Medical Profession (Responsible Officers) Regulations 2010
Earl Howe Excerpts(14 years, 7 months ago)
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Earl Howe
My Lords, the purpose of the draft Medical Profession (Responsible Officers) Regulations 2010 is to protect patients and to support doctors to improve the quality of care they give. They require certain designated organisations in England, Wales and Scotland to nominate or appoint responsible officers and to support those responsible officers in carrying out their statutory functions. They give responsible officers statutory functions relating to the evaluation of a doctor’s fitness to practise. In England only, responsible officers will be given additional functions relating to monitoring the conduct and performance of doctors. The regulations set out the connections between doctors and the designated organisation relevant for them.
Under the regulations, responsible officers will have to be licensed medical practitioners with at least five years’ experience. However, this is a statutory minimum. In practice, organisations will want to appoint senior doctors with experience of the management of other doctors as their responsible officers. The responsibilities of responsible officers relating to the evaluation of fitness to practise include ensuring that the designated body carries out regular appraisals, establishing and implementing procedures to investigate concerns and, where appropriate, referring the doctor to the General Medical Council.
Under their duties to evaluate fitness to practise, responsible officers will make recommendations on individual doctors to the General Medical Council. The responsible officer will have to make a recommendation as the basis for revalidation when it is introduced. This will normally be every five years. In England, their additional responsibilities will include identifying any issues arising from information about conduct and performance and ensuring that the designated body takes steps to address any such issues. These functions will enable responsible officers to support doctors to improve the care they give at the earliest opportunity.
Most of the statutory functions are activities already undertaken by medical directors and staff. These regulations do not specify who will take on the role of responsible officer; rather they allow organisations to determine how the functions may best be carried out. In the NHS and independent providers, it is likely to be existing medical directors. Except perhaps in the smallest organisations, we would not expect responsible officers to undertake the tasks, such as appraisals and investigations, personally, but they will be responsible for ensuring that they are carried out appropriately. This will involve ensuring that their designated body has sufficient staff who are appropriately trained, whether in undertaking appraisals or in investigating concerns. The regulations also make provision for the appointment of an additional responsible officer where there is a conflict of interest or appearance of bias between a doctor and the responsible officer.
The Merits of Statutory Instruments Committee has drawn these regulations to the attention of the House and I have no doubt that in the light of the Motion she has tabled, the noble Baroness, Lady Thornton, will wish to raise certain issues and concerns. I stand ready to address them, but in the mean time, I beg to move.
Amendment to the Motion
Earl Howe
My Lords, I thank all noble Lords who have spoken. In particular, I welcome the positive comments made about the regulations and the rationale for them. I am grateful especially to the noble Lords, Lord Walton, Lord Patel and Lord Kakkar, and my noble friend Lord Alderdice for their strong support and very helpful comments, and indeed to the noble Lord, Lord Rea, for what he said. A number of questions have been asked and perhaps I could begin by addressing the timing of these regulations.
First, I know that medical revalidation was a concern of the Merits Committee, reflecting in turn the concerns raised by the BMA and the Royal College of Surgeons. Noble Lords who are medically qualified will be aware, and other noble Lords may well be aware, that the piloting period for revalidation has been extended for a further year. This will allow time for a better understanding of the costs, benefits and practicalities of implementation and to enable full engagement with the profession, the service and the public. Despite there being issues which the extended period of piloting will help us address, one thing remains clear; recommendations on an individual’s revalidation can be based only on substantiated information. That information will come from doctors themselves, supplemented by information from an organisation’s clinical governance systems. The responsible officers’ roles, in other words, are wider than the process of revalidation. It is important that we have those officers in place to implement improved systems of clinical governance and to ensure that organisations are prepared and doctors are supported, ready for revalidation.
The noble Lord, Lord Rea, was right; having responsible officers in place would help to ensure that doctors are appraised and that systems are in place that will enable the information to be collected and shared as appropriate, such as when doctors move to a new organisation. Where there are concerns, their duties will ensure that the appropriate action is taken, and will continue to be taken, so that patients are protected. The noble Baroness, Lady Thornton, also argued that the regulations had been overtaken by the Government’s proposed reforms of the NHS. It is worth re-emphasising what my honourable friend Anne Milton said in her letter: that the majority of organisations designated under the regulations will not be directly affected by the removal of primary care trusts and strategic health authorities, which of course has not yet happened and is still some distance away. Clinical governance systems are needed regardless of the White Paper proposals.
Now is precisely the right time to introduce the role of responsible officer. I simply repeat that medical leadership and stability are needed if organisations and their doctors are going to be ready for revalidation when it starts.
Of course the regulations will in due course need to reflect the changes in NHS architecture, should those be agreed by Parliament. We are currently exploring options for this and I can repeat the assurances given by my honourable friend Anne Milton in another place. To answer in particular the concern of the noble Baroness, Lady Finlay, about primary care, we will consult on options for responsible officers within primary care as we move to a system of commissioning consortia, and on identifying a responsible officer’s own responsible officer, who in England currently sits within the strategic health authority, as the noble Baroness, Lady Thornton, rightly pointed out.
The noble Baroness also reflected professional concerns about conflicts of interest between a responsible officer’s statutory duties and their duty to their organisation. All doctors who have a management or supervisory role for other doctors already manage on a day-to-day basis any tensions that may arise between the need to ensure high professional standards and values on the one hand and the needs of employers and service provision on the other. Medical directors already address concerns about doctors in their organisations, whether through local performance management, disciplinary systems or referrals to the GMC. The Government believe that, in the vast majority of cases, medical directors will be guided by their professional values to manage such issues fairly and in the best interests of patients. The alternative—an entirely independent structure of responsible offices in every healthcare organisation in the United Kingdom—would replicate the system of GMC affiliates, which was proposed, as noble Lords may remember, in 2007, and which professional bodies rejected during consultation as being disproportionate, impracticable and unaffordable.
I also draw the House’s attention to the evidence given to the Health Select Committee on 4 November 2010 by Professor Peter Furness, who is president of the Royal College of Pathologists and revalidation lead for the Academy of Medical Royal Colleges. Professor Furness acknowledged the potential for a conflict of interest, but he also said that the view that medical directors should not be responsible officers was held by “a minority” of medical royal colleges. He observed that the potential for conflict could be balanced by the fact that medical directors are best placed to resolve any problems that might arise. He also thought that the potential for conflict needs to be addressed by “open processes” to ensure that it does not cause problems.
We must also remember—this is a fundamental point— that responsible officers can make recommendations only about a doctor’s fitness to practise; they do not have the power to remove a doctor’s licence to practise. Their recommendations must be based on evidence, and it should be clear immediately if that is not the case. Further, if responsible officers make recommendations that are not based on evidence, they may be failing in their duties under good medical practice, which requires that doctors must,
“be honest and open and act with integrity”.
In that case, responsible officers could even bring their own fitness to practise into question. These are very serious issues for any responsible officer.
The Merits Committee’s concern that the regulations provide for no process of appeal against the recommendation of a responsible officer has also been raised by noble Lords. First, let me stress that the regulations will result in no change to the current situation, in which every doctor, including the medical director, has a professional duty to report serious concerns about another doctor to the GMC. Under the regulations, the responsible officer will be required to decide what recommendation to make to the GMC about an individual doctor’s fitness to practise. However, the GMC would then need to go through its own processes, which provide the doctor with an opportunity to defend allegations—including through an appeals mechanism—before the doctor can be considered unfit to practise. Under the regulations, local procedures to investigate concerns must provide for a doctor’s comments to be sought and taken into account.
