Blood and Blood Products

Earl Howe Excerpts

Monday 10th January 2011 Lords Chamber

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

My Lords, I should now like to repeat a Statement made earlier by my right honourable friend the Secretary of State for Health in another place. The Statement is as follows.

“With permission, I should like to make a Statement on hepatitis C and HIV infected blood.

Mr Speaker, what happened during the 1970s and 1980s when thousands of patients contracted hepatitis C and HIV from NHS blood and blood products is one of the great tragedies in modern healthcare. It is desperately sad to recall that during this period the best efforts of the NHS to restore people to health actually consigned so many to a life of illness and hardship. As the current Health Secretary, and on behalf of Governments extending back to the 1970s, I begin by saying how sorry I am that this happened and express my deep regret for the pain and misery that many have suffered as a result.

It is now almost two decades since the full extent of the infection was established and two years since the independent inquiry led by the noble and learned Lord, Lord Archer of Sandwell, reported. The majority of the noble and learned Lord’s recommendations are in place, as are programmes of ex gratia payments, administered by the Macfarlane Trust and the Eileen Trust for the HIV infected and by the Skipton Fund for those with hepatitis C. But significant anomalies remain and I pay tribute to the noble and learned Lord, Lord Archer, to other noble Lords, and to honourable Members from all parties for highlighting them.

In October, my honourable friend the Member for Guildford announced a review into the current support arrangements to look at reducing the differences between the hepatitis C and HIV financial support schemes and to explore other issues raised by Members during the recent Back-Bench debate, including prescription charges and wider support for those affected. We also asked clinical experts to advise on the impact of hepatitis C infection on a person’s health and quality of life and to consider whether an increase in financial support was needed.

My honourable friend the Member for Guildford met with representative groups to understand the impact that these infections were having on people’s lives. She also met many right honourable and honourable Members and noble Lords who have been strong advocates on behalf of those affected.

We have now considered the findings of the clinical expert group and accept that the needs of those with advanced liver disease from hepatitis C merit higher levels of support. At present, the amount of money paid to this group depends on the seriousness of the infection.

There are two stages at which the Skipton Fund will make a payment. The first is when the person develops chronic hepatitis C infection. At this point, a person is eligible for a stage 1 relief payment—currently a lump sum payment of £20,000. Some may reach a second stage of developing advanced liver disease, such as cirrhosis or cancer, or require a liver transplant. They then become eligible for a stage 2 payment, which is currently another lump sum payment, of £25,000. Under the new arrangements that we will introduce, this second-stage payment will increase from £25,000 to £50,000. This will apply retrospectively. So if a person has already received an initial stage 2 payment of £25,000, they will now get another £25,000 lump sum, bringing the total to £50,000. In addition to this, we will also introduce a new, annual payment of £12,800 for those with hepatitis C reaching the second stage. This is the same amount that those who were infected with HIV receive.

Those infected with both HIV and hepatitis C from contaminated blood will now receive two annual payments of £12,800 if they meet the stage 2 criteria—one payment for each infection—along with the respective lump sums. All annual payments made to both those so infected with HIV and those with hepatitis C will now be uprated annually in line with the consumer prices index to keep pace with living costs.

We know that some of those infected with HIV or hepatitis C from NHS blood and blood products face particular hardship and poverty. Those infected with HIV can already apply for additional discretionary payments from the Eileen Trust and the Macfarlane Trust, but no equivalent arrangements are in place for those infected with hepatitis C. Therefore, we will now establish a new charitable trust to make similar payments to those with hepatitis C who are in serious financial need. These payments will be available for those at all stages of their illness, based on individual circumstances. Discretionary payments will also be available to support dependants of those infected with hepatitis C, including dependants of those who have since died. Again, this will echo the arrangements in place for those infected with HIV and enable us to give more to those in greatest need.

We must also ensure that those infected through NHS blood and blood products get the right medical and psychological support. I can therefore announce two further measures. First, those infected with hepatitis C or HIV will no longer pay for their prescriptions. They will now receive the cost of an annual prescription prepayment certificate if they are currently charged for prescriptions. Secondly, the representative groups raised the issue of counselling support for those infected through blood and blood products. We fully recognise the emotional distress that they experience. As a result, we will provide £300,000 over the next three years, allowing for around 6,000 hours of counselling to help these groups.

