Autism
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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?
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(14 years, 2 months ago)
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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.
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(14 years, 2 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House, I shall now repeat a Statement 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.
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.
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?
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(14 years, 2 months ago)
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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(14 years, 2 months ago)
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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
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.
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
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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?
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
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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, 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.
Department of Health: Arm’s-length Bodies
Earl Howe Excerpts(14 years, 3 months ago)
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Lord Knight of Weymouth
To ask Her Majesty’s Government what estimate they have made of the cost of organisational changes required to implement the proposals to reform the Department of Health’s non-departmental public bodies; and whether the cost will be allocated to that department’s budget.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government have announced that administration costs will reduce by a third in real terms across the health sector. This will impact on the Department of Health’s arm’s-length bodies. Currently, we cannot determine the exact costs, as they will be affected by how the reduction is distributed across the health sector and how much is met by levels of natural wastage. The department’s spending review settlement will meet these costs.
Lord Knight of Weymouth
I thank the noble Earl for that reply. He will, I am sure, have listened carefully to the debate last week on the Public Bodies Bill. He will have heard half a dozen of your Lordships raise concerns about two health bodies in particular—the Human Tissue Authority and the Human Fertilisation and Embryology Authority. Both have the schedule of Damocles hanging over them; both need independence and sensitivity; and both cost the public purse very little. Will the noble Earl now follow the precedent set by the noble Baroness, Lady Rawlings, when she announced during Questions last Thursday that Ofcom will not be scrapped and was being pulled from Schedule 7. Will he do the same for the Human Tissue Authority and the Human Fertilisation and Embryology Authority?
Earl Howe
My Lords, we will obviously have an opportunity to debate these matters in Committee on the Public Bodies Bill, but I would just make a couple of general points. There are clear synergies between some of the functions performed by the HFEA, the HTA and the Care Quality Commission—they all license treatment. In addition, there is significant read-across to the potential scope of a new research regulator. All political parties at the election were agreed that we have too many of these bodies—too many quangos—and we have to reduce the cost of administration across government as a whole. We can debate at greater length the merits, and perhaps demerits, of the Government’s proposals. I look forward to that debate.
Baroness Hussein-Ece
My Lords, will my noble friend give an assurance that the necessary functions of these bodies will continue and, importantly, will they be more accountable?
Earl Howe
My Lords, the key point to make about our proposals around the HFEA and the HTA is that we are not proposing to change the functions or alter the provisions of the underlying statutes. All we are doing is proposing to transfer various functions in different directions. As for the independence of the advice, I see no reason at all why the current independence should not be maintained under the new arrangements.
Baroness Deech
My Lords, is the Minister aware that a pre-legislative scrutiny committee gave an opinion two or three years ago that there was not a read-across between the HTA and the HFEA and that they had different skill sets? It accepted evidence that there was no money to be saved and that there would be a considerable loss of experience and probably money in bringing the two together. Does the Minister agree that we cannot keep revisiting this issue, which has been so thoroughly looked at?
Earl Howe
They are different skill sets, but I am not aware that Parliament has visited these issues, let alone revisited them. As I said, we will have the opportunity to do that, but the proposals we have outlined will ensure that the teams that are currently involved in inspection activities will be kept together. I see no reason why they should not be.
Lord Turnberg
My Lords, perhaps I may ask the noble Earl about the Health Protection Agency. What advantages does he expect to come out of moving the HPA into the Department of Health?
Earl Howe
The advantages will come from collocating all aspects of public health in one place, including the Health Protection Agency. I emphasise that there will continue to be independent advice on health protection. We will have a clear line of sight in all public health matters from the Secretary of State right down the chain to local authorities and to public health programmes implemented on the ground. We do not have that at the moment.
Baroness Gardner of Parkes
Is the Minister aware that, in health services in general—and I apply this also to these bodies—there is a tendency that if someone leaves a post, it is kept unfilled? Will the Minister assure us that, instead of allowing that to happen on an unspecified basis, the Government will make sure that if a post is essential it is retained and not left simply because a person has given up their job?
Earl Howe
My Lords, my noble friend makes a good point. We need to distinguish between posts that are administrative in nature, where we will see considerable reductions, as I have mentioned, and posts that relate to clinical activities. There is obviously a clear case for the latter posts to be advertised and filled where necessary.
Baroness Thornton
Will the Minister explain to the House why the Human Tissue Authority and the Human Fertilisation and Embryology Authority have been included in the Public Bodies Bill when some 28 other NDPBs—I apologise to the House for that—were listed on 14 October in the announcement made about quangos? Will the Minister also explain whether an impact assessment has been done on any or all of these bodies, and when we might see the results of that? How many people does he expect will be made redundant, and at what cost?
Earl Howe
My Lords, the impact assessment will be published as soon as we know the size and shape of the costs involved. As I mentioned in my original Answer, we do not know that at the moment because we do not know about natural wastage, the grades of the people who will have to leave, and so on. The main reason why those two bodies have been included in the Bill is that our proposals, when we finalise them, will be very simple. As I have outlined, they will involve reparcelling the current functions of the bodies in different directions. That is not a difficult thing to do: it can be done very easily by secondary legislation.