In England, as part of the responsible officer’s role in dealing with concerns about a doctor’s conduct or performance, the responsible officer will also be able to recommend suspension to the designated body. However, the decision on suspension is for the designated body and should engage that organisation’s performance management and grievance procedures. I think that sufficient mechanisms are already in place that protect the doctor’s interests without the need to create an additional bureaucratic structure to allow doctors to appeal against what are, after all, simply recommendations.
Two further issues were raised by, I think, the noble Baronesses, Lady Thornton and Lady Finlay. The first relates to a failure to specify that appraisal should encompass the whole of a doctor’s practice. That is in fact provided for in Regulation 11(3), which states:
“The responsible officer must ensure that appraisals … involve obtaining and taking account of all available information relating to the medical practitioner’s fitness to practise in the work carried out by the practitioner for the designated body, and for any other body, during the appraisal period”.
Nevertheless, I repeat the assurances given in another place that we will consider whether we can strengthen the guidance to make it clearer that appraisals must address the whole of a doctor’s professional practice.
The second issue relates to indemnity and, in particular, to the fact that organisations should provide indemnity for responsible officers. Indemnity payments are already calculated on the basis of a shared risk. At this stage, we understand from the medical defence organisations that there is no suggestion that the contributions from those who take on the responsible officer role would need to rise. However, we are told that the medical defence organisations will keep the situation under review. I assure noble Lords that, if we find contributions rising as a result of these regulations, we will review the position.
Baroness Finlay of Llandaff
Will the Minister clarify that the way in which the regulations are written is sufficiently flexible to allow a doctor to take a career break, to move into a different area or to take a break from clinical practice as it currently stands? Are they also sufficiently flexible to allow the responsible officer role not to be tied to the medical director of a trust, but if the medical director of a trust resigns from that post but is very suitable to remain the responsible officer, they can remain the responsible officer and the medical director can be someone else? Furthermore, are they sufficiently flexible to allow you to be able to get rid of a responsible officer if it turns out that they are not being wise enough?
Although this is slightly irregular, I should point out for clarification that I am not against these regulations at all—I think that they need to go through. My concern about five years is that most doctors are still in training at that stage.
Earl Howe
My Lords, the answer to the first question of the noble Baroness, about career breaks and so on, is yes, the regulations allow for that. In answer to her second question, we are not specifying that responsible officers have to be medical directors. As she knows, we are leaving it up to the organisations to decide that. Therefore, she can be reassured on her other questions.
Baroness Thornton
My Lords, I thank all noble Lords for contributing to this debate, particularly the noble Baroness, Lady Finlay, the noble Lord, Lord Colwyn, and my noble friend Lord Rea. I also thank the Minister for his comprehensive answer. Noble Lords will have heard me say from the outset that I did not intend to delay the implementation of the regulations. However, noble Lords should also acknowledge that if we ignored the reservations expressed by the Merits Committee and various medical organisations, and did not to pay heed to what they had to say about this, we would not be carrying out our duty of scrutiny. I thought that the most important thing was to get on record the answers to the very questions that we have raised.
I thank the Minister for his usual comprehensive and competent answer, which helpfully addressed many concerns. The abolition of PCTs and strategic health authorities is on the “wait and see” bit of this agenda. We can take it that the Department of Health has not yet worked out what it is going to do. I take some comfort from the fact that this, like much else, is in the melting pot of what is becoming the NHS at the moment; it is work in progress. With that and with thanks, again, to the Minister, I beg leave to withdraw the amendment to the Motion.
Health: Chronic Obstructive Pulmonary Disease
Earl Howe Excerpts(14 years, 7 months ago)
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Baroness Thornton
To ask Her Majesty’s Government when they will implement the National Clinical Strategy for Chronic Obstructive Pulmonary Disease.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the reforms set out in Equity and excellence: Liberating the NHS will ensure that the NHS focuses on improving outcomes for patients. As a result, we are looking at the role and nature of clinical strategies within the reformed NHS to ensure that they reflect this focus.
Today is World COPD Day. I can assure the House that we are committed to improving outcomes for those who suffer from COPD and from asthma. We will make further announcements shortly.
Baroness Thornton
I join the Minister in welcoming World COPD Day, which draws attention to this incurable, degenerative lung condition. However, I am disappointed that he has not thought fit to use today to adopt the COPD strategy, which was left up and ready, as it were, when the previous Government left office. Apart from anything else, I wonder whether he is aware that the British Lung Foundation’s research shows that up to 80 per cent of GPs cannot tell the difference between asthma and COPD. That is a very serious issue for prescribing. The adoption of the COPD strategy would bring systematic training and awareness-raising of this condition.
Earl Howe
My Lords, as I indicated in my Answer, the reform programme that we have outlined is intended to ensure that all parts of the system work more effectively in improving health outcomes. That has to include COPD. We have to ensure that everything that we do fits into the proposed new architecture of the NHS. In the mean time, we will continue to work with key organisations and with clinical leads for COPD and asthma to make sure that change happens. I know that a great deal of activity is in hand across the NHS to improve outcomes for patients with COPD and asthma as a result of the good work undertaken so far.
Baroness Liddell of Coatdyke
Will the Minister give a pledge on World COPD Day to ensure that the compensation scheme for miners affected by COPD that was begun by the previous Administration will continue?
Baroness Wilkins
My Lords, both my brothers and my father died after years of breathlessness, which is an appalling condition. Can the Minister say why pulmonary rehabilitation courses are being closed around the country, despite being recommended by the NICE guidelines?
Earl Howe
My Lords, I am concerned to hear the noble Baroness’s comments because I know that an enormous amount of good work is going on around the country. There are programmes to encourage clinical leadership, improvement projects designed to integrate services, a commissioning toolkit, benchmarking data on outcomes and tools to aid local campaigns. If the services designed to help COPD patients are being diluted in any way, I should be very concerned about that and interested to hear the details.
The Earl of Listowel
My Lords, does the Minister recall the recent paper from the Royal College of Psychiatrists that highlights that mental disorder is behind a large number of people taking up smoking and drinking? Will he consider whether this is not an argument for further investment in child and adolescent mental health services, so that children and young people suffering from anxiety and depression receive the help that they need at an early stage and do not reach for alcohol, tobacco and other substances that can have these awful outcomes in later life?
Earl Howe
My Lords, I congratulate the noble Earl on linking mental health with COPD in that neat way. He is absolutely right that smoking is an activity that puts one at high risk of COPD and that smoking is closely associated with poor mental health. Fifty per cent of the tobacco smoked in this country is smoked by those with mental health problems. We are determined to continue efforts to discourage smoking in the general population. We are also keen to raise awareness of good lung health generally, which brings us back to the Question on the Order Paper. To a large extent, such efforts will fall to the new public health service in future.
Baroness Barker
Will the Minister say whether the Government have noted the conclusions of the Environmental Audit Committee in the other place, which reported that poor air quality aggravates and is a contributory factor to COPD? Has the Department of Health been in discussion with the Department for Transport about scaling back pollution as part of the forthcoming paper that the noble Lord mentioned?
Earl Howe
My noble friend is right to raise the issue of air quality, which is of concern to my department. She is also right that we are working with colleagues across government to look at air quality—particularly in London but also in other cities—which has such a damaging effect on the health of a number of people.
Lord Boswell of Aynho
My Lords, is not the network of breathe easy clubs, which is widely extended across this country, a very good example of the involvement of the statutory and NHS services with volunteers and patient response? Could not that reasonably be said to be a very good precursor to the big society?
Earl Howe
My Lords, my noble friend is absolutely right. We have been working with the breathe easy groups and the British Lung Foundation to ensure that the good work that they are doing, along with that of the newly appointed strategic health authority respiratory leads, will improve outcomes for those with COPD and asthma. I agree with him fully that this is a very good example of the big society in action.