While we focus on those still living with infections, we must also recognise the bereaved families of those who have died. At present, no payment can be made to those infected with hepatitis C who passed away before the Skipton Fund was established. This is a source of understandable distress for those who survive them and it is something that we now want to put right. I can therefore announce that, until the end of March 2011, there will be a window of opportunity where a posthumous claim of up to £70,000 can be made on behalf of those infected with hepatitis C who died before 29 August 2003.

A single payment of £20,000 will be available if the individual had reached the first stage of chronic infection and another single payment of £50,000 will be made if their condition had deteriorated to the second stage where they suffered serious liver disease or required a liver transplant. We will work with the Skipton Fund and various patient groups to publicise this new payment to those who may benefit. These new payments, which will go to the individual’s estate, should help more families to get the support that they deserve.

Taken together, these announcements represent a significant rise in the support available to those affected by this tragedy. Putting an exact figure on the package is difficult, as there is some uncertainty about how many will be eligible and how their illnesses may progress. However, we believe that these new arrangements could provide from £100 million to £130 million-worth of additional support over the course of this Parliament.

All payments will be disregarded for calculating income tax and eligibility for other state benefits, including social care, and while these changes apply only to those infected in England I will be speaking to the devolved Administrations to see if we can extend this across the UK.

Today’s announcements cannot remove the pain and distress that these individuals and families have suffered over the years, but I hope that these measures can at least bring some comfort, some consolation and perhaps some closure for those affected. I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

My Lords, I am heartened by and grateful for the welcome given by the noble Baroness to this Statement and the package of support that was announced in it. We think that it represents a fair and reasonable recognition of the suffering that many of these victims endure. We wanted to recognise that and I hope, as I said in the Statement, that it will be of some comfort to them and their families that they will receive better support.

The noble Baroness asked me some specific questions. She asked me first about the new trust and in what respects it will be different from the trusts that currently exist. I can say to her that we intend to set up the new charitable trust as quickly as possible. Its primary task will be to administer the discretionary elements of the payments that we have announced. In the mean time, the payments will begin immediately; in other words, there will be an in-year pro rata payment for the current financial year where people are due for an annual payment, and we can proceed with that speedily. As she will see in the paper that we have published, our advice is that those who feel that they have a claim should contact the Skipton Fund. There will also be a notice on the department’s website to direct them appropriately. The new trust will be essentially a charitable trust with the kind of mandate that we have seen with the Macfarlane and Eileen trusts and the Skipton Fund, but for a different cohort of people.

The noble Baroness also asked me about prescription charges. What we concluded was that, while many of the victims of this tragedy are already in receipt of free prescriptions, there are some who are not. We have received vociferous representations from them and their representatives. Therefore, we will make arrangements through one of the charitable trusts, probably the new one, to pay those who are eligible a sum equivalent to the cost of an annual prepayment certificate, so that in practice all their prescriptions will be free of charge.

The noble Baroness asked about insurance and what consideration we had given to the requests made by campaigning groups on that score. The review highlighted to us that making provision for access to insurance was, first, unlikely to represent value for money because the administrative costs would be enormous in comparison with the benefits obtained. Also, and crucially, it would have been fraught with difficulty, including administrative complexity. There is no need to remind the noble Baroness that the current fiscal context makes it even more imperative that we achieve value for money in everything that we do. We judged that it was more important to set up a discretionary fund where, if necessary, people who were in particular hardship could look for additional support and perhaps fund insurance premiums from that support. However, an across-the-board arrangement for insurance premiums, as will be apparent from the report that we have published—I should also tell her that we took advice on this from the Association of British Insurers and various specialist insurers—ruled itself out for a number of reasons.

We intend support for the Haemophilia Society to continue. The noble Baroness also asked where the money is coming from. There will be a significant immediate cost to the departmental budget during this current year. I am pleased to say that we have found savings in our current expenditure for this year, which enables us to make room for these payments. We have had this in mind for some considerable time and I am pleased that it has come to fruition. In future years, we have found room in our central budgets for the ongoing annual payments.

As regards Scotland, Wales and Northern Ireland, obviously it would have been preferable if there could have been a UK-wide announcement, but clearly it is not for us to prescribe to the devolved Administrations what they should do. However, as I indicated, we are talking to them actively and it is up to them to consider whether this is something that they wish to do for those infected in hospitals in the various devolved regions.

