to intellectual property, which is what we are taking about with packaging, is it not a very brave Government—even a coalition Government—that interfere with international laws that are already on the statute book to protect intellectual property, which is basically what packaging is?

[Earl Howe]

My Lords, of course my noble friend is right that there are legal issues inherent in this whole question, which we will look into very closely.

On his first point, it is always a pleasure to hear of someone who has lived a long time in good health despite smoking. However, I say to my noble friend that the Royal College of Physicians estimates that more than 300,000 primary care consultations are recorded each year across the UK for conditions in children due to exposure to second-hand smoke.

[Baroness Finlay of Llandaff]

Given the risk to children that has just been highlighted of exposure to passive smoking, what action do the Government intend to take against smoking in cars—which is a very restricted space, particularly when the windows are closed—and also in schools or among young people generally, so that young people have the courage to challenge when somebody lights up in close vicinity?

[Earl Howe]

My Lords, we have no plans to legislate further for banning smoking in cars. As she will know, when a car is used as a workplace smoking is illegal, but when a car is being used privately that is a different matter. We do not intend to legislate.

On messages in schools, we know that youngsters are concerned about parental smoking. In fact, the younger the child, the more concerned the child tends to be. Schools are encouraged to include advice on smoking in the PSHE curriculum.

[Baroness Thornton]

My Lords, following the successful implementation of the smoking ban in all workplaces and public places in July 2007, which was opposed by many in the party opposite, will the Minister undertake—

[Baroness Thornton]

I except the noble Baroness, Lady O’Cathain, from that.

Will the Minister undertake to ensure that, under the proposals for GP commissioning, NHS smoking cessation services will continue to be effectively commissioned and funded and that nicotine products will continue to be prescribed?

[Earl Howe]

My Lords, the noble Baroness, Lady Thornton, is wrong. The Conservative Party did not oppose the second-hand smoke provisions. We did not oppose them in principle; we supported the Government. We opposed some of the detail, but that is a different thing.

On smoking cessation, there is no doubt that local stop-smoking services are effective and are available free of charge in communities across the country. Evidence shows that the most effective way of stopping smoking is with local stop-smoking services because smokers get behavioural support as well as effective medicines and treatments on the NHS.

Public Health

Earl Howe Excerpts

Tuesday 30th November 2010 Lords Chamber

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

My Lords, with the leave of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health.

“With permission Mr Speaker, I would like to make a Statement on public health. Today, the Government publish a public health White Paper with two clear aims: first, to protect and improve the health of the nation; and, secondly, to reduce health inequalities by improving the health of the poorest, fastest.

The need for this White Paper is beyond question. Britain currently has among the highest rates of obesity and sexually transmitted infections in Europe. Smoking still claims 80,000 lives a year. Alcohol-related admissions to hospital are unacceptably high and, in recent years, inequalities in health have widened, rather than narrowed. As Professor Sir Michael Marmot’s review to my department put it,

‘dramatic health inequalities are still a dominant feature of health … across all regions’.

There is a seven-year gap in life expectancy between the richest and poorest neighbourhoods, but a gap of nearly 17 years for disability-free life expectancy. About a third of all cases of circulatory disease, half of all cases of vascular dementia and many cancers could be avoided by reducing smoking, improving diet and increasing physical activity.

We need to do better, and we will not make progress if public health continues to be seen just in terms of NHS provision and of state interventions. Two-thirds of our potential impact on life expectancy depends on issues outside healthcare. Factors like employment, education, environment and equality all are determinants of health. They are, as Michael Marmot put it,

‘the causes of the causes’,

the underlying factors leading to poorer health. Unhealthy behaviours, like drinking too much, smoking or taking drugs are part of a complex chain of individual circumstances and social causes, typically rooted in poor aspiration, adverse peer pressure and low self-esteem.

The human cost of poor health is obvious. So, too, is the financial one. Alcohol abuse costs us an estimated £2.7 billion and obesity costs an extra £4.2 billion each year to the NHS alone. And, while there are things we can do to help, we cannot resolve all the difficult issues from Whitehall. Hence, this White Paper has one clear message above all others: that it is time for politicians to stop telling people to make healthy choices, and time to start actually helping them to do it.

There will be a profound shift in tone, attitude and outlook. Rather than nannying people, we will nudge them by working with industry to make healthy lifestyles easier. Rather than lecturing people about their habits, we will give them the support they need to make their own choices and, rather than dictating policies from the centre, we will support leadership from communities by giving local authorities more power to develop the right approaches for their communities.

This White Paper is a genuine cross-government strategy. Through the Cabinet Sub-Committee on Public Health, we will put good health and well-being at the heart of all our policies. To do so, we will recognise that we need to provide support at key times in people’s lives. We will not only measure general well-being, we will seek to achieve it.

For instance, because we know a mother’s health is key to a child’s health and development, we are investing in Sure Start children’s centres and 4,200 more health visitors to give families the support they need. Because we know that those who are unemployed for long periods are more likely to be admitted to hospital and more likely to die prematurely, we are transforming the welfare system, ending the benefits trap, and making sure that work always pays through a single universal credit. Because we know more people would cycle to work or school more often if there were safer routes for them to use, the Government are investing £560 million in sustainable transport.

Subject to parliamentary approval, there will be a new dedicated public health service—Public Health England—which will provide the resources, the ideas, the evidence and the funding to support local strategies. Public Health England will bring together, within the Department of Health, expertise from a range of public health bodies, including the Health Protection Agency, the National Treatment Agency for Substance Misuse and the Chief Medical Officer’s department. It will work with industry and other government departments to shape the wider environment as it affects our health. It will also develop health protection plans”.

[The Countess of Mar]

I am awfully sorry to disturb the noble Earl and I am sorry to have to ask two very venerable noble Lords if they would mind having their conversation outside the Chamber as suggested in the Companion to the Standing Orders. I cannot concentrate on what the Minister is saying.

[Earl Howe]

The Statement continues:

“It will also develop health protection plans and screening programmes to protect people from health risks. Because we also know that the foundations of good health are rooted in the community, often at a neighbourhood level, we must strengthen and renew local leadership to ensure that these efforts reach deeply into communities and match their unique circumstances.

Under this White Paper, the lead responsibility for improving health will pass to local government for the first time in 40 years. We intend to give local authorities new powers to plan, co-ordinate and deliver local strategies with the NHS and other partners and to embed the foundations of good health in ways that fit local circumstances. Directors of public health will provide strong and consistent leadership within local councils.