Baroness Murphy
My Lords, patients with COPD are classically those who do not get access to palliative care services at the end of life. Will the Minister tell us what the Government will do to improve the access to palliative care of patients with COPD and other chronic conditions at the end of life?
Earl Howe
My Lords, the noble Baroness will know that an enormous amount of work is going on with palliative care services, and a great deal of money is being directed towards them. I share her concern that hospices tend to focus above all on patients with cancer, to the detriment of those with other conditions. This is an area that we are looking at very closely.
NHS: Prebiotics
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Baroness Masham of Ilton
To ask Her Majesty’s Government what consideration they will give to using prebiotics to prevent Clostridium difficile in a clinical setting, with a view to improving patient experience and saving NHS resources.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
There is currently insufficient evidence to show that prebiotics offer benefits in a clinical setting to be able to make a general recommendation in relation to prevention of Clostridium difficile infection. Of course, we will keep this issue under review. However, it is important for all patients, including those who have contracted Clostridium difficile infection, to have a well-balanced diet.
Baroness Masham of Ilton
My Lords, I thank the noble Earl for that answer. Is he aware that C. difficile costs the country about £100 million a year and prebiotics are very cheap? Prebiotics are a food supplement that bypasses the stomach and goes into the gut and helps to keep a person fit, so that they may not get C. difficile. Does he agree that anything is worth trying with such a debilitating and dangerous condition?
Earl Howe
The noble Baroness is absolutely right, not for the first time, about the devastating incidence of C. difficile infection. More than 25,000 cases of C. difficile infection are reported annually and there remain significant variations in outcomes among organisations.
In principle, prebiotics should be beneficial, but there is in fact little good evidence to show that they work or that food can provide a prebiotic effect. There is likely to be considerable inter-patient variation in the gut flora response to prebiotics, which could be exacerbated by differences in diet. However, as I have already indicated, we will look closely at the issue.
Lord Alderdice
My Lords, given the difficulties and dangers of Clostridium difficile, can my noble friend reassure me that the Department of Health has noted that the Food and Drug Administration has in recent days approved fast-track designation for a parenteral toxoid vaccine, which thus opens the possibility—I hope—that immunisation will be possible, in particular for elderly, vulnerable people who are in danger of developing Clostridium difficile infection?
Earl Howe
My Lords, I am aware of the interesting development of a vaccine for C. difficile, but I understand that the vaccine is still in clinical trials. As my noble friend indicated, the company may be seeking agreement from the US FDA to fast-track the application when the development programme is complete, as that would give them access to the US market. It is of course for the manufacturer to decide when and if it wishes to seek access to the market in the UK and the wider EU.
Lord Walpole
My Lords, I will try again. Can the Minister tell me whether carbolic—either as a soap or as a cleaner—has any effect on C. difficile, or is C. difficile resistant to carbolic?
Earl Howe
My Lords, my advice is that best practice guidance on the diagnosis and treatment of Clostridium difficile infection is clear and is available. The management of the infection requires the isolation of cases, hand-washing with soap and water and the use of the antibiotics metronidazole or vancomycin.
Baroness Knight of Collingtree
My Lords, the Minister said that there was not enough evidence to be sure that prebiotics are effective. Can he say whether any active efforts will be made to get that evidence, or does he mean that people must wait until a request has been made before such efforts are embarked upon?
Earl Howe
My Lords, we regard the departmental budget as being there to enable those who have good-quality and well-designed research projects to bid for those funds. I will take on board my noble friend’s implicit suggestion that the department should pursue the issue but, in doing so, I bear in mind that these products are commercially produced and that it is really for the manufacturers to come up with robust clinical data.
Baroness Wall of New Barnet
My Lords, is the noble Earl aware that there are more trials on probiotics than on the prebiotics mentioned by the noble Baroness, Lady Masham? Although there are no Department of Health trials that I am aware of, was the Minister suggesting in his earlier response that he is seeking the opportunity for such trials to take place?
Earl Howe
My Lords, I merely meant to indicate that we would welcome good-quality proposals. On probiotics, I understand that one study using live yoghurt showed a patient benefit but my advice is that the study methodology was flawed and its findings were not generalisable. Probiotics are not therefore recommended, as studies have failed to show any convincing evidence that they either treat or prevent C. difficile infection.
Lord Kakkar
My Lords, is the noble Earl concerned about the presence of the potentially more aggressive and resistant forms of C. difficile that have been identified in our hospitals? What action is being taken to ensure that they do not spread more widely?
Earl Howe
My Lords, the noble Lord is absolutely right. It is appropriate for me to emphasise that, as he will well know, inappropriate prescribing of antibiotics is above all what has caused the high levels of infection that we have seen in recent years. The use of broad-spectrum antibiotics predisposes people to C. difficile infection, so it is important that those in the health service understand the cause and effect relationship involved.
It is also worth mentioning that tomorrow is European Antibiotic Awareness Day, so it is appropriate that this Question has been asked today.
Lord Colwyn
My Lords, I know what an antibiotic is, but can the Minister help me with what a prebiotic is and what a probiotic is?
Earl Howe
My noble friend has asked the question, and I hope that he will be pleased with the answer. Prebiotics are non-digestible carbohydrates that act by promoting the growth and/or activity of probiotic bacteria in the gut. The most common prebiotics are fructo-oligosaccharides, inulin and galacto-oligosaccharides. They are found in various vegetables and fruit, such as tomatoes, asparagus and bananas. The best example of a probiotic is yoghurt.
Department of Health: Arm’s-length Bodies
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Lord Knight of Weymouth
To ask Her Majesty’s Government what estimate they have made of the cost of organisational changes required to implement the proposals to reform the Department of Health’s non-departmental public bodies; and whether the cost will be allocated to that department’s budget.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government have announced that administration costs will reduce by a third in real terms across the health sector. This will impact on the Department of Health’s arm’s-length bodies. Currently, we cannot determine the exact costs, as they will be affected by how the reduction is distributed across the health sector and how much is met by levels of natural wastage. The department’s spending review settlement will meet these costs.
Lord Knight of Weymouth
I thank the noble Earl for that reply. He will, I am sure, have listened carefully to the debate last week on the Public Bodies Bill. He will have heard half a dozen of your Lordships raise concerns about two health bodies in particular—the Human Tissue Authority and the Human Fertilisation and Embryology Authority. Both have the schedule of Damocles hanging over them; both need independence and sensitivity; and both cost the public purse very little. Will the noble Earl now follow the precedent set by the noble Baroness, Lady Rawlings, when she announced during Questions last Thursday that Ofcom will not be scrapped and was being pulled from Schedule 7. Will he do the same for the Human Tissue Authority and the Human Fertilisation and Embryology Authority?
Earl Howe
My Lords, we will obviously have an opportunity to debate these matters in Committee on the Public Bodies Bill, but I would just make a couple of general points. There are clear synergies between some of the functions performed by the HFEA, the HTA and the Care Quality Commission—they all license treatment. In addition, there is significant read-across to the potential scope of a new research regulator. All political parties at the election were agreed that we have too many of these bodies—too many quangos—and we have to reduce the cost of administration across government as a whole. We can debate at greater length the merits, and perhaps demerits, of the Government’s proposals. I look forward to that debate.
Baroness Hussein-Ece
My Lords, will my noble friend give an assurance that the necessary functions of these bodies will continue and, importantly, will they be more accountable?
Earl Howe
My Lords, the key point to make about our proposals around the HFEA and the HTA is that we are not proposing to change the functions or alter the provisions of the underlying statutes. All we are doing is proposing to transfer various functions in different directions. As for the independence of the advice, I see no reason at all why the current independence should not be maintained under the new arrangements.