[Lord Morris of Manchester]

My Lords, I have two interests to declare, both non-pecuniary: as president of the Haemophilia Society, and as the architect of the independent public inquiry into the contaminated blood disaster headed by my noble and learned friend Lord Archer of Sandwell.

Is the Minister aware that, of the 1,241 haemophilia patients infected with HIV, only 361—29 per cent—are still alive, and that the number of deaths in the hepatitis C-infected community is much higher and continues to rise? Is he further aware that, as of now, an estimated 2,007 people have died from being treated with contaminated NHS blood and blood products? I congratulate the Minister on the progress that he has made, but will he now meet the haemophilia community and listen again to its plea for a response that is more in keeping with the scale of the disaster?

[Earl Howe]

My Lords, the noble Lord, Lord Morris of Manchester, to whose efforts I pay particular tribute in the context of this debate, as in many other contexts, has reminded us of the devastating effect of this tragedy on individuals and families. The previous Government recognised this and significantly improved the payments that were available to the victims of this disaster. We felt that there was still further to go, hence today’s Statement. We have arrived at this point following a brief but nevertheless thorough review of the arrangements, informed by a scientific report which is also published today—noble Lords can read the advice that we received—to enable us to understand rather better the suffering that these victims endure in clinical terms as well as in human terms. On the basis of that, we have arrived at the arrangements whose details I have repeated.

We believe that this is a fair and reasonable package of support for these poor victims. We do not intend to revisit it in the future. I acknowledge that some people might have different views on the appropriate level of payments for this patient group, but the package needs to be considered in the context of the whole range of support that is available for the group, especially Department for Work and Pensions benefits, the care available under the NHS and the care available from social services. Having consulted widely, we consider that the sums announced in this package, taken in the round with the other support available to this patient group, are both appropriate and reasonable. So, while I understand the noble Lord’s request, I am not in a position to accede to it at this point.

[Baroness Hussein-Ece]

My Lords, I congratulate my noble friend the Minister on the package announced in the Statement today. We very much welcome both it and, as the noble Baroness, Lady Thornton, said, the huge progress that has been made. Given that the commitment to review the current arrangements was made just last October, the Minister is to be congratulated on the swiftness with which this matter has been brought back to your Lordships' House. I hope that it serves to bring some comfort to those who have for so many years campaigned for justice, and particularly to the relatives of the deceased and the many other victims of this tragic episode.

The Minister announced that there would be a window for posthumous claims until the end of March 2011. There is concern that that is not a very big window and that it does not offer a lot of time to locate people and, for the many who may need assistance, to put a claim together. Perhaps the Minister can say why it is such a small window. Is he satisfied that it is sufficient time in which to track down as many people as possible who may have lost out?

It is not quite clear from the Statement who will receive posthumous payments. Will widows, partners and children be included in the arrangements? I would appreciate clarification on those points.

--- Later in debate ---

[Earl Howe]

I am very grateful to my noble friend. The window of opportunity referred to in the Statement—until the end of March, which is the best part of three months—should be sufficient to enable those with a valid claim to come forward. On the whole, we believe that, in the haemophiliac community, the victims’ families know who they are. I acknowledge that there is more difficulty with those who were in receipt of whole blood, but, again, we believe that the victims’ families know who those individuals were as well. Our job now is to publicise these arrangements so that the families are aware of the support that is currently available to them. We think that the window is sufficient.

My noble friend asked who is to be included in posthumous claims. One claim per deceased estate will be considered. The deceased person may have left his or her estate to a spouse or, indeed, to charity, but whoever it is, the beneficiary of that estate is the person entitled to come forward to claim the money. We will deal with claims on the basis that the validity of the claim is proven in relation to the estate of the deceased person. That is a matter of public record.

[Lord Archer of Sandwell]

I thank the noble Earl for repeating the Statement and recognise his readiness to listen to and act on representations, but will he also recognise the efforts of a vast number of people of all political parties and none who have worked assiduously for a very long time to ensure that financial relief of a proper order is made available to those who have suffered from the tragedy and to their dependants? If it is in order, I would also like to pay tribute to the work of my noble friend Lady Thornton, who throughout this has shown a ready ear and sympathy for those who are affected. Of course I also pay tribute to my noble friend Lord Morris, who has worked tirelessly throughout so many years.