Healthcare: Costs
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government have guaranteed that health spending will increase in real terms in each year of the Parliament. However, in order to meet rapidly rising demands while improving quality, substantial improvements in economy and efficiency will be required across all areas of health spending. This response is best led by the NHS locally, while the centre will focus on reforming the health service to create a long-term sustainable NHS.
Lord Taylor of Warwick
My Lords, I thank the Minister for his reply. Does he agree with me that putting more funding now into research into terrible conditions such as dementia, in which I include Alzheimer’s disease—for which there is no cure—will ultimately bring down healthcare costs? We must find a cure, and I ask the Minister to commit more research funding to the terrible condition of dementia.
Earl Howe
My Lords, my noble friend is quite right to identify dementia as a particular cost pressure over the next few years. The coalition Government signalled in their programme our intention to prioritise funding for dementia research. The spending review confirmed that and committed to real-terms increases in spending on health research. This investment is indeed essential if we are to increase the quality, productivity and cost-effectiveness of the NHS.
Lord Brooke of Alverthorpe
My Lords, I return to a question which I posed previously to the Minister and which remains unanswered. Does he not agree that if patients in the health service knew what the costs of their treatment, care and drugs were, as they do in the private sector, this would create a downward pressure, which would reduce costs overall?
Earl Howe
My Lords, I know that this is a question to which the noble Lord and other noble Lords regularly return, and it has a superficial attraction. The problem with it, I am advised, is that patients who are informed of the cost of their treatment—some patients, at any rate—take that as a deterrent to accepting the treatment in the first place. That is something we need to avoid. Nevertheless, there is an underlying point here; there is a need to provide better information to patients about their treatment so that they can take ownership of their state of health.
Baroness Finlay of Llandaff
My Lords, what consideration are the Government giving to seven-day working in the NHS, including renegotiating Agenda for Change, to make better use of the NHS’s equipment, promote early diagnosis and decrease morbidity from complications of treatment that is not overseen by senior staff—particularly over weekends and bank holidays?
Earl Howe
My Lords, creating a seven-day service is a particular concern of mine, and the noble Baroness is quite right to raise it, particularly given her long experience in the health service. As for Agenda for Change, any alterations to existing terms and conditions, such as the unsocial hours payment or sick pay, would need to be negotiated in partnership with NHS Employers and trade unions, through the NHS Staff Council.
Lord Alderdice
My Lords, I know it is extremely difficult, but has my noble friend had the opportunity to explore how much of the increase in health service costs in recent years has come about because of the increase in administration and management costs? I refer not simply to the salaries of administrators and managers but to the administration for the administrators, and to the amount of time that clinical and professional staff must spend in servicing the requirements put on them by administrators and management.
Earl Howe
My noble friend is right to pinpoint this area. If my memory serves me correctly, the average annual increase in management and administration costs over the past 10 years has been 6.2 per cent per year, which is by far and away higher than the increase in costs in clinical areas, for example. That is why we are determined to reduce the administrative cost of running the NHS, and we are in the process of planning for exactly that.
Baroness Wall of New Barnet
Does the noble Earl agree that that is an opportunity for us to look at saving costs in the health service by ensuring that we think of methods to persuade people to attend their day clinics? The cost of people not attending—DNA, as it is called in the health service—is huge, particularly in day surgery.
Earl Howe
The noble Baroness is quite right, and I am well aware that she speaks from personal experience. Many hospital trusts, and indeed GPs’ surgeries where applicable, have devised inventive ways of reminding patients of their appointments, either on the day or on the day before, perhaps by text. Good practice in this area is something that we need to focus on.
Lord Kakkar
My Lords, clinical leadership is critical if we are to secure the greatest benefit for patients from NHS spending and the appropriate use of resources. What strategies do Her Majesty's Government have for developing clinical leadership in the NHS? I declare an interest as patron of UCL Partners’ NHS staff college.
Earl Howe
Again, my Lords, the noble Lord is absolutely right to focus on clinical leadership, which will be critical if we are to deliver the improvements in the quality of care that we wish to see, and also to roll out the vision laid out in the Government's White Paper. The department has a number of initiatives under way, as do deaneries in strategic health authority areas around the country, to promote clinical leadership. There are also active programmes in acute trusts. Without good clinical leadership, the programme cannot proceed as we all hope and wish.
Lord Eden of Winton
My Lords, can my noble friend say what proportion of total National Health Service costs is represented by drugs and medicines? Might it not be that if there were tighter control over the dissemination of pills and medicines, particularly in outpatient departments, there could be important savings?
Earl Howe
My Lords, my noble friend is right that drugs and medicines account for a sizeable proportion of the NHS bill. Successive rounds of the pharmaceutical price regulation scheme, combined with what we call the category M scheme for generic drugs, have held down the cost of drugs to the NHS very successfully over the years. However, this is an area to which we are devoting a great deal of attention, not least in our plans for value-based pricing in the longer term.