Baroness Deech
My Lords, is the Minister aware that a pre-legislative scrutiny committee gave an opinion two or three years ago that there was not a read-across between the HTA and the HFEA and that they had different skill sets? It accepted evidence that there was no money to be saved and that there would be a considerable loss of experience and probably money in bringing the two together. Does the Minister agree that we cannot keep revisiting this issue, which has been so thoroughly looked at?
Earl Howe
They are different skill sets, but I am not aware that Parliament has visited these issues, let alone revisited them. As I said, we will have the opportunity to do that, but the proposals we have outlined will ensure that the teams that are currently involved in inspection activities will be kept together. I see no reason why they should not be.
Lord Turnberg
My Lords, perhaps I may ask the noble Earl about the Health Protection Agency. What advantages does he expect to come out of moving the HPA into the Department of Health?
Earl Howe
The advantages will come from collocating all aspects of public health in one place, including the Health Protection Agency. I emphasise that there will continue to be independent advice on health protection. We will have a clear line of sight in all public health matters from the Secretary of State right down the chain to local authorities and to public health programmes implemented on the ground. We do not have that at the moment.
Baroness Gardner of Parkes
Is the Minister aware that, in health services in general—and I apply this also to these bodies—there is a tendency that if someone leaves a post, it is kept unfilled? Will the Minister assure us that, instead of allowing that to happen on an unspecified basis, the Government will make sure that if a post is essential it is retained and not left simply because a person has given up their job?
Earl Howe
My Lords, my noble friend makes a good point. We need to distinguish between posts that are administrative in nature, where we will see considerable reductions, as I have mentioned, and posts that relate to clinical activities. There is obviously a clear case for the latter posts to be advertised and filled where necessary.
Baroness Thornton
Will the Minister explain to the House why the Human Tissue Authority and the Human Fertilisation and Embryology Authority have been included in the Public Bodies Bill when some 28 other NDPBs—I apologise to the House for that—were listed on 14 October in the announcement made about quangos? Will the Minister also explain whether an impact assessment has been done on any or all of these bodies, and when we might see the results of that? How many people does he expect will be made redundant, and at what cost?
Earl Howe
My Lords, the impact assessment will be published as soon as we know the size and shape of the costs involved. As I mentioned in my original Answer, we do not know that at the moment because we do not know about natural wastage, the grades of the people who will have to leave, and so on. The main reason why those two bodies have been included in the Bill is that our proposals, when we finalise them, will be very simple. As I have outlined, they will involve reparcelling the current functions of the bodies in different directions. That is not a difficult thing to do: it can be done very easily by secondary legislation.
Healthcare: Costs
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government have guaranteed that health spending will increase in real terms in each year of the Parliament. However, in order to meet rapidly rising demands while improving quality, substantial improvements in economy and efficiency will be required across all areas of health spending. This response is best led by the NHS locally, while the centre will focus on reforming the health service to create a long-term sustainable NHS.
Lord Taylor of Warwick
My Lords, I thank the Minister for his reply. Does he agree with me that putting more funding now into research into terrible conditions such as dementia, in which I include Alzheimer’s disease—for which there is no cure—will ultimately bring down healthcare costs? We must find a cure, and I ask the Minister to commit more research funding to the terrible condition of dementia.
Earl Howe
My Lords, my noble friend is quite right to identify dementia as a particular cost pressure over the next few years. The coalition Government signalled in their programme our intention to prioritise funding for dementia research. The spending review confirmed that and committed to real-terms increases in spending on health research. This investment is indeed essential if we are to increase the quality, productivity and cost-effectiveness of the NHS.
Lord Brooke of Alverthorpe
My Lords, I return to a question which I posed previously to the Minister and which remains unanswered. Does he not agree that if patients in the health service knew what the costs of their treatment, care and drugs were, as they do in the private sector, this would create a downward pressure, which would reduce costs overall?
Earl Howe
My Lords, I know that this is a question to which the noble Lord and other noble Lords regularly return, and it has a superficial attraction. The problem with it, I am advised, is that patients who are informed of the cost of their treatment—some patients, at any rate—take that as a deterrent to accepting the treatment in the first place. That is something we need to avoid. Nevertheless, there is an underlying point here; there is a need to provide better information to patients about their treatment so that they can take ownership of their state of health.
Baroness Finlay of Llandaff
My Lords, what consideration are the Government giving to seven-day working in the NHS, including renegotiating Agenda for Change, to make better use of the NHS’s equipment, promote early diagnosis and decrease morbidity from complications of treatment that is not overseen by senior staff—particularly over weekends and bank holidays?
Earl Howe
My Lords, creating a seven-day service is a particular concern of mine, and the noble Baroness is quite right to raise it, particularly given her long experience in the health service. As for Agenda for Change, any alterations to existing terms and conditions, such as the unsocial hours payment or sick pay, would need to be negotiated in partnership with NHS Employers and trade unions, through the NHS Staff Council.
Lord Alderdice
My Lords, I know it is extremely difficult, but has my noble friend had the opportunity to explore how much of the increase in health service costs in recent years has come about because of the increase in administration and management costs? I refer not simply to the salaries of administrators and managers but to the administration for the administrators, and to the amount of time that clinical and professional staff must spend in servicing the requirements put on them by administrators and management.
Earl Howe
My noble friend is right to pinpoint this area. If my memory serves me correctly, the average annual increase in management and administration costs over the past 10 years has been 6.2 per cent per year, which is by far and away higher than the increase in costs in clinical areas, for example. That is why we are determined to reduce the administrative cost of running the NHS, and we are in the process of planning for exactly that.
Baroness Wall of New Barnet
Does the noble Earl agree that that is an opportunity for us to look at saving costs in the health service by ensuring that we think of methods to persuade people to attend their day clinics? The cost of people not attending—DNA, as it is called in the health service—is huge, particularly in day surgery.
Earl Howe
The noble Baroness is quite right, and I am well aware that she speaks from personal experience. Many hospital trusts, and indeed GPs’ surgeries where applicable, have devised inventive ways of reminding patients of their appointments, either on the day or on the day before, perhaps by text. Good practice in this area is something that we need to focus on.
Lord Kakkar
My Lords, clinical leadership is critical if we are to secure the greatest benefit for patients from NHS spending and the appropriate use of resources. What strategies do Her Majesty's Government have for developing clinical leadership in the NHS? I declare an interest as patron of UCL Partners’ NHS staff college.
Earl Howe
Again, my Lords, the noble Lord is absolutely right to focus on clinical leadership, which will be critical if we are to deliver the improvements in the quality of care that we wish to see, and also to roll out the vision laid out in the Government's White Paper. The department has a number of initiatives under way, as do deaneries in strategic health authority areas around the country, to promote clinical leadership. There are also active programmes in acute trusts. Without good clinical leadership, the programme cannot proceed as we all hope and wish.
Lord Eden of Winton
My Lords, can my noble friend say what proportion of total National Health Service costs is represented by drugs and medicines? Might it not be that if there were tighter control over the dissemination of pills and medicines, particularly in outpatient departments, there could be important savings?
Earl Howe
My Lords, my noble friend is right that drugs and medicines account for a sizeable proportion of the NHS bill. Successive rounds of the pharmaceutical price regulation scheme, combined with what we call the category M scheme for generic drugs, have held down the cost of drugs to the NHS very successfully over the years. However, this is an area to which we are devoting a great deal of attention, not least in our plans for value-based pricing in the longer term.