I congratulate the Government on addressing one very important anomaly that is suffered by the dependants of deceased recipients of the Skipton Fund. Do I take it that that is the only anomaly that the Government are proposing to address, or will their ears be open throughout the discussions to some of the other anomalies that have been uncovered? I am grateful for the increased benefits, but will the Minister explain why they are paid through charitable trusts and not directly from government offices as a direct entitlement of the beneficiary? There may be good reasons for that, but, so far as I am aware, they have never been given.

Finally, since this announcement was in the form of a Statement, does that foreclose further discussion on what is to be done, or will there continue to be discussions about the proposals during their progress through Parliament and into the future?

[Earl Howe]

My Lords, the noble and learned Lord, Lord Archer, is himself to be thanked and congratulated on the immense amount of work he did to inform the thinking of the previous Government and the current Government in these matters. I immediately echo his tribute to the work of so many people—people, as he said, of all political parties and none—who enabled us to gain a proper understanding of these issues. I am also well aware that the noble Baroness, Lady Thornton, was working very hard up to the time of the last general election to see whether a better package could be delivered. I was particularly pleased to hear her support for this series of announcements.

The noble and learned Lord asked me about the benefits for deceased victims and whether these were the only anomaly that we sought to correct. We identified two principal anomalies in the situation that has pertained hitherto: the first was the one to which he referred in relation to those who died prior to 29 August 2003, which was an arbitrary cut-off date; and the second was the clear imbalance of benefits for those who suffer hepatitis C as a result of receipt of contaminated blood. There was a gap to be filled there, and we were even clearer on that having read the scientific report that we received. We therefore sought to redress that particular imbalance. There are a number of other new elements in the package, but I have identified the two main ones that stood out to us.

The noble and learned Lord asked why we were choosing to use charitable trusts as the mechanism for payment. We feel that the arrangements have worked well so far through charitable trusts and we do not think it appropriate for these benefits to be paid through the Department for Work and Pensions. It is not really in the department’s remit to do that; it is there to pay benefits and certainly not to decide on discretionary payments. We hope and believe that the victims who are currently in receipt of the benefits have good relationships with the trustees of all the funds.

As for the practical arrangements for paying these new sums, if there are queries we will endeavour to answer them. As I have indicated, we are directing people towards the Skipton Fund as the point of information on this, but the package that my right honourable friend announced today should be regarded as the final one because we believe that it settles the outstanding issues that we needed to address.

[Lord Reid of Cardowan]

My Lords, I thank the Minister and welcome the Statement today. As a former Health Secretary, I took some interest in this matter, but, like the Minister, I would like to congratulate my colleagues who have been involved in the issue in recent years. The one thing that I came to understand was that this was not only an intractable problem but an increasingly intractable problem. There are two reasons for that: first, as time passed, the human tragedy of the people afflicted became more and more obvious; and secondly, the scientific evidence became more and more complicated and difficult for the Government to avoid.

I have two quick questions. First, we have finally reached a stage which may not be completely the end and may not be completely satisfactory, but which is much fairer than the previous one. But does he accept that if there is a disparity between Scotland, England and Wales in terms of the treatment of victims and there is seen to be inequality and unfairness, it will detract greatly from any value that this has created? Secondly, as my noble friend and colleague Lord Morris said, although this goes a long way, there may still be outstanding issues. Will he not close the door completely to further discussions that could arise in the light of further scientific evidence?

--- Later in debate ---

[Earl Howe]

My Lords, I am grateful to the noble Lord, who comes to this with considerable knowledge and experience as a former Secretary of State for Health. He is right: it has been a difficult if not an intractable problem for successive Secretaries of State. He is also right to say that the human tragedy has become more obvious as the years have passed. For one thing, it was not so obvious in the early days that there would be so many victims of hepatitis C, because that condition only tends to emerge after a considerable lapse of time. The HIV infection was more immediate and more obvious.

The noble Lord is right that in making this announcement for England, we are creating an immediate disparity with the devolved Administrations. As I indicated, I hope that in our discussions with the devolved Administrations—who are, after all, autonomous—we can arrive at a more equitable package for all victims across the United Kingdom. I am sure, without wishing to appear to interfere in the affairs of the devolved Administrations, that that is something that, as human beings, we would like to see. But I cannot pre-empt the decisions that will be taken in those Administrations.