We also intend to establish the new local statutory health and well-being boards as a way of bringing together the NHS and local government. Whereas before, public health budgets were constantly raided by other parts of the NHS, we will prioritise public health spending through a new ring-fenced budget. We will look to the highest standards of evidence and evaluation to ensure that this money is spent wisely. The new outcomes framework for public health, on which we will consult shortly, will provide consistent measures to judge progress on key elements across all parts of the system—nationally and locally. The framework will emphasise the need to reduce health inequalities and will be supported by a new health premium incentivising councils which demonstrate progress in improving outcomes.

We have learnt over the last decade that state interventions alone cannot achieve success. We need a new sense of collective endeavour—a partnership between communities, businesses and individuals, which transforms not only the way we deliver public health, but also the way we think about it.

Through the public health responsibility deal, the Government will work with industry to help people make informed decisions about their diet and lifestyle, to improve the environment for health, and to make healthy choices easier. Through greater use of voluntary and community organisations, we will reach out to families and individuals and develop new ways to target the foundations of good health. Reflecting the framework in the ladder of interventions developed by the Nuffield Council on Bioethics, we will adopt voluntary and less intrusive approaches so that we can make more progress, more quickly and resort to regulation only where we cannot make progress in partnership.

This is a time when the NHS and social care are under intense pressure from an ageing population and higher costs. It is a time when we must therefore put as much emphasis on preventing illness as we do on treating it. In the past, public health has been a fragmented and forgotten branch of the health service. This White Paper will make it a central part of everything we do, and we will bring forward legislation in the new year to enact these changes.

By empowering local authorities, by strengthening our knowledge of what works and by establishing the right incentives to drive better outcomes, the White Paper will deliver the strategy and support needed to reduce health inequalities and to improve the nation’s health. I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

My Lords, I am grateful to the noble Baroness for the welcome she has given to at least certain elements of the White Paper, and I join her in expressing the hope that this is an area where we can work across the parties. That is because, as the White Paper says, this is very much a matter for all citizens and all elements in society, including industry and employers as well as parliamentarians. However, she asked a number of questions and made several criticisms, so I shall endeavour to reply to as many as I can.

The noble Baroness started by saying that she feels that the White Paper is a little short on strategy. I do not share that view. It makes it clear that we are making a conscious shift of power to local government to draw together public health with the factors that are so influential in achieving good health outcomes. Examples of those factors are housing, transport and education. It is about simplifying, strengthening and unifying national arrangements to reduce red tape and duplication, and to have a clear focus and high priority on public health within central government as well. I believe that the strategy is clear and I hope that, when she has had time to read the White Paper at leisure, she will modify her view.

She referred to the Health Protection Agency and she was right to say that the functions of the agency are, if Parliament agrees, going to be subsumed into Public Health England. The new body will bring together key professionals involved in public health from the national to the local level. It will have a mission to protect and help improve the nation’s health and well-being.

She asked about directors of public health in the new system. With the abolition of primary care trusts, directors of public health, employed by local authorities but jointly appointed with Public Health England, will be responsible for commissioning health improvement and some health protection services using the ring-fenced budget to which I referred. We envisage that, through local partnership working, including through the local health and well-being board, directors of public health will be able to influence the wider determinants of health and well-being and improve outcomes for their local population.

The noble Baroness was sceptical about the concept of “nudge”. The Government’s approach to health improvement is not based solely on nudging people. We accept that the evidence base for applying insights from behavioural science and health contexts is relatively undeveloped. That means that we need to develop the evidence base for that approach, clearly, and that we need to use a wide variety of methods to encourage people to adopt healthier behaviours, not just based on nudges but by continuing to use other effective approaches, such as customer insight and segmentation. As the Statement mentioned, there will always be a role for regulation. However, the Nuffield ladder, which the noble Baroness will see in the White Paper, gives a very good illustration of the menu of options available to us in this context.

The noble Baroness referred to schools, and I note her concerns. At the same time, we have plans for developing the use of school nurses. I see that as a very important part of the vision to ensure that we can have a workforce that is alive to public health issues in the school context. A great deal of work is going on, and I would be happy to brief the noble Baroness on that.

She referred to tobacco, an issue to which we regularly return. I have little, I fear, to add to what I told the House during the Question earlier this afternoon. However, we are considering plain packaging, as I mentioned earlier. The current intention is to ask retailers to cover up their displays of cigarettes so that children are not attracted by the packaging. This is widely accepted as the last form of marketing available to tobacco companies to recruit new smokers. We also want to look at how plain packaging could further protect children from taking up smoking in the first place, and help support people who are trying to quit. It is early days. We cannot say more than that at the moment, but it is something to which I am sure that we can return. On tobacco displays, I cannot add to what I told the House earlier this afternoon. This is still under consideration.

I am glad that the noble Baroness welcomed the concept of the ring-fenced budget. Local authorities will be accountable for the use of the budget. We expect that directors of public health will take the lead in local authorities on the use of the budget. We will be clear about the outcomes that we are seeking, but we will not be prescriptive about how those outcomes are achieved. I think that there will be transparency about the use of the budget through the normal, local, democratic means. More details on the accountability arrangements will be set out in the public health funding and commissioning consultation document, which will be published very shortly.

Finally, the noble Baroness asked me to clarify how we viewed the system as being joined up. We do, I think, view this as potentially a joined-up system. Successful delivery of public health services will require strong links not only from Public Health England at the centre with local authorities, but also between local authorities and the NHS. Joint working will be essential in supporting the collection and provision of the information needed to inform future commissioning, and to enable specific public health services to be commissioned through and delivered by the NHS. That will require a sharing of expertise and knowledge across the two services.

I look forward, as I hope the noble Baroness does, to a new public health effort. We will doubtless return to this topic when, in due course, the health and social care Bill reaches this House as there are important measures in it on which this service will depend.

--- Later in debate ---

[Baroness Northover]

I remind noble Lords that we have a very short amount of time and that they should be extremely brief, either with a question or with a comment. They can do either but they should be as brief as possible. I shall try to be as fair as possible in getting around the House.

[Earl Howe]

My Lords, my noble friend asked a series of important questions. He has put his finger on how, in many senses, the system will be joined up. He is right to say that Public Health England will be instrumental in supporting local directors of public health in their task. We envisage that Public Health England will create a common sense of purpose and values among a widely dispersed group of workforces. We will develop a workforce strategy with representative organisations and publish that next year. That, I hope, will help to support a smooth transition. At the same time, we do not want to cramp the style of local directors of public health. Much will be down to local decision-making and, in particular, the individuals now employed in PCTs will be looking to transfer across to local authorities as the size and shape of public health teams materialises over the months ahead. We are not going to prescribe from above in determining how public health teams should be configured in local authorities, but there will be considerable support in the advice and expertise available from the centre.