Mental Health
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Baroness Murphy
To ask Her Majesty’s Government what plans they have to address mental health factors in their public health agenda.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, mental health is recognised as an integral part of public health. The public health White Paper will set out a new approach to public health, giving mental health the same prominence as physical health conditions such as cancer and heart disease. The Government recognise that there is no public health without public mental health.
Baroness Murphy
I thank the Minister for that encouraging reply. Of course, he will recognise that there is a long way to go. Some 50 per cent of all smoking related deaths in this country are attributed to people with mental disorders, and in fact those with mental illnesses account for almost half of all the tobacco consumed. People with schizophrenia and other mental illness have by far the worst outcomes in terms of mortality, losing on average 20 years of their lives. Will there be specific targets in the forthcoming White Paper around the physical health outcomes in terms of mortality and morbidity of those with serious mental disorders?
Earl Howe
My Lords, yes. We know that people with severe mental illness die on average 20 years sooner than others and that the majority of these deaths are smoking related. Improving public health is at the core of the Government’s health policy, as I expect the noble Baroness is aware. We will make clear our priorities in this area when the public health White Paper is published.
Lord Alderdice
My Lords, we know that early years development is absolutely critical to whether adults will be vulnerable to mental illness later. What things do the Government intend to do in terms of early development, not just in health but across departments, to try to ensure less vulnerability not only in young people, although that is important, but also in adults, since these vulnerabilities develop early on?
Earl Howe
My Lords, my noble friend is absolutely right: this is a cross-government effort. It is not simply for the Department of Health to deal with the issue because just about every department has some sort of remit in this area. I would say that, in particular on the attainment of children at school, we will focus very much on children from disadvantaged backgrounds because there is a high correlation between mental ill health and poverty, and mental ill health and deprivation. That will be a major focus.
Lord Turnberg
My Lords, what steps are the Government taking to ensure that GP consortia have access to the expert advice they will need if they are to commission positive mental health messages and the prevention of mental illness?
Earl Howe
My Lords, many GPs understand the issues very well and are keen to get on with the agenda. Our proposed model of GP commissioning means that practices will have flexibility within the new legislative framework to form consortia in ways designed to secure the best healthcare and outcomes for their patients. That will include mental health and could involve, for example, taking commissioning decisions collectively with perhaps a lead consortium for mental health.
Baroness Howarth of Breckland
My Lords, I know that the number of young people being detained in adult mental health hospitals is decreasing steadily, but can the Minister tell us, first, how many remain, and secondly, what policy will be set out in the framework for seriously disturbed young people who will be contained within the community?
Earl Howe
My Lords, the noble Baroness is right to say that there is legislative provision to ensure age-appropriate accommodation for young people in particular suffering from mental health difficulties. A range of products has been produced by the National Mental Health Development Unit to assist hospitals to meet the legal requirement to provide that age-appropriate setting. It does not mean, of course, that no under 18 year-olds may be treated on adult psychiatric wards as there are circumstances where that is appropriate. But my understanding is that this legislation is being observed and is making a difference.
Baroness Corston
My Lords, given that two-thirds of the women in prison have diagnosable mental health disorders and that services are currently commissioned through primary care trusts, how will such services be provided once the trusts are abolished?
Lord Northbourne
My Lords, the noble Earl has already mentioned children with mental health problems. Does he agree that a parent with mental health problems can have a serious and damaging effect on a child’s life chances? Are there any statistics on how many children are today growing up in families with a parent with mental ill health? If not, will the Government consider collecting such statistics in the future?
Earl Howe
My Lords, I do not believe that we collect data on the attainments at school of children with parents who have mental health difficulties. However, we know that severe parental mental health problems are one of a range of risk factors that are statistically associated with poor emotional health. There are some statistics, which I will endeavour to supply to the noble Lord, but my understanding is that long-term outcomes are not particularly clear. Nevertheless, there is evidence that children and young people who are emotionally and mentally healthy and active achieve more and participate more fully with their peers at school.
Lord Patel of Bradford
My Lords, we know that a range of mental health issues disproportionately affect black and minority ethnic communities—for example, the high risk of developing psychosis among the black Caribbean community. What steps are the Government taking to ensure that we have targeted prevention strategies in this area to continue the work of the previous Government?
Earl Howe
My Lords, the previous Government’s Delivering Race Equality in Mental Health Care programme ended in January of this year. That programme was delivered through working in partnership with service users, carers, clinicians and third sector agencies. A tremendous amount of information came out of it and the learning and findings from that programme will inform the work that we are now carrying out on a new mental health strategy, which we plan to publish in a few weeks time.
Lord Wills
My Lords, Professor Marmot’s review of health inequalities found that unemployment has a significant impact on both physical and mental health. In the light of that and indeed of the rest of that excellent report, what are the Government doing to implement its recommendations?
Earl Howe
My Lords, we very much welcome the Marmot review. Fairness and social justice are both key principles of the coalition Government. The Secretary of State for Health has said that he wants to build on the review’s findings and its six main policy objectives, from early years to ill health prevention. The forthcoming public health White Paper will set out our approach to tackling health inequalities and addressing the wider determinants of health.
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Health: Chronic Fatigue Syndrome
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The Countess of Mar
To ask Her Majesty’s Government what event precipitated the Department of Health decision to exclude all people who have or have had myalgic encephalomyelitis/chronic fatigue syndrome from donating blood from 1 November 2010.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this decision by the UK blood services was prompted by a recent independent expert risk assessment of a possible link between a murine retrovirus and CFS/ME. Although the risk assessment found no evidence of a link or of a risk to transfusion recipients, the UK blood services recognised that practice for CFS/ME should be brought in line with other conditions where individuals are permanently excluded from blood donation to protect their own health.
The Countess of Mar
My Lords, I am grateful to the noble Earl for that reply. I offer my congratulations on the precautionary principle being called on in this instance, but ask him why the Department of Health did not say this in its press release. The notice said only that it was for the benefit of patients and no one, but no one, believed it. In the light of the findings on various viruses, not just XMRV, in the blood of patients suffering from ME, what new biological research as opposed to psychological research is being conducted into this terrible illness?
Earl Howe
My Lords, it is important to make clear to the noble Countess that no definite picture has yet emerged from the published literature on whether the virus in question, XMRV, is implicated in CFS/ME. The National Expert Panel on New and Emerging Infections has considered all the available evidence about XMRV and has reported that no public health action is required at this time. The Advisory Committee on the Safety of Blood, Tissues and Organs, on the basis of current evidence,
“does not recommend further measures at present, but wishes to continue to monitor the situation”.
As regards research into CFS/ME, the Medical Research Council is committed to supporting scientific research into all its aspects, including studies into the biological basis of the condition and evaluation of treatments. In 2009-10, the MRC spent £109,000 on research directly related to the condition.
Baroness Gardner of Parkes
My Lords, I am sure that everyone would agree that we would rather be too cautious, but can the Minister explain why anyone over a certain age is automatically excluded from being a blood donor?
Earl Howe
My Lords, this is a pragmatic decision by the advisory committee on donation. In the case of CFS/ME, which we are looking at at the moment, the committee recommended that the donation policy should be brought into line with other relapsing conditions, where the rule is that we do not take blood from people with such conditions.
Lord Alderdice
My Lords, given that there is no medical test that is pathognomonic for this disorder or group of disorders, how do the authorities propose to police its exclusion other than simply by hoping that people will come forward with the information themselves?
Earl Howe
My noble friend is right to say that there is no diagnostic test for CFS/ME other than a process of elimination and watching the symptoms. It is largely on a self-reporting basis that the blood transfusion authorities will be alerted to the condition unless, of course, a patient’s GP is involved and can report his or her opinion.