[Baroness Masham of Ilton]

My Lords, I declare an interest as a vice-president of the Haemophilia Society. I am very pleased that the Government have recognised the plight of so many people and families who have suffered this disaster. But what safeguards are in place to prevent any infections from blood transfusions or blood products happening in the future? Prevention is so important and one never knows what is on the horizon.

[Earl Howe]

My Lords, the noble Baroness is, as always, absolutely on the mark. This has been an important issue not just for the current Government but for the previous one.

The measures in place to ensure the safety and quality of human blood, blood components and the blood products manufactured from them have developed significantly since the mid-1980s. We test for viral markers. Donations contribute to a plasma pool which is also tested for viral markers. In 1985, the introduction of heat treatment in the UK removed the risk of both HIV and hepatitis from blood products. Testing of all donations for HIV was also introduced in 1985. Testing for hepatitis C was introduced in 1991 when tests became available. The European directive is now in force. As of 2002, it sets standards of quality and safety for the collection, testing, processing and storage and distribution of human blood and blood components. We have a Community code for medicinal products which affects blood products such as clotting factors. On completion of manufacture, blood products are tested for compliance with specification by the manufacturer. All batches of blood products undergo independent testing by an EU official medicines control laboratory. We are in a different world entirely now from that of the 1970s and 80s.

[Lord Corbett of Castle Vale]

My Lords, can I ask—

Health: Parkinson’s Disease

Earl Howe Excerpts

Monday 10th January 2011 Lords Chamber

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

My Lords, I begin by thanking the noble Baroness, Lady Gale, for tabling this Question for Short Debate. I very much recognise the considerable personal insight that she brings to this subject, not least as chair of the all-party parliamentary group.

Noble Lords have spoken eloquently this evening about Parkinson’s and the devastating impact that it can have. The all-party group’s report paints a compelling picture of the many failings of the health and social care system: limited information for patients and poor access to expert nursing and therapy services, underpinned by a failure to deliver joined-up services. The previous Government produced a number of policy documents designed to improve services and support people with Parkinson’s disease. The National Service Framework for Long-Term Conditions, to which noble Lords have referred, and the NICE clinical guideline are both strong statements, which this Government support. The problem, made clear in this evening’s debate, not least by the noble Lord, Lord Walton, is that all too often the vision of these documents is not put into practice and areas such as Parkinson’s services find themselves at a disadvantage when competing for attention and resources. We want to put that right. Our reforms to the NHS will ensure that patients have far more information about services, more choice about their treatments and more influence over how healthcare is shaped in their community.

Local Health Watch organisations, building on local involvement networks, will ensure that the views and feedback of patients and carers feed into decisions about local health and social care services. Devolving responsibility for commissioning to GP consortia will mean that decision-making is closer to patients and more responsive to their individual needs. The noble Baroness, Lady Gale, is right: we will have to ensure that GP commissioners are ready and have the skills and awareness that they need to take these decisions. The noble Baroness, Lady Thornton, referred to that matter, as did the noble Baroness, Lady Masham.

As noble Lords are aware, poor commissioning is one of the main reasons for the low quality of some Parkinson’s services and the patchwork quilt of standards about which we have heard. I know that some patient groups have expressed concerns about the skills and knowledge of GP commissioners. The key to this will be creating better care pathways. That is my main answer to the noble Lord, Lord Walton, who expressed his scepticism on this score. We will expect consortia to involve relevant health and social care professionals in helping to design care pathways or care packages for those with Parkinson’s that achieve more integrated delivery of care, higher quality and more efficient use of resources. They should also talk with their local authorities, which will play an increasingly important role in co-ordinating care as we move toward joint commissioning and planning through health and well-being boards. There are certainly opportunities for patient groups to contribute to developing GPs’ understanding of the condition and how to commission for it effectively. Regional neurological alliances, to which a number of noble Lords referred, have an important role to play, working with the NHS and councils, to make sure that patient needs are being met locally.

The noble Baroness, Lady Gale, referred to outcomes. The new NHS outcomes framework will help to deliver care that is safer and more effective and provides a better experience for patients. The outcomes and indicators in the NHS outcomes framework have been chosen specifically to capture the full range of NHS responsibilities. Where appropriate, they are not condition specific, but rather seek to capture those outcomes that an individual with any condition would consider important.

In these financially challenging times, it is important that we make the most of the resources available. Parkinson’s services are a good example of where much more can be done and where inadequate services waste resources. With an ageing population, the number of people with Parkinson’s is increasing and, as the Fair Care campaign highlights, the best way to save money is to deliver good-quality Parkinson’s services when and where people need them.