[Baroness Finlay of Llandaff]

There is much that is welcome within the report but I have some reservations. When the directors of public health are employed by local authorities, will the local authorities also be responsible for their appraisal? Who will be responsible for their revalidation? Will there be audits of the impact of any interventions? Will there be co-ordination of those audits to see which interventions are the most effective? Will there be research in public health to find the most effective ways of guiding people’s behaviour so that they contemplate change? The word “nudge” has been used in the Statement. This goes back to Julian Tudor Hart’s work, many years ago, highlighting the inverse care law. It will be really important that directors of public health do not become isolated in a local authority where they find it difficult to bring about change.

[Earl Howe]

My Lords, the noble Baroness will see when she has a chance to read the relevant section of the White Paper that local directors of public health will be jointly appointed by Public Health England at the centre and by local authorities. We see that as important because they will be fulfilling multiple roles. For example, the health protection role fulfilled by Public Health England will have to be delivered at a local level and, to that extent, it is important that directors of public health are accountable upwards to the centre. At the same time, in much of their work, particularly on health improvement, local directors will be accountable to their local authority and their local population. There is a dual accountability working here.

On appraisal mechanisms, I think it is too soon to say, as we have not worked out the detail of that, but clearly, that will have to reflect the dual accountability I mentioned.

On the audit question, we are issuing a paper about the outcomes framework. The way in which outcomes are assessed and audited will be key to ensuring that the interventions and initiatives that are put in place are evidence-based, that they are relevant and that they have an effect. I hope that the noble Baroness, for one, will feed into that consultation.

Finally, the noble Baroness asked about research. There will be two main engines for public health research. One is the NIHR school for public health research, which will consist of leading academic centres of excellence focusing on evaluation and what works practically and can be applied across the whole country. The other will be the policy research unit on behaviour and health, located in the department, the opening programme of which will initially focus on four behaviours; namely, diet, physical activity, smoking and alcohol consumption. It is very important that we get closer to what motivates people to change behaviour.

[Lord Cunningham of Felling]

There is much to welcome in the noble Earl’s Statement and I agree with my noble friend Lady Thornton that there are some things to be concerned about. We should be careful that nudge does not become fudge in respect of the implementation of these policies. My question relates to the very substantial reductions in teaching grants to our universities. Has anyone in Government yet done any work on or given any thought to the implications of the reductions in those grants for the training of doctors, dentists and other paramedics in our higher education institutes and other colleges? If they have not, they should do so quickly, because the implications of those cuts could have a very substantial bearing on the number of doctors, dentists and others coming out of our universities in the future.

[Earl Howe]

My Lords, the training of the workforce will be key—I would not disagree with the noble Lord on that question. This is a matter on which we are focusing very closely. I will need to write to the noble Lord on the specifics of his first question because the figures are not in my brief, but we are clear that, without the necessary workforce to deliver the public health programme on the ground at local authority level, we will not be able to see the improvements that we need. That will be a major focus for my department.

[Baroness Browning]

Does my noble friend recall in “Dr Finlay’s Casebook” the role of Dr Snoddie, the very independent but suitably qualified director of public health, for want of a more modern phrase? When my noble friend comes to look at the qualifications for directors of public health, will he ensure that they have the appropriate qualifications, so that we do not repeat what has happened elsewhere in the health service, with a generation of administrators who override the clinical judgments of those who are more medically qualified to take decisions?

[Earl Howe]

My noble friend takes me back to happy days watching “Dr Finlay’s Casebook”. I seem to remember that Dr Snoddie always had an encounter with Mistress Niven, who came down with all manner of complaints and ailments that the redoubtable duo usually diagnosed and dealt with.

My noble friend is correct. We have to ensure that we have the right people trained at the right level to deliver this service and that we do not get bogged down in managerial bureaucracy. Health and well-being boards will be a vehicle for public health, social care, the GP consortia, when they are formed, and the patient organisations, such as HealthWatch, to come around the same table, so to speak—maybe literally—in order to look at the broader health needs of an area and decide on priorities. I see that as powerfully playing into the public health agenda. This will be far from being a process that is bogged down in bureaucracy.

[Baroness Gould of Potternewton]

My Lords, I welcome this document as well as the concept of cross-party working on public health services. I particularly welcome, as the Minister might expect me to say, the references in the document to improving sexual health.

I have a number of questions. On the directors of public health, the Minister talked about them being at the right level. What level is that expected to be within the framework of local government? Unless they have a high status within local government then, unfortunately, they might not be able to influence some of the things that they might want to influence. I have another question regarding the directors. In working with GP consortia, what if there is a difference of view that needs to be resolved? Who takes the final decision? Who has the final say in respect of that?

How is it going to be determined whether an area qualifies for the new health premiums? With regard to ring-fenced budgeting, the aid support grant lost its ring-fencing. Does that mean that it will be in the public health ring-fenced budget or not?

When the independent advisory group on sexual health, of which I was chair, was abolished, we were told that a new sexual health organisation would be established. What will be the process for that and when is it likely to happen?

[Earl Howe]

My Lords, the noble Baroness asked me a number of questions there. I may not be able to answer all of them now, but I will certainly write on those that I cannot.

As I mentioned earlier, it is important to recognise that in part the status of directors of public health will be confirmed by virtue of not simply being appointed locally, but also by being appointed from the centre by Public Health England. That will confer an added status to them. With the dual accountability that I referred to, primary accountability would be to their employer, the local authority, but the Secretary of State would have a backstop power to dismiss directors of public health on the basis of a failure to discharge local authority responsibilities in the area of health protection. Again, while one does not want to dwell on that power, it signifies that this is a person who will be there very much as the representative of the Secretary of State.

The noble Baroness asked what happens if there is a difference of view. Differences of view will arise but the important point to emphasise here is that we want to see them sorted out at a local level wherever possible. That will not always be possible but it should be the aim that health and well-being boards and consortia should decide, in the light of the joint strategic needs assessment and other factors, what the priorities are locally and how the budget is to be spent. It has to be that way: second-guessing from the centre is bound to lead to perverse consequences. However, there will be mechanisms available to ensure that the NHS commissioning board will have a role in trying to resolve these issues and the noble Baroness will see, when we publish the health and social care Bill, that the Secretary of State will have a backstop power in extremis.