Mental Health
Earl Howe Excerpts(14 years, 3 months ago)
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Baroness Murphy
To ask Her Majesty’s Government what plans they have to address mental health factors in their public health agenda.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, mental health is recognised as an integral part of public health. The public health White Paper will set out a new approach to public health, giving mental health the same prominence as physical health conditions such as cancer and heart disease. The Government recognise that there is no public health without public mental health.
Baroness Murphy
I thank the Minister for that encouraging reply. Of course, he will recognise that there is a long way to go. Some 50 per cent of all smoking related deaths in this country are attributed to people with mental disorders, and in fact those with mental illnesses account for almost half of all the tobacco consumed. People with schizophrenia and other mental illness have by far the worst outcomes in terms of mortality, losing on average 20 years of their lives. Will there be specific targets in the forthcoming White Paper around the physical health outcomes in terms of mortality and morbidity of those with serious mental disorders?
Earl Howe
My Lords, yes. We know that people with severe mental illness die on average 20 years sooner than others and that the majority of these deaths are smoking related. Improving public health is at the core of the Government’s health policy, as I expect the noble Baroness is aware. We will make clear our priorities in this area when the public health White Paper is published.
Lord Alderdice
My Lords, we know that early years development is absolutely critical to whether adults will be vulnerable to mental illness later. What things do the Government intend to do in terms of early development, not just in health but across departments, to try to ensure less vulnerability not only in young people, although that is important, but also in adults, since these vulnerabilities develop early on?
Earl Howe
My Lords, my noble friend is absolutely right: this is a cross-government effort. It is not simply for the Department of Health to deal with the issue because just about every department has some sort of remit in this area. I would say that, in particular on the attainment of children at school, we will focus very much on children from disadvantaged backgrounds because there is a high correlation between mental ill health and poverty, and mental ill health and deprivation. That will be a major focus.
Lord Turnberg
My Lords, what steps are the Government taking to ensure that GP consortia have access to the expert advice they will need if they are to commission positive mental health messages and the prevention of mental illness?
Earl Howe
My Lords, many GPs understand the issues very well and are keen to get on with the agenda. Our proposed model of GP commissioning means that practices will have flexibility within the new legislative framework to form consortia in ways designed to secure the best healthcare and outcomes for their patients. That will include mental health and could involve, for example, taking commissioning decisions collectively with perhaps a lead consortium for mental health.
Baroness Howarth of Breckland
My Lords, I know that the number of young people being detained in adult mental health hospitals is decreasing steadily, but can the Minister tell us, first, how many remain, and secondly, what policy will be set out in the framework for seriously disturbed young people who will be contained within the community?
Earl Howe
My Lords, the noble Baroness is right to say that there is legislative provision to ensure age-appropriate accommodation for young people in particular suffering from mental health difficulties. A range of products has been produced by the National Mental Health Development Unit to assist hospitals to meet the legal requirement to provide that age-appropriate setting. It does not mean, of course, that no under 18 year-olds may be treated on adult psychiatric wards as there are circumstances where that is appropriate. But my understanding is that this legislation is being observed and is making a difference.
Baroness Corston
My Lords, given that two-thirds of the women in prison have diagnosable mental health disorders and that services are currently commissioned through primary care trusts, how will such services be provided once the trusts are abolished?
Lord Northbourne
My Lords, the noble Earl has already mentioned children with mental health problems. Does he agree that a parent with mental health problems can have a serious and damaging effect on a child’s life chances? Are there any statistics on how many children are today growing up in families with a parent with mental ill health? If not, will the Government consider collecting such statistics in the future?
Earl Howe
My Lords, I do not believe that we collect data on the attainments at school of children with parents who have mental health difficulties. However, we know that severe parental mental health problems are one of a range of risk factors that are statistically associated with poor emotional health. There are some statistics, which I will endeavour to supply to the noble Lord, but my understanding is that long-term outcomes are not particularly clear. Nevertheless, there is evidence that children and young people who are emotionally and mentally healthy and active achieve more and participate more fully with their peers at school.
Lord Patel of Bradford
My Lords, we know that a range of mental health issues disproportionately affect black and minority ethnic communities—for example, the high risk of developing psychosis among the black Caribbean community. What steps are the Government taking to ensure that we have targeted prevention strategies in this area to continue the work of the previous Government?
Earl Howe
My Lords, the previous Government’s Delivering Race Equality in Mental Health Care programme ended in January of this year. That programme was delivered through working in partnership with service users, carers, clinicians and third sector agencies. A tremendous amount of information came out of it and the learning and findings from that programme will inform the work that we are now carrying out on a new mental health strategy, which we plan to publish in a few weeks time.
Lord Wills
My Lords, Professor Marmot’s review of health inequalities found that unemployment has a significant impact on both physical and mental health. In the light of that and indeed of the rest of that excellent report, what are the Government doing to implement its recommendations?
Earl Howe
My Lords, we very much welcome the Marmot review. Fairness and social justice are both key principles of the coalition Government. The Secretary of State for Health has said that he wants to build on the review’s findings and its six main policy objectives, from early years to ill health prevention. The forthcoming public health White Paper will set out our approach to tackling health inequalities and addressing the wider determinants of health.
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