Better, more effective care does not necessarily mean more resources. Doing things differently, good multidisciplinary teamwork, specialist support, early interventions and care planning can all make a significant difference. High-quality information, combined with the right support, is the key to achieving better care, better outcomes and reduced costs. We have been consulting on a new information strategy to improve the range and quality of information available to patients, professionals and the public, to increase transparency and strengthen accountability in the system.

Good social care is vital for people living with Parkinson’s. It enables them and their carers to live the independent life that most of us take for granted. We want to build a social care system that is fair and sustainable—one that reflects individual autonomy and ensures that everybody is treated with dignity and respect. In November, we published our vision for social care, setting the future direction for adult social care in England. The vision looks at the role of social care in contributing to the development of the big society and includes a new leadership role for local councils to improve preventive services and develop community capacity, which is in part an answer to the question posed by the noble Baroness, Lady Thornton—in other words, inspiring and supporting communities to look after themselves. The vision encourages care and support to be delivered in a partnership between individuals, communities, the voluntary sector, the NHS and councils, including wider support services, such as housing.

Carers exemplify the big society. They provide care and support entirely from their own time and resources. In government, we need to reciprocate this commitment with measures that support carers. Last year, we published an update to the National Carers Strategy—Next Steps for the Carers Strategy. It provides a clear plan of action for the next four years, focusing on what will have the biggest impact on carers’ lives.

A number of noble Lords, including the noble Baroness, Lady Gale, my noble friend Lady Hussein-Ece and the noble Baroness, Lady Masham, referred enthusiastically to the role of specialist Parkinson’s nurses. Specialist nurses provide a very important source of support and advice to patients with Parkinson’s disease and enable many patients to manage their condition effectively. It is of course the responsibility of local health bodies to make decisions on the funding of Parkinson’s nursing posts. The Long-Term Conditions Delivery Support Team has, however, developed a guide to writing a business case for epilepsy specialist nurses for commissioners to use in making the case for improving those services. This guide could be adapted to make the case for specialist nurses for other long-term neurological conditions, including Parkinson’s. The new commissioning arrangements will take all the evidence into account in deciding to what extent specialist nursing will be commissioned.

The noble Baroness, Lady Gale, asked whether all areas will retain their levels of Parkinson’s nurses. We think that localism is the best way of holding local organisations to account. These decisions should in the end be made locally and will be influenced by the important inquiry that she has chaired.

The noble Baroness, Lady Gale, and others referred to the national service framework. While the vision of the NSF reflects that of the White Paper, the new NHS architecture, and particularly the arrangements for commissioning, will render somewhat outdated any lessons learnt from the review. Better outcomes for people with long-term neurological conditions will in future be achieved through the NHS outcomes framework. The framework will enable patients to judge the overall performance of the NHS and to hold the Government to account for progress. Through the Long-Term Neurological Conditions Research Initiative, the department has funded the development of Quality Neurology, a comprehensive audit tool for local health and social care economies to use in assessing their current status in meeting the quality requirements of the NSF for long-term conditions.

The noble Lords, Lord Harrison and Lord Walton of Detchant, referred to GP consortia needing to involve the third sector. I have already referred to this issue. The onus is on regional neurological alliances and patient groups to engage with GP consortia in the first instance. Through the then Section 64 scheme, the department funded the Neurological Alliance to establish a network of RNAs across England. The case for developing a quality standard for Parkinson’s disease will be considered as part of the development of the comprehensive library of standards, in line with the plan set out in the White Paper. The longer-term aim is to develop a broad library of quality standards covering the majority of NHS activity.

The noble Baroness, Lady Gale, and my noble friend Lady Hussein-Ece asked about the status of the NSF for long-term conditions. The Government’s health reforms place outcomes at its heart, as I mentioned. That fits very well with the aspirations of the NSF for long-term conditions. The issue is not the delivery mechanism—in other words, the NSF versus the Government’s health reforms—but, rather, ensuring that services for people with a long-term neurological condition achieve the best possible outcomes.

The noble Baroness, Lady Gale, asked how we can ensure that money for carers would be spent as intended. It is for PCTs and, after them, GP consortia to manage their budgets and make decisions about how best to meet the health needs of their local populations, but we are looking at how we can make decision-making more transparent. That includes using the NHS operating framework, which sets out the priorities for the year ahead and makes it clear that breaks for carers are important. The NHS outcomes framework and the outcomes framework for adult social care will also push for clear and unambiguous accountability in this area.