She asked about the health premium. We will be publishing a document for discussion on this. We want to hear the views of everybody as to how this should work. Clearly, if a health premium is paid it has to reflect a measure of genuine progress in reducing health inequalities, while recognising that some areas start off with the handicap of having particularly deprived communities to work with and that the task is thereby more difficult. It is important that the department receives the views of interested parties to see how this is going to work.

On sexual health, we are looking to see what more can be done to increase the awareness of risks, prevent infection and promote access to screening and treatment. The consultation documents, which will be issued shortly, will set out the proposed funding and commissioning routes for public health services, including how comprehensive sexual health services might best be commissioned. I hope the noble Baroness will feed into that.

[The Countess of Mar]

My Lords, the noble Earl mentioned looking at the causes of the causes very early on in his Statement. I think it is now well accepted that a foetus is not protected by either the placenta or the blood-brain barrier from environmental assaults. I am concerned that a lot of the obesity that we see now in young children who run around normally and cannot be described as couch potatoes—although perhaps their diet is deficient—may have originated in the womb from oestrogen-mimicking hormones and by chemicals such as bisphenol A and phthalates. It seems to me that we disregard these factors at our peril and we are blaming people for factors that are beyond their ability to control. Another point is the effect of maternal stress on the foetus. High cortisol levels in the mother affect the child and cause ADHD and educational problems later on in their lives. What is the Minister doing to look at what is happening to babies in the womb and the effects on them in their future life?

[Earl Howe]

I shall need to write to the noble Countess on exactly what work programmes are in train in that area but she is absolutely right—this is an area that I have taken a close interest in over the years. It is fundamental to understanding both health in childhood and later on in adulthood, and behaviour in children.

We fully recognise that good nutritional status is important at all stages of life. That includes the role of the diet in pre-maternal health, and affects teenagers in particular and the elderly, where there are concerns about malnutrition; I know that is not the focus of the noble Countess’s question. The national diet and nutrition survey will allow us to continue monitoring the status of the diet in the UK population and to target interventions where they are needed. I will write to the noble Countess to give her further particulars.

[Lord Ryder of Wensum]

My Lords, could my noble friend please explain one tiny inconsistency in government policy? Today he announced that some parts of NHS expenditure would be ring-fenced to deal with the problem of obesity. However, earlier in the week the Education Secretary removed ring-fencing on school sports, which was partly designed to tackle the same problem. Am I right about this being an inconsistency, or can my noble friend explain whether I am making a mistake?

--- Later in debate ---

[Earl Howe]

Far be it from me to say that my noble friend makes mistakes. No, he has not misunderstood the situation. The point of the ring-fence is to ensure that the money we supply to local authorities is genuinely used for public health purposes. That is obvious. However, there will be flexibility for local authorities to decide what falls within the public health definition. As long as they can justify their decision that the expenditure is public health-related, they will be free to spend the money accordingly. There may be uses for public health money that involve schools or sport and so on. This, again, is something that we will need to look at when we define how much money there will be—that is being worked out—and in our dialogues with local authorities, to ensure that the rules are absolutely clear.

Health: Academic Health Partnerships

Earl Howe Excerpts

Monday 29th November 2010 Lords Chamber

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

My Lords, I begin by joining all other noble Lords in thanking the noble Baroness, Lady Finlay, for having tabled this debate and spoken to it with her usual deep knowledge and enthusiasm. She is absolutely right to highlight the essential links between universities and the NHS as well as the importance of medical research and education which are, as she so eloquently described, essential for the ongoing success of the UK economy and of a high-quality NHS. The Government absolutely recognise and support the need to maintain investment in these areas for the benefit of patients.

The noble Baroness raised a number of specific issues to which I will respond in a moment. It is right to remind ourselves that most of the issues that have been raised should be considered within the context of the UK. Although there will be shared principles across the four Administrations, we are also dealing with devolved matters. However, my responses today will inevitably deal with England alone.

Since the NHS was founded in 1948, investment in health research has brought incalculable benefits for patients. Treatments have been improved, inequalities have been reduced and productivity has increased. In both the strategic spending review and our White Paper, Equity and Excellence: Liberating the NHS, we have emphasised the importance of research, as the noble Baroness rightly noted. Despite the incredibly challenging pressure on budgets across government, we are committed to increasing spending on health research over the next four years. When funds are tight is precisely the time when innovation, investigation and invention become most valuable. In the long term, research saves money and allows us to identify new ways of preventing, diagnosing and treating disease. It is essential if we are to increase the quality and productivity of the NHS, which are, after all, the best ways of making savings.

The Department for Business, Innovation and Skills will ensure that Medical Research Council expenditure is maintained, ensuring that total health research funding will increase. Among other things, the extra funding will support the National Institute for Health Research. I was grateful to the noble Baroness for her appreciation of the NIHR’s work and, indeed, to other noble Lords for the tributes which they paid to it. Through the NIHR, the Department of Health spends more than £50 million every year to fund posts aimed at encouraging junior doctors to pursue clinical research careers. Through the intrinsic bond between the NHS and universities, the NIHR is turning laboratory-based discoveries into cutting-edge treatments that make a real difference to people’s lives. Through its internationally recognised biomedical research centres and units, the NIHR is helping to translate pure research into practical success.

The noble Baroness, Lady Donaghy, referred to academic health science centres, in particular the King’s Health Partners, and that was a theme strongly taken up by the noble Lords, Lord Kakkar and Lord Butler, among others. As the noble Lord, Lord Butler, said, there are now five academic health science centres in England. Their core mission is to bring together world-class research, teaching and patient care in order to speed up the process of translating developments in research into benefits for patients, both in the NHS and, as the noble Baroness, Lady Finlay, said, across the world.

The noble Lord, Lord Kakkar, referred to the UK as a target for inward investment in these areas. He will be interested to know that we are taking forward a range of measures to promote and develop the UK as a place for inward investment by global industry through the Office for Life Sciences and the health and business departments. The noble Lord, Lord Butler, referred, I think in passing, to funding for academic health science centres. It is worth pointing out that AHSCs are underpinned by funding from NIHR as well as the research councils and other funding sources.

The coalition Government confirmed in the White Paper that they see an important role for AHSCs in delivering the translational research agenda, unlocking synergies between research, education and patient care. As regards their potential development as institutions, which the noble Lord, Lord Kakkar, invited us to consider, as he knows, AHSC status was awarded in March 2009 for a period of five years and will be subject to review. However, we will be working with interested parties to determine the next steps for AHSCs, and I take his suggestions fully on board.