Baroness Finlay of Llandaff
My Lords, do the Government intend to ask NICE to evaluate pathogen inactivation, which is already used on fresh frozen plasma for children, for blood components as well because of new and emerging infections and the increased risk of infections in donors because of the increase in international travel?
Earl Howe
My Lords, I understand why the noble Baroness asked that question. I believe that platelets cannot be stored in refrigerated conditions and are therefore, in theory, open to more infection. I am advised that SaBTO, the expert committee, looked at this and advised that no action was currently necessary.
Baroness Thornton
My Lords, I took a look at the blood transfusion service’s excellent website over the weekend to see what it had to say about who should and who should not donate blood. Basically, it said that you should be in good health. People with CFS/ME often experience a range of symptoms that could be made worse by donating blood. Notwithstanding the problem of diagnosis and that the precautionary principle is exactly right, surely that is the point. There should be a common-sense approach that people with ME should not give blood because they are not well enough.
Earl Howe
My Lords, the noble Baroness has put her finger on it. On a precautionary basis, even though the risk is considered low to those with CFS/ME when they are without symptoms, it was considered appropriate to exclude them permanently from being blood donors in case it affected their own health.
Lord Skelmersdale
My Lords, my noble friend gave us the figure for total research into CFS/ME. How much was for biological research as opposed to psychiatric research?
Lord Turnberg
My Lords, is it not the case that we have not been able to discover the cause of this very unpleasant disease so far and we have no real effective treatments? While we are waiting for both of those, the best form of management seems to be cognitive behavioural therapy. Does he agree?
Earl Howe
My Lords, cognitive behavioural therapy is indeed part of the NICE recommendations, but only a part in so far as it is appropriate for any chronic condition to have such therapy. I am sure that the noble Lord agrees that the NICE guidance recognised a clinical and physical basis to this condition as well. Therefore, a multifactorial approach is appropriate.
Health: Diabetes
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Harrison, very much indeed for tabling this Question, and indeed other noble Lords for their contributions on such a very important aspect of care for people with diabetes.
As we have heard, the latest figures suggest that 3 million people—about 7 per cent of the adult population—now live with the disease. Many experience severe complications, most notably heart disease, stroke, kidney failure, loss of sight and limb problems. The growing numbers with the disease are a prelude to many more suffering the worst ravages of the condition. Already the human cost is truly awful. The noble Baroness, Lady Young, whom I warmly congratulate on her appointment, gave us the figures on amputations resulting from complications in diabetes, making it the single most common cause of non-traumatic limb amputation. As she reminded us, this will inevitably have a major impact on a patient’s life. They may lose their job, their income and status, have reduced mobility and suffer from depression. However, as the noble Baroness rightly said, with the right care, it is estimated that four out of five amputations could be prevented. Eighty-four per cent of all major amputations in diabetes are preceded by ulceration, with at least 49,000 people developing foot ulcers every year.
Regular foot reviews with advice on prevention and prompt treatment of ulcers are essential. If identified early enough, foot complications can be treated effectively. Therefore, it is vital that every person with diabetes has access to a multidisciplinary specialist diabetes foot team as soon as they need it. The noble Baroness, Lady Thornton, was right in all she said in that connection. Dr Rowan Hillson, National Clinical Director for Diabetes, considers diabetic foot care services and the prevention of amputations as a major priority.
The Department of Health welcomes the publication of Putting Feet First, produced in partnership between our service improvement team, NHS Diabetes, and Diabetes UK. The report highlights the importance of proper management of diabetic foot disease. The evidence shows that the introduction of multidisciplinary specialist diabetes foot teams has led to a significant reduction in the number of amputations.
In addition to the consequences to a patient’s quality of life, there is a significant financial impact on the NHS. This gets to the heart of the question of the noble Baroness, Lady Thornton, about how we can afford this. Diabetic foot care is part of the QIPP long-term conditions programme, which is the department’s programme to improve the quality of NHS care, while making substantial savings which can be ploughed back into the NHS. By reducing unnecessary amputations, money is saved—the noble Lord, Lord Harrison, was absolutely right—not only on the clinical procedure, but on the longer term rehabilitation and social care costs.
Reducing the amputation rate by half would save the NHS more than £10 million a year. The prevention and good management of foot ulcers could save considerably more. NHS Diabetes is working on the economic case for improving foot care services. It is currently facilitating 10 local projects specifically focused on improving foot care services. In addition and in partnership with several other organisations, NHS Diabetes has published a commissioning guide for diabetic foot care services. This responds to the need for nationally recognised minimum skills for the commissioning of diabetes foot care services. This will stand the GPs in good stead when they come to commission services for diabetes.
A number of Peers spoke about prevention. The NHS is starting to focus on preventing foot complications. In some parts of England, the amputation rate has been drastically reduced by establishing integrated multidisciplinary specialist foot care teams. In particular, Ipswich and the Imperial College Healthcare NHS Trust now have amputation rates among the lowest in Europe. However, the noble Baroness, Lady Young, was right to say that the NHS must do more to embed this approach across the country.
The noble Lord, Lord Harrison, asked about NICE. I am pleased to tell him that NICE is finalising guidelines, to be published in March next year, on the in-patient management of people with diabetic foot ulcers and infection. I can reassure the noble Lord on a more general level about diabetic medication. Prior to the introduction of value-based pricing, which is what we wish to move to, we will continue to ensure that the NHS funds drugs that have been positively appraised by NICE. I assure the House that NICE will continue to play an important role in advising on quality standards of treatment in the NHS—including after the introduction of value-based pricing.
Last year, the National Diabetes Inpatient Audit revealed that one-in-30 patients with diabetes in hospital developed a preventable foot ulcer. NHS Diabetes is making vigorous efforts to ensure that every in-patient with diabetes has a foot check and appropriate preventive care. We will repeat this audit of diabetes care in hospitals next week. More than 90 per cent of acute trusts in England will participate. The audit includes questions on foot checks, the management of complications, prescribing and patient experience. The results will help us to identify the places that need to improve and drive forward change in those areas. NICE clinical guidelines recommend annual foot screening for all people with diabetes and the targeting of prevention and treatment to those at high risk. We will continue to work to ensure that these guidelines are reflected by PCTs when they commission diabetes services.
As many noble Lords pointed out, patients have a role to play. They must learn to manage their condition effectively, and there is strong evidence that a healthy lifestyle—maintaining a healthy weight and so on—along with good treatment can prevent disability and reduce mortality. The noble Lord, Lord Harrison, was right again when he said that education is key to empowering patients to be partners in their own care. NICE has highlighted the importance of structured education in supporting people with diabetes to manage their condition. However, education across the country is patchy, so we are working with NHS Diabetes to see how we can spread these education programmes more widely across the NHS.
The noble Lord also mentioned diabetic retinopathy, which is another serious, preventable complication that can cause blindness. Screening is the responsibility of the national screening committee. Ninety-five per cent of people with diabetes were offered screening in the 12 months to June this year. The department is supporting the minority of primary care trusts that have not offered screening to all people with diabetes, to ensure that they do so as quickly as possible.
I could speak for some time about the importance of early diagnosis. The best way to avoid the complications of diabetes is to prevent people from getting it in the first place. We are committed to doing far more to prevent diabetes wherever possible. Here, I refer to type 2 diabetes, which often is related to obesity and lack of exercise. Around 80 per cent of cases could have been prevented if the person had led a healthier life. Much of that has to do with improving the general health of the population and educating people about good and healthy ways of living.
The noble Baroness, Lady Young, spoke about the need to pick up undiagnosed cases of diabetes. She is of course correct. The NHS health check programme will play a significant role in the early detection of diabetes. As noble Lords will know, the health check is a risk assessment and management programme for everyone between the ages of 40 and 74. It will assess an individual's risk of a variety of conditions, including diabetes, and will support them to reduce their risk. This could prevent more than 4,000 people per year from developing diabetes, and detect at least 20,000 cases of diabetes and kidney disease earlier, in order to allow better management of the condition. Most of the care for people with diabetes is delivered in the community and through primary care. The relationship between primary and specialist services is central to the management of complications and the prevention of admission for amputations.
I have a little time to answer questions. The noble Lord, Lord Harrison, asked about the number of specialist diabetes nurses and diabetologists. We do not collect these data, but we know from the 2009 Diabetes UK survey that 1,278 specialist diabetes nurses were working in the UK in 2007. The noble Lord also pointed to a number of international comparisons. It is often difficult to make international comparisons of prevalence because of the way in which data are collected. The Yorkshire and Humber Public Health Observatory published a recent estimate of the prevalence of diabetes in England that suggests that there are 800,000 people with diabetes who do not yet know it.
The noble Lord spoke about sport in schools and about targeting those who are most at risk from diabetes. The noble Baroness, Lady Hussein-Ece, also spoke in this vein. The key here is for Governments to work with local commissioners to promote the benefits of investing in physical activity and to ensure that local investment in that area is based on an assessment of need. We will set out a strong business case for investment in physical activity, which evidence shows is one of the best buys in public health.
I think that generally decisions taken locally are the way forward. In particular, local commissioners are best placed to target groups that are most at risk from inactivity. The Let’s Get Moving model, which implements brief interventions in primary care, is a good example of that approach.
Similar considerations apply when we reflect on the concerns of the noble Lord, Lord Harrison, about the postcode lottery of services. Healthcare organisations, with their knowledge of the healthcare needs of the population around them, are best placed to determine the services required to deliver safe and effective care.
The noble Baroness, Lady Hussein-Ece, as I mentioned, talked about high-risk groups. We are committed to reducing mortality rates from diabetes. Dr Rowan Hillson, the National Clinical Director for Diabetes, chairs the working group, Good Diabetes Care for All, which has brought together leading stakeholders and providers of diabetes services who are concerned with inequalities. I say to the noble Lord, Lord Rennard, that to support NHS organisations to design services that reflect the whole diabetes community, NHS Diabetes has produced a comprehensive diabetes commissioning toolkit to provide advice and support for commissioners.
Time prevents me from answering all the other questions, to my great regret, as I have copious answers in front of me. However, I shall just say that I believe that the principles that we have set out in the White Paper of pushing power downwards, paying for quality and strengthening the voice of the patient will bring fresh impetus to improving outcomes for diabetes. This is not an issue that the NHS can ignore. We need to strengthen both preventive action and treatment for diabetes. By doing that, we can have a huge impact on the quality of people’s lives.
Health: NICE
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Baroness Sherlock
To ask Her Majesty’s Government which groups were consulted prior to the announcement that the National Institute for Health and Clinical Excellence was to lose the power to decide that some drugs may not be supplied by the National Health Service.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is important to make clear that the National Institute for Health and Clinical Excellence does not have any powers to ban the use of drugs in the NHS, so suggestions that this is a role that will be removed from it are based on a misunderstanding of the position. Our NHS White Paper makes it clear that the role of NICE will continue and, indeed, that it will be extended.
Baroness Sherlock
My Lords, I thank the Minister for that Answer. I am a little confused, but perhaps he can help me to understand the change. In the world that he envisages, is it intended that every single GP consortium will take its own decision about which drugs it is willing to fund? If that is the case, will it be about every single individual drug or treatment? And, if that is the case, can the Minister explain how he will protect patients from the uncertainty and confusion that must arise from a return to a postcode lottery of that magnificence?
Earl Howe
My Lords, currently the NHS is faced with the decision of whether to say in effect yes or no to a new drug at the price that is proposed by a pharmaceutical company. We want to change that so that the price of a drug to the NHS is based on an assessment of its value, rather than pharmaceutical companies being free to set whatever price they choose and expecting the NHS to pay. So value-based pricing, which is the term we have used, will ensure that licensed and effective drugs are available to NHS clinicians and patients at a price to the NHS that reflects the value that they bring. That should get rid of the postcode lottery.
Lord Alderdice
My Lords, of course we already have four NHSs in our United Kingdom. What discussions are there among the authorities of the four NHSs when decisions are being taken about medications of this kind?
Lord Turnberg
Does the Minister agree that to devolve responsibility for prescribing expensive drugs to GPs faces them with a very difficult ethical dilemma? Should they prescribe a very expensive drug, costing thousands of pounds, with only marginal benefit for the heart-rending patient with cancer facing them, knowing that to do so may prevent them from funding 20 or 30 patients requiring eye operations or hip replacements or drugs for schizophrenia, or should they refuse that treatment? Have the Government thought through the implications of devolving the cost-benefit analysis that NICE does so well?
Earl Howe
My Lords, I think the noble Lord has perhaps misunderstood the purpose of the plans that we have set out. Prior to the introduction of value-based pricing, we will continue to ensure that the NHS funds drugs that have been positively appraised by NICE. I hope that that reassures him that clinicians are not going to be placed in an awkward position. We will be consulting on our plans for value-based pricing before the end of the year, but I can assure the House that the point of moving to a new pricing system is to increase patient access to new effective drugs. That is what we aim to do.
Baroness Trumpington
My Lords, my noble friend has already spoken about the time it takes to develop a drug—often many years. This costs money and accounts, in some cases, for the high price of the drug.
Earl Howe
My noble friend, with her experience, is of course quite right. I am told that it costs upwards of $1 billion to develop a new molecule and bring it to the market. It is a very expensive process. That is recognised in the freedom of pricing that currently exists for drug companies at launch and in the patents that they are able to enjoy in subsequent years.
Lord Crisp
My Lords, I declare an interest as I was in the Department of Health at the time that NICE was created. If the Minister accepts that the NHS, which spends upwards of £11 billion a year on drugs, is right to have a clinically-led method of assessing whether they work satisfactorily, will he confirm—there seems to be some confusion—that that will not be replaced by some hundreds of separate ways of doing the same thing? Will he also confirm that, whatever new arrangements he has in mind, the Government will speed up the process? There is sometimes that complaint about the NICE process at the moment.
Earl Howe
My Lords, we have been very clear that NICE, which enjoys international pre-eminence in the evaluation of drugs and health technologies, will continue to have an important expert advisory role, including the assessment of clinical benefits for new medicines. The noble Lord will know, I am sure, that in recent years NICE has done a lot to speed up its evaluations of new medicines and has introduced end-of-life flexibilities, for example, which have meant that patients have had increased and improved access to those new medicines.
Healthcare
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been an extremely wide-ranging and well informed debate, and I thank my noble friend Lord Hunt of Wirral for raising these important issues and all noble Lords who have spoken very eloquently. I share the wish that we had more time to debate these matters.
Just three months ago, my right honourable friend the Secretary of State for Health published the White Paper, Equity and Excellence: Liberating the NHS. It is an ambitious plan for reform. It is focused around three key purposes, which are the three themes of today’s debate: first, to put patients first and for patients genuinely to feel that no decision is made about them without them; secondly, to concentrate not on inputs and processes but on outcomes and to build a culture of evidence and evaluation and for innovation and evidence to drive quality care; and thirdly, in aiming to deliver the best care, we must empower the people whose responsibility it is to deliver that care. We will give general practice the power to commission services on behalf of patients, combining clinical decision-making with control of resources.
The Government are determined to improve the quality of the NHS and the outcomes for patients. Our ambition is clear: it is for the health outcomes in this country to be among the best in the world. Today, the NHS has some of the best people and the best facilities in the world, and I do not in the least belittle the improvements made to the NHS by the previous Administration, but the fact of the matter is that when it comes to what is really important—to outcomes—we lag behind. I hope that all noble Lords agree that patients deserve better. The NHS can be better, and with the reforms we have set out in the White Paper, it will be better. I know that there is a wide range of opinion about the White Paper. There always is when you try to do something substantial and challenging, but the Government have been encouraged by the widespread acceptance of the vision that we have set out and the principles of our reforms.
To deliver the best care, we must empower the NHS staff whose responsibility it is to give that care. In essence, GP-led consortia, led by GPs in close partnership with other healthcare professionals, will establish the range of services and contracts needed to give their local population the high-quality services they need and the choices they want.
The success of GP commissioning decisions will be determined by the relationships that they develop with others. Local specialist community nurses will be there to help GPs design the best community services, just as hospital consultants will be essential for designing specialist pathways before, during and after a period in hospital. Local authorities will be crucial for helping to integrate health with other local public services to optimise outcomes.
GP commissioning will not turn GPs into managers but it will enhance their role as leaders. When it comes to day-to-day managerial and administrative tasks, consortia will have a separate budget with which to buy in the support that they need, be that from a local authority, a charity, an NHS provider, an independent contractor or elsewhere. I say to the noble Baroness, Lady Thornton, that, in effect, there are going to be pilots. We plan to roll out pathfinder consortia over the next few months that will indeed pave the way and learn lessons that others can follow. GP commissioning also opens up the potential for working closely with local authorities.
Baroness Thornton
My Lords, the pilots will be running at the same time as the legislation is going through Parliament. I fail to see how that will influence the legislation.
Earl Howe
My Lords, under current powers introduced by the noble Baroness’s own Government, GP commissioning can take place within certain limitations, but it is possible for GPs to engage now in the kind of joint working that we envisage and indeed that her Government put in place. I see no inconsistency there, and I think that that will helpfully inform our debates on the Bill.
GP commissioning, as I said, opens up the potential for working closely with local authorities to jointly commission services, even for the pooling of budgets to tackle local priorities. For example, by working closely with the local authority and social care providers, far more can be done to help older people or those with a disability to live independently, reducing their reliance on the NHS by avoiding things such as hospital admissions.
GPs will lead but they will not be alone. The NHS commissioning board will be there to support and advise GP commissioners and to share and spread their experiences. There will be no need to reinvent the wheel hundreds of times. One thing that the commissioning board will do as little as possible, though, is tell health professionals how to do their job.
We will also give far more power to patients. Research clearly demonstrates that treatment is better and often cheaper when the patient is an active participant in their care, not simply a passive recipient. In the coming years, we will give patients real control over when, where and by whom they are treated. They will be central to all decisions about their aftercare, often—where appropriate—spending their own budget in a way that suits their needs rather than the needs of the system.
Personal choice will not be the only way that people will be able to shape their care; they will also have a say in how local services develop. Strong local democratic accountability will be an essential part of the new system. Patients will have a strong voice in local decision-making through local authorities and HealthWatch, a new patient champion. For the first time, local people will have real powers of scrutiny over local health services.
We are very good at treating ill health in this country but we are less good at preventing it. We have the highest rates of obesity in Europe, rising levels of drug and alcohol use and, despite recent falls, stubbornly high rates of smoking. As a result, nearly one-quarter of all deaths in England stem at least in part from an unhealthy lifestyle. We have to do far more to stop people from needing treatment in the first place—to keep people healthy. We need a new emphasis on public health. Later this year we will publish a second White Paper on public health. Its aim will be to transform our approach to public health, protecting the public from health emergencies such as swine flu and improving the nation’s overall health and well-being.
I turn to some of the questions that have been asked. As I said earlier, the debate has ranged far and wide, and there have been a great many questions. We are short of time and I apologise to those noble Lords to whom I shall have to write, but I shall endeavour to cover as many topics as I can.
The speech of the noble Lord, Lord Winston, was uncharacteristic of him. I am sorry that he does not buy into the vision that we have set out. I am sorry that he does not think that we published the White Paper in good faith. The noble Lord gave the House to believe that the considerable efficiencies which we have signalled to the NHS it needs to achieve over the next four years were initiated by this Government. He will, I am sure, recall that they were in fact instigated by the previous Government. They are necessary and have nothing whatever to do with the Government’s White Paper. We need to treat more patients for approximately the same money without diminishing quality. That is the challenge.
I could hardly believe what the noble Lord said about the research budget. The announcements that we have made about research, arising out of the spending review, have been widely welcomed by the research community. We were clear that we wanted to protect science and we have done so. In the current economic climate, that is exceedingly good news.
The noble Lord, Lord Turnberg, in particular, should be reassured of our commitment to the promotion and conduct of research as a core NHS role. The White Paper makes that commitment clear. It also commits the department to a culture of evaluation. The reasons are straightforward. Research provides the NHS with the new knowledge needed to improve health outcomes. Research enables the department to know whether our policies are effective, cost effective and acceptable. The Government are committed to maintaining a ring-fence on research funding and will cut the bureaucracy involved in medical research. Work is in hand to achieve that.
The noble Lord, Lord Winston, also expressed scepticism about the whole idea of measuring health outcomes. Again, I was astonished that he, of all people, should pour cold water on our wish to do so. Just because it can sometimes be difficult to measure certain outcomes in a meaningful way does not mean that you should just give up. Great care must, of course, be taken when interpreting outcome indicators. You cannot simply make black-and-white judgments. However, if we focus only on processes, we risk creating a whole system of accountability that has lost sight of the overall purpose: improving the health of patients.
The noble Baroness, Lady Wall, asked me to underline the importance of local decision-making in the NHS. I readily do so. Those in a position to know what services are required to meet the needs of their patients are those closest to those patients—not politicians in Whitehall, but local doctors in general practice, local doctors and managers in hospitals and patient groups with local knowledge. All of this is part of our vision, which we intend to give substance. I was grateful to the noble Lord, Lord Mawson, for all that he said on this.
I welcome the remarks of the noble Lord, Lord Beecham, about health and well-being boards. It is not only they that will be scrutinising their own activities. As part of the public health service, health and well-being boards will be subject to quality and outcome standards set by the Secretary of State, and will be supported in their efforts by the public health service centrally.
The noble Baroness, Lady Masham, spoke in her characteristically impassioned way about patient safety. I agree with her that patient safety is absolutely vital. It is a key domain of our proposed outcomes framework; a key part of the quality agenda. My noble friend Lady Knight will, I am sure, agree that the most important thing that we need to do is bring about an open and transparent safety culture within all NHS organisations, a culture that is open about when mistakes are made and in which the number of serious incidents falls. Most importantly, it must be an NHS that learns from its mistakes.
The noble Baroness, Lady Masham, referred to the case of the tetraplegic man in Wiltshire whose life-support machine was cut off. This is a tragic and deeply distressing case, currently being investigated by the Nursing and Midwifery Council. Under the new registration framework, introduced in April 2010 for NHS trusts, all providers of regulated activities must register with the Care Quality Commission and meet a set of 16 requirements of essential safety and quality. These include a requirement to ensure that all staff have the necessary qualifications, skills and experience, which are necessary for the work to be performed. All agency staff must meet the same professional standards as permanent staff, as set out by the independent regulator, the CQC and each local safeguarding board. The Department of Health expects all NHS trusts to ensure that they employ appropriately qualified and supervised locums and agency staff.
My noble friend Lady Miller set out her view on which outcomes patients want. Her remarks were very helpful. I am pleased that there appears to be much commonality between what she set out and what was included in our proposals for the NHS outcomes framework. At the highest level, the outcomes that