As so often happens, the clock is moving against me. I have much material here to answer every question posed by noble Lords. I apologise that I will not have time to do that in my allocated slot and I will write to all noble Lords with answers. Suffice it to say that, while tonight’s debate has highlighted variations in the quality of care, the fact is that there are some very good examples of Parkinson’s services. In Barnsley, for example, there is an holistic, multidisciplinary service in a range of locations tailored to meet the needs of patients. We need to replicate such models, ensuring that everybody has access to comprehensive services and expert multidisciplinary care. Through our health reforms, we are determined to continue to transform standards and to achieve better outcomes for people with Parkinson’s disease.

NHS: Targets

Earl Howe Excerpts

Monday 20th December 2010 Lords Chamber

[Lord Wills]

To ask Her Majesty’s Government what they propose the role of targets in the National Health Service should be.

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

My Lords, from 2012-13 the NHS commissioning board will be responsible for the delivery of NHS services, based on the NHS outcomes framework. The operating framework for the NHS published last week sets out the priorities for the NHS for the transition year of 2011-12 and details how the NHS will move to a health economy driven by outcomes for 2012-13.

[Lord Wills]

I am grateful to the Minister for that Answer. He will recall that, in October, the Health Secretary said that the coalition never committed to a one-week target for cancer patients to get their test results

“because there is not enough clinical evidence to support it”.

However, in November, the noble Earl the Minister told this House that a

“one-week access target would not be the best use of the resources that we have”.—[Official Report, 11/11/10; col. 319.]

Why exactly did the Government scrap the target? Was it the cost, or was there a clinical justification? If it was both, which justification was the most important? If the clinical evidence played any part in this decision, could he please place the evidence in the Library of the House?

[Earl Howe]

My Lords, the announcement made by the previous Government for the one-week target was an unfunded, as well as very expensive, commitment. At the moment, the median wait for the 15 key diagnostic tests is 1.8 weeks—it fluctuates between 1.5 weeks and thereabouts. To bring that down to a maximum of one week would have cost many hundreds of millions of pounds. We judged that there are better ways in which to speed up access to diagnostic tests for a lot less money. That is why we recently announced that £25 million will be made available next year to help GPs to get direct access to tests for cancer without first having to make an appointment with a specialist. That money will buy up to 150,000 extra tests. We have thought round this problem—if I may put it that way—and thought around the conventional referral pathways. I believe that we will arrive at a very satisfactory result.

[Baroness Gardner of Parkes]

Can the Minister tell me his view as to how exactly things will work? Although some targets were considered bad, unnecessary and unproductive, others produced some good results. Will the targets be replaced by a code of practice or guidance, or will people simply be left to manage as best they can?

[Earl Howe]

My noble friend is right. Of course the waiting time target achieved a great deal in bringing down waits for elective procedures, but the target had some unwanted effects in that it distorted clinical priorities and, many people felt, took the focus away from many areas of care that deserved greater focus. We need to focus on outcomes for patients. Therefore, instead of setting process-based targets, our aim will be to ensure that, wherever possible, the NHS uses the measures that clinicians themselves use as a basis for improving their services—in other words, measures that are clinically credible and evidence based. That is how we have tried to frame the outcomes framework.

[Lord Davies of Coity]

Does not the Minister agree that the Secretary of State’s proposals for competitiveness within the health service will in effect privatise the NHS?

[Earl Howe]

My Lords, I do not accept that. The previous Government recognised that contestability in the provision of care was a very powerful driver to improve quality of services. I do not think that privatisation of the health service will result from the proposals. We will reach a better stage of quality in provision of care only if we allow the best providers out there to compete for services. As long as the principles of the NHS remain—which they will do under this Government—for a service free at the point of need without being based on ability to pay, we will have the NHS that we all know and love.

[Lord Alderdice]

My Lords—

--- Later in debate ---

[Earl Howe]

My Lords, many of the data that will underpin the monitoring of the outcomes framework are already collected as a matter of routine but are just not used. In the outcomes framework, we shall reduce the number of outcomes to many fewer than have been in play under the previous Government’s process-based targets. We do not see our proposals as imposing unnecessary or impossible extra burdens on the NHS.