For now, I think it is right for me to acknowledge that the organisations in AHSC partnerships are already making extremely impressive contributions to the translational endeavour. Our announcements in the spending review will allow us all to work even harder to ensure that the breakthroughs made by our world-class scientists are pulled through into real benefits for patients. The noble Lord, Lord Butler, referred briefly to mental health research, and he was right to pinpoint that area as one on which we should focus. The Department of Health is the largest UK funder of mental health research, and our investment in research infrastructure is having a significant and positive impact on the numbers of patients recruited to clinical trials in this area.

The noble Lord, Lord Kakkar, referred very eloquently to the process of promoting translation from bench to bedside and into widespread adoption. I can confirm that undoubtedly the AHSCs have a role to play in crossing those translation gaps. Together with the NIHR investment in biological research councils, biological research units, and collaborations for leadership in applied health research and care, I am confident that we can make a real impact on getting cutting-edge ideas faster into improving health. We will continue to promote the role of BRUs, BRCs, academic health science centres and collaborations for leadership in applied health research and care, all of which can help develop research and unlock the synergies to which I referred earlier.

In England there are also 17 health innovation and education clusters, which are cross-sector partnerships between NHS organisations, the higher education sector and industry. Their task is to bring quickly the benefits of research and innovation directly to patients. They will also strengthen the co-ordination of education and training, and bring together those responsible for healthcare with the local academic community. Currently in their first year, they focus on a variety of healthcare themes in line with local strategic objectives. We need to reward locally relevant, high-impact work and to encourage partnerships with industry. Through HEFCE’s research excellence framework, we will continue to develop an assessment framework that rewards the impact that the highest levels of research excellence have on society and on the wider economy.

I doubt that many people do not also recognise the importance of medical education. It ensures that the next generation of clinicians develops skills and expertise to meet patients’ needs. Linked to this is the complex area of workforce planning—to which the noble Baroness, Lady Thornton, referred—to ensure that we have the right numbers with the right skills in the right places. Aligning workforce planning and education, both in universities and in postgraduate medical training, must be considered in the context of the White Paper proposals and of our forthcoming consultation on education and training. The White Paper reforms are bold, and the way that we plan and develop the healthcare workforce needs to respond to and support the reforms, and align with new ways of commissioning and providing services. There is an opportunity now to review and fundamentally reshape the whole system for planning and developing the workforce. The Government have committed to consult widely on the design of a new framework for education and training. We will publish a consultation document shortly. The new system will be driven by patients' needs, led by healthcare providers and underpinned by strong clinical leadership.

There has been concern in some circles about ensuring that graduates of UK medical schools are able to obtain full registration with the GMC by securing a place on the first year of the foundation programme. To date, this has always been the case. Although there have been more applicants to the programme for 2011, the programme office has predicted that all eligible applicants will secure a place.

The noble Lord, Lord Kakkar, also correctly highlighted the vital role that medical schools will play in preparing medical students for a future where a greater proportion of care will be delivered in the community. However, it is not only in medical schools that the emphasis on community care needs to change, but also in postgraduate medical training. That has been recognised in the priorities of the Government's advisory body, Medical Education England.

The noble Baroness, Lady Finlay, asked what levers would be in the new system to encourage research and innovation. My noble friend Lord Alderdice was absolutely right: it is largely thanks to the noble Lord, Lord Darzi, and to Dame Sally Davies in the department that these levers exist and will continue to operate. I have referred to a number of the ways in which the NIHR is continuing to support the system—not least the BRCs, BRUs and so on—by pulling through ideas from the laboratory into new approaches to healthcare. It is through these and the AHSCs that we will continue to see a drive to research and innovation in the new system.

My noble friend Lord Alderdice referred to the NHS Commissioning Board commissioning research. We expect that the board will promote the conduct of research and patient participation. He also rightly said that we need to encourage excitement among young clinicians. I fully agree: that is one reason why the NIHR is funding so many new clinical academic fellowships every year, which enable young clinicians to get enthused by this career path.

The noble Baroness, Lady Finlay, stressed the need for effective joint working between the Department of Health, the Department for Business, Innovation and Skills and other key partners. She is of course quite right. The Health and Education National Strategic Exchange provides a national forum where senior members of the higher education and health sectors discuss strategic issues and influence cross-government working. However, I of course agree that such links should be strengthened where possible in order to maintain our proud tradition of high-quality medical education and research, the purpose of which is, above all, to benefit patients.

Medical Profession (Responsible Officers) Regulations 2010

Earl Howe Excerpts

Tuesday 23rd November 2010 Lords Chamber

Moved By

[Earl Howe]

That the draft regulations laid before the House on 26 July be approved.

Relevant documents: 3rd Report from the Joint Committee on Statutory Instruments, 7th Report from the Merits Committee.

[Earl Howe]

My Lords, the purpose of the draft Medical Profession (Responsible Officers) Regulations 2010 is to protect patients and to support doctors to improve the quality of care they give. They require certain designated organisations in England, Wales and Scotland to nominate or appoint responsible officers and to support those responsible officers in carrying out their statutory functions. They give responsible officers statutory functions relating to the evaluation of a doctor’s fitness to practise. In England only, responsible officers will be given additional functions relating to monitoring the conduct and performance of doctors. The regulations set out the connections between doctors and the designated organisation relevant for them.

Under the regulations, responsible officers will have to be licensed medical practitioners with at least five years’ experience. However, this is a statutory minimum. In practice, organisations will want to appoint senior doctors with experience of the management of other doctors as their responsible officers. The responsibilities of responsible officers relating to the evaluation of fitness to practise include ensuring that the designated body carries out regular appraisals, establishing and implementing procedures to investigate concerns and, where appropriate, referring the doctor to the General Medical Council.

Under their duties to evaluate fitness to practise, responsible officers will make recommendations on individual doctors to the General Medical Council. The responsible officer will have to make a recommendation as the basis for revalidation when it is introduced. This will normally be every five years. In England, their additional responsibilities will include identifying any issues arising from information about conduct and performance and ensuring that the designated body takes steps to address any such issues. These functions will enable responsible officers to support doctors to improve the care they give at the earliest opportunity.

Most of the statutory functions are activities already undertaken by medical directors and staff. These regulations do not specify who will take on the role of responsible officer; rather they allow organisations to determine how the functions may best be carried out. In the NHS and independent providers, it is likely to be existing medical directors. Except perhaps in the smallest organisations, we would not expect responsible officers to undertake the tasks, such as appraisals and investigations, personally, but they will be responsible for ensuring that they are carried out appropriately. This will involve ensuring that their designated body has sufficient staff who are appropriately trained, whether in undertaking appraisals or in investigating concerns. The regulations also make provision for the appointment of an additional responsible officer where there is a conflict of interest or appearance of bias between a doctor and the responsible officer.

The Merits of Statutory Instruments Committee has drawn these regulations to the attention of the House and I have no doubt that in the light of the Motion she has tabled, the noble Baroness, Lady Thornton, will wish to raise certain issues and concerns. I stand ready to address them, but in the mean time, I beg to move.

Amendment to the Motion

Moved by

--- Later in debate ---

[Earl Howe]

My Lords, I thank all noble Lords who have spoken. In particular, I welcome the positive comments made about the regulations and the rationale for them. I am grateful especially to the noble Lords, Lord Walton, Lord Patel and Lord Kakkar, and my noble friend Lord Alderdice for their strong support and very helpful comments, and indeed to the noble Lord, Lord Rea, for what he said. A number of questions have been asked and perhaps I could begin by addressing the timing of these regulations.

First, I know that medical revalidation was a concern of the Merits Committee, reflecting in turn the concerns raised by the BMA and the Royal College of Surgeons. Noble Lords who are medically qualified will be aware, and other noble Lords may well be aware, that the piloting period for revalidation has been extended for a further year. This will allow time for a better understanding of the costs, benefits and practicalities of implementation and to enable full engagement with the profession, the service and the public. Despite there being issues which the extended period of piloting will help us address, one thing remains clear; recommendations on an individual’s revalidation can be based only on substantiated information. That information will come from doctors themselves, supplemented by information from an organisation’s clinical governance systems. The responsible officers’ roles, in other words, are wider than the process of revalidation. It is important that we have those officers in place to implement improved systems of clinical governance and to ensure that organisations are prepared and doctors are supported, ready for revalidation.

The noble Lord, Lord Rea, was right; having responsible officers in place would help to ensure that doctors are appraised and that systems are in place that will enable the information to be collected and shared as appropriate, such as when doctors move to a new organisation. Where there are concerns, their duties will ensure that the appropriate action is taken, and will continue to be taken, so that patients are protected. The noble Baroness, Lady Thornton, also argued that the regulations had been overtaken by the Government’s proposed reforms of the NHS. It is worth re-emphasising what my honourable friend Anne Milton said in her letter: that the majority of organisations designated under the regulations will not be directly affected by the removal of primary care trusts and strategic health authorities, which of course has not yet happened and is still some distance away. Clinical governance systems are needed regardless of the White Paper proposals.

Now is precisely the right time to introduce the role of responsible officer. I simply repeat that medical leadership and stability are needed if organisations and their doctors are going to be ready for revalidation when it starts.

Of course the regulations will in due course need to reflect the changes in NHS architecture, should those be agreed by Parliament. We are currently exploring options for this and I can repeat the assurances given by my honourable friend Anne Milton in another place. To answer in particular the concern of the noble Baroness, Lady Finlay, about primary care, we will consult on options for responsible officers within primary care as we move to a system of commissioning consortia, and on identifying a responsible officer’s own responsible officer, who in England currently sits within the strategic health authority, as the noble Baroness, Lady Thornton, rightly pointed out.

The noble Baroness also reflected professional concerns about conflicts of interest between a responsible officer’s statutory duties and their duty to their organisation. All doctors who have a management or supervisory role for other doctors already manage on a day-to-day basis any tensions that may arise between the need to ensure high professional standards and values on the one hand and the needs of employers and service provision on the other. Medical directors already address concerns about doctors in their organisations, whether through local performance management, disciplinary systems or referrals to the GMC. The Government believe that, in the vast majority of cases, medical directors will be guided by their professional values to manage such issues fairly and in the best interests of patients. The alternative—an entirely independent structure of responsible offices in every healthcare organisation in the United Kingdom—would replicate the system of GMC affiliates, which was proposed, as noble Lords may remember, in 2007, and which professional bodies rejected during consultation as being disproportionate, impracticable and unaffordable.

I also draw the House’s attention to the evidence given to the Health Select Committee on 4 November 2010 by Professor Peter Furness, who is president of the Royal College of Pathologists and revalidation lead for the Academy of Medical Royal Colleges. Professor Furness acknowledged the potential for a conflict of interest, but he also said that the view that medical directors should not be responsible officers was held by “a minority” of medical royal colleges. He observed that the potential for conflict could be balanced by the fact that medical directors are best placed to resolve any problems that might arise. He also thought that the potential for conflict needs to be addressed by “open processes” to ensure that it does not cause problems.

We must also remember—this is a fundamental point— that responsible officers can make recommendations only about a doctor’s fitness to practise; they do not have the power to remove a doctor’s licence to practise. Their recommendations must be based on evidence, and it should be clear immediately if that is not the case. Further, if responsible officers make recommendations that are not based on evidence, they may be failing in their duties under good medical practice, which requires that doctors must,

“be honest and open and act with integrity”.

In that case, responsible officers could even bring their own fitness to practise into question. These are very serious issues for any responsible officer.

The Merits Committee’s concern that the regulations provide for no process of appeal against the recommendation of a responsible officer has also been raised by noble Lords. First, let me stress that the regulations will result in no change to the current situation, in which every doctor, including the medical director, has a professional duty to report serious concerns about another doctor to the GMC. Under the regulations, the responsible officer will be required to decide what recommendation to make to the GMC about an individual doctor’s fitness to practise. However, the GMC would then need to go through its own processes, which provide the doctor with an opportunity to defend allegations—including through an appeals mechanism—before the doctor can be considered unfit to practise. Under the regulations, local procedures to investigate concerns must provide for a doctor’s comments to be sought and taken into account.

In England, as part of the responsible officer’s role in dealing with concerns about a doctor’s conduct or performance, the responsible officer will also be able to recommend suspension to the designated body. However, the decision on suspension is for the designated body and should engage that organisation’s performance management and grievance procedures. I think that sufficient mechanisms are already in place that protect the doctor’s interests without the need to create an additional bureaucratic structure to allow doctors to appeal against what are, after all, simply recommendations.

Two further issues were raised by, I think, the noble Baronesses, Lady Thornton and Lady Finlay. The first relates to a failure to specify that appraisal should encompass the whole of a doctor’s practice. That is in fact provided for in Regulation 11(3), which states:

“The responsible officer must ensure that appraisals … involve obtaining and taking account of all available information relating to the medical practitioner’s fitness to practise in the work carried out by the practitioner for the designated body, and for any other body, during the appraisal period”.

Nevertheless, I repeat the assurances given in another place that we will consider whether we can strengthen the guidance to make it clearer that appraisals must address the whole of a doctor’s professional practice.

The second issue relates to indemnity and, in particular, to the fact that organisations should provide indemnity for responsible officers. Indemnity payments are already calculated on the basis of a shared risk. At this stage, we understand from the medical defence organisations that there is no suggestion that the contributions from those who take on the responsible officer role would need to rise. However, we are told that the medical defence organisations will keep the situation under review. I assure noble Lords that, if we find contributions rising as a result of these regulations, we will review the position.

--- Later in debate ---

[Baroness Finlay of Llandaff]

Will the Minister clarify that the way in which the regulations are written is sufficiently flexible to allow a doctor to take a career break, to move into a different area or to take a break from clinical practice as it currently stands? Are they also sufficiently flexible to allow the responsible officer role not to be tied to the medical director of a trust, but if the medical director of a trust resigns from that post but is very suitable to remain the responsible officer, they can remain the responsible officer and the medical director can be someone else? Furthermore, are they sufficiently flexible to allow you to be able to get rid of a responsible officer if it turns out that they are not being wise enough?

Although this is slightly irregular, I should point out for clarification that I am not against these regulations at all—I think that they need to go through. My concern about five years is that most doctors are still in training at that stage.

[Earl Howe]

My Lords, the answer to the first question of the noble Baroness, about career breaks and so on, is yes, the regulations allow for that. In answer to her second question, we are not specifying that responsible officers have to be medical directors. As she knows, we are leaving it up to the organisations to decide that. Therefore, she can be reassured on her other questions.

[Baroness Thornton]

My Lords, I thank all noble Lords for contributing to this debate, particularly the noble Baroness, Lady Finlay, the noble Lord, Lord Colwyn, and my noble friend Lord Rea. I also thank the Minister for his comprehensive answer. Noble Lords will have heard me say from the outset that I did not intend to delay the implementation of the regulations. However, noble Lords should also acknowledge that if we ignored the reservations expressed by the Merits Committee and various medical organisations, and did not to pay heed to what they had to say about this, we would not be carrying out our duty of scrutiny. I thought that the most important thing was to get on record the answers to the very questions that we have raised.

I thank the Minister for his usual comprehensive and competent answer, which helpfully addressed many concerns. The abolition of PCTs and strategic health authorities is on the “wait and see” bit of this agenda. We can take it that the Department of Health has not yet worked out what it is going to do. I take some comfort from the fact that this, like much else, is in the melting pot of what is becoming the NHS at the moment; it is work in progress. With that and with thanks, again, to the Minister, I beg leave to withdraw the amendment to the Motion.

Health: Chronic Obstructive Pulmonary Disease

Earl Howe Excerpts

Wednesday 17th November 2010 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government when they will implement the National Clinical Strategy for Chronic Obstructive Pulmonary Disease.

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

My Lords, the reforms set out in Equity and excellence: Liberating the NHS will ensure that the NHS focuses on improving outcomes for patients. As a result, we are looking at the role and nature of clinical strategies within the reformed NHS to ensure that they reflect this focus.

Today is World COPD Day. I can assure the House that we are committed to improving outcomes for those who suffer from COPD and from asthma. We will make further announcements shortly.

[Baroness Thornton]

I join the Minister in welcoming World COPD Day, which draws attention to this incurable, degenerative lung condition. However, I am disappointed that he has not thought fit to use today to adopt the COPD strategy, which was left up and ready, as it were, when the previous Government left office. Apart from anything else, I wonder whether he is aware that the British Lung Foundation’s research shows that up to 80 per cent of GPs cannot tell the difference between asthma and COPD. That is a very serious issue for prescribing. The adoption of the COPD strategy would bring systematic training and awareness-raising of this condition.

[Earl Howe]

My Lords, as I indicated in my Answer, the reform programme that we have outlined is intended to ensure that all parts of the system work more effectively in improving health outcomes. That has to include COPD. We have to ensure that everything that we do fits into the proposed new architecture of the NHS. In the mean time, we will continue to work with key organisations and with clinical leads for COPD and asthma to make sure that change happens. I know that a great deal of activity is in hand across the NHS to improve outcomes for patients with COPD and asthma as a result of the good work undertaken so far.

[Baroness Liddell of Coatdyke]

Will the Minister give a pledge on World COPD Day to ensure that the compensation scheme for miners affected by COPD that was begun by the previous Administration will continue?

--- Later in debate ---

[Earl Howe]

My Lords, I will be happy to write to the noble Baroness on that matter, as I have not been briefed on it.

[Baroness Wilkins]

My Lords, both my brothers and my father died after years of breathlessness, which is an appalling condition. Can the Minister say why pulmonary rehabilitation courses are being closed around the country, despite being recommended by the NICE guidelines?

[Earl Howe]

My Lords, I am concerned to hear the noble Baroness’s comments because I know that an enormous amount of good work is going on around the country. There are programmes to encourage clinical leadership, improvement projects designed to integrate services, a commissioning toolkit, benchmarking data on outcomes and tools to aid local campaigns. If the services designed to help COPD patients are being diluted in any way, I should be very concerned about that and interested to hear the details.

[The Earl of Listowel]

My Lords, does the Minister recall the recent paper from the Royal College of Psychiatrists that highlights that mental disorder is behind a large number of people taking up smoking and drinking? Will he consider whether this is not an argument for further investment in child and adolescent mental health services, so that children and young people suffering from anxiety and depression receive the help that they need at an early stage and do not reach for alcohol, tobacco and other substances that can have these awful outcomes in later life?

[Earl Howe]

My Lords, I congratulate the noble Earl on linking mental health with COPD in that neat way. He is absolutely right that smoking is an activity that puts one at high risk of COPD and that smoking is closely associated with poor mental health. Fifty per cent of the tobacco smoked in this country is smoked by those with mental health problems. We are determined to continue efforts to discourage smoking in the general population. We are also keen to raise awareness of good lung health generally, which brings us back to the Question on the Order Paper. To a large extent, such efforts will fall to the new public health service in future.

[Baroness Barker]

Will the Minister say whether the Government have noted the conclusions of the Environmental Audit Committee in the other place, which reported that poor air quality aggravates and is a contributory factor to COPD? Has the Department of Health been in discussion with the Department for Transport about scaling back pollution as part of the forthcoming paper that the noble Lord mentioned?

[Earl Howe]

My noble friend is right to raise the issue of air quality, which is of concern to my department. She is also right that we are working with colleagues across government to look at air quality—particularly in London but also in other cities—which has such a damaging effect on the health of a number of people.

[Lord Boswell of Aynho]

My Lords, is not the network of breathe easy clubs, which is widely extended across this country, a very good example of the involvement of the statutory and NHS services with volunteers and patient response? Could not that reasonably be said to be a very good precursor to the big society?

[Earl Howe]

My Lords, my noble friend is absolutely right. We have been working with the breathe easy groups and the British Lung Foundation to ensure that the good work that they are doing, along with that of the newly appointed strategic health authority respiratory leads, will improve outcomes for those with COPD and asthma. I agree with him fully that this is a very good example of the big society in action.

[Baroness Murphy]

My Lords, patients with COPD are classically those who do not get access to palliative care services at the end of life. Will the Minister tell us what the Government will do to improve the access to palliative care of patients with COPD and other chronic conditions at the end of life?

[Earl Howe]

My Lords, the noble Baroness will know that an enormous amount of work is going on with palliative care services, and a great deal of money is being directed towards them. I share her concern that hospices tend to focus above all on patients with cancer, to the detriment of those with other conditions. This is an area that we are looking at very closely.

NHS: Prebiotics

Earl Howe Excerpts

Wednesday 17th November 2010 Lords Chamber

[Baroness Masham of Ilton]

To ask Her Majesty’s Government what consideration they will give to using prebiotics to prevent Clostridium difficile in a clinical setting, with a view to improving patient experience and saving NHS resources.

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

There is currently insufficient evidence to show that prebiotics offer benefits in a clinical setting to be able to make a general recommendation in relation to prevention of Clostridium difficile infection. Of course, we will keep this issue under review. However, it is important for all patients, including those who have contracted Clostridium difficile infection, to have a well-balanced diet.

[Baroness Masham of Ilton]

My Lords, I thank the noble Earl for that answer. Is he aware that C. difficile costs the country about £100 million a year and prebiotics are very cheap? Prebiotics are a food supplement that bypasses the stomach and goes into the gut and helps to keep a person fit, so that they may not get C. difficile. Does he agree that anything is worth trying with such a debilitating and dangerous condition?

[Earl Howe]

The noble Baroness is absolutely right, not for the first time, about the devastating incidence of C. difficile infection. More than 25,000 cases of C. difficile infection are reported annually and there remain significant variations in outcomes among organisations.

In principle, prebiotics should be beneficial, but there is in fact little good evidence to show that they work or that food can provide a prebiotic effect. There is likely to be considerable inter-patient variation in the gut flora response to prebiotics, which could be exacerbated by differences in diet. However, as I have already indicated, we will look closely at the issue.

[Lord Alderdice]

My Lords, given the difficulties and dangers of Clostridium difficile, can my noble friend reassure me that the Department of Health has noted that the Food and Drug Administration has in recent days approved fast-track designation for a parenteral toxoid vaccine, which thus opens the possibility—I hope—that immunisation will be possible, in particular for elderly, vulnerable people who are in danger of developing Clostridium difficile infection?

[Earl Howe]

My Lords, I am aware of the interesting development of a vaccine for C. difficile, but I understand that the vaccine is still in clinical trials. As my noble friend indicated, the company may be seeking agreement from the US FDA to fast-track the application when the development programme is complete, as that would give them access to the US market. It is of course for the manufacturer to decide when and if it wishes to seek access to the market in the UK and the wider EU.

[Lord Walpole]

My Lords—

[Lord Rea]

My Lords, could not a strong case be made for the Department of Health to commission a suitably designed pilot study of prebiotics to see whether they are beneficial in the prevention of Clostridium difficile and other conditions?

[Earl Howe]

My Lords, as I have said, we will continue to look at the matter with interest. Of course the department has a very sizeable clinical research budget, which is open to all bids of a high quality. There is no reason why a bid should not be made on this issue as well.

[Lord Walpole]

My Lords, I will try again. Can the Minister tell me whether carbolic—either as a soap or as a cleaner—has any effect on C. difficile, or is C. difficile resistant to carbolic?

[Earl Howe]

My Lords, my advice is that best practice guidance on the diagnosis and treatment of Clostridium difficile infection is clear and is available. The management of the infection requires the isolation of cases, hand-washing with soap and water and the use of the antibiotics metronidazole or vancomycin.

[Baroness Knight of Collingtree]

My Lords, the Minister said that there was not enough evidence to be sure that prebiotics are effective. Can he say whether any active efforts will be made to get that evidence, or does he mean that people must wait until a request has been made before such efforts are embarked upon?

[Earl Howe]

My Lords, we regard the departmental budget as being there to enable those who have good-quality and well-designed research projects to bid for those funds. I will take on board my noble friend’s implicit suggestion that the department should pursue the issue but, in doing so, I bear in mind that these products are commercially produced and that it is really for the manufacturers to come up with robust clinical data.

[Baroness Wall of New Barnet]

My Lords, is the noble Earl aware that there are more trials on probiotics than on the prebiotics mentioned by the noble Baroness, Lady Masham? Although there are no Department of Health trials that I am aware of, was the Minister suggesting in his earlier response that he is seeking the opportunity for such trials to take place?

[Earl Howe]

My Lords, I merely meant to indicate that we would welcome good-quality proposals. On probiotics, I understand that one study using live yoghurt showed a patient benefit but my advice is that the study methodology was flawed and its findings were not generalisable. Probiotics are not therefore recommended, as studies have failed to show any convincing evidence that they either treat or prevent C. difficile infection.

[Lord Kakkar]

My Lords, is the noble Earl concerned about the presence of the potentially more aggressive and resistant forms of C. difficile that have been identified in our hospitals? What action is being taken to ensure that they do not spread more widely?

[Earl Howe]

My Lords, the noble Lord is absolutely right. It is appropriate for me to emphasise that, as he will well know, inappropriate prescribing of antibiotics is above all what has caused the high levels of infection that we have seen in recent years. The use of broad-spectrum antibiotics predisposes people to C. difficile infection, so it is important that those in the health service understand the cause and effect relationship involved.

It is also worth mentioning that tomorrow is European Antibiotic Awareness Day, so it is appropriate that this Question has been asked today.

[Lord Colwyn]

My Lords, I know what an antibiotic is, but can the Minister help me with what a prebiotic is and what a probiotic is?

[Earl Howe]

My noble friend has asked the question, and I hope that he will be pleased with the answer. Prebiotics are non-digestible carbohydrates that act by promoting the growth and/or activity of probiotic bacteria in the gut. The most common prebiotics are fructo-oligosaccharides, inulin and galacto-oligosaccharides. They are found in various vegetables and fruit, such as tomatoes, asparagus and bananas. The best example of a probiotic is yoghurt.