[Lord Patel]

I need to cultivate a louder voice, obviously. Can the Minister give an example of where competition in healthcare delivery has improved outcomes?

[Earl Howe]

I am sorry that the noble Lord is a sceptic on these matters. In the field of mental health care, for example, where there is a long-standing position of private sector contestability, we have seen that standards have been driven up. There is no doubt that the foundation trust model has also paved the way for higher quality in healthcare.

[Baroness Thornton]

My Lords, turning to waiting lists for accident and emergency services, which we obviously want to provide the highest possible care, I want to ask how the newly proposed scheme will improve the quality of care. For example, how will the abolition of the 19-minute response time to a 999 call that is not life threatening affect the health outcome for an elderly lady who has slipped and broken her wrist on the ice? Such a slip may not be life threatening, but the elderly lady may wait for quite some time for an ambulance and then wait considerably longer than four hours in accident and emergency. Is the waiting time not an outcome here? If the Government do not intend to introduce a new outcomes framework for two years, would the Government not be better to leave the current guarantees in place because we know that they ensure patient safety?

[Earl Howe]

My Lords, on ambulance response times, the existing eight-minute target will remain in place for category A calls. For category B calls, which are serious but not immediately life threatening, Peter Bradley, who is the national ambulance director, has been working with Professor Cooke to develop a set of 11 clinical quality indicators for the ambulance service. We are clear that those indicators will provide a much better and more rounded set of objectives than a mere 19-minute response time. Of course response times are important, but there are other things that should be focused on as well. We hope to improve standards in this way as from April next year.

NHS: Global Health

Earl Howe Excerpts

Monday 20th December 2010 Lords Chamber

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

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

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

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

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

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

My noble friend Lord McColl—

[Lord Davies of Stamford]

I am extremely grateful to—

--- Later in debate ---

[Earl Howe]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NHS: Reorganisation

Earl Howe Excerpts

Thursday 16th December 2010 Lords Chamber

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hospices and Palliative Care Services

Earl Howe Excerpts

Wednesday 15th December 2010 Lords Chamber

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Autism

Earl Howe Excerpts

Tuesday 7th December 2010 Lords Chamber

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

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

[Lord Touhig]

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

[Earl Howe]

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

[Baroness Browning]

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

[Earl Howe]

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

[Baroness Pitkeathley]

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

[Earl Howe]

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

[Lord Low of Dalston]

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

[Earl Howe]

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

[Baroness Thornton]

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

[Earl Howe]

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

[Baroness Hollins]

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

[Earl Howe]

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

[Baroness Hussein-Ece]

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

[Earl Howe]

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

Health: Passive Smoking

Earl Howe Excerpts

Tuesday 30th November 2010 Lords Chamber

[Lord Faulkner of Worcester]

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

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

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

[Lord Faulkner of Worcester]

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

[Earl Howe]

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

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

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

--- Later in debate ---

[Lord Alderdice]

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

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

[Earl Howe]

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

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

[Lord Patel]

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

[Earl Howe]

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

[Lord Naseby]

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

[Lord Naseby]

Well, that was not his view.

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

[Earl Howe]

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

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

[Baroness Finlay of Llandaff]

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

[Earl Howe]

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

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

[Baroness Thornton]

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

[Baroness Thornton]

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

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

[Earl Howe]

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

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

Public Health

Earl Howe Excerpts

Tuesday 30th November 2010 Lords Chamber

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

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

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

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

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

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

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

‘the causes of the causes’,

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

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

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

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

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

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

[The Countess of Mar]

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

[Earl Howe]

The Statement continues:

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

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

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

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

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

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

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

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

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

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

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

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

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

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

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

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

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

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

--- Later in debate ---

[Baroness Northover]

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

[Earl Howe]

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

[Baroness Finlay of Llandaff]

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

[Earl Howe]

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

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

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

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

[Lord Cunningham of Felling]

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

[Earl Howe]

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

[Baroness Browning]

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

[Earl Howe]

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

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

[Baroness Gould of Potternewton]

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

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

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

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

[Earl Howe]

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

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

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

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

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

[The Countess of Mar]

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

[Earl Howe]

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

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

[Lord Ryder of Wensum]

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

--- Later in debate ---

[Earl Howe]

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

Health: Academic Health Partnerships

Earl Howe Excerpts

Monday 29th November 2010 Lords Chamber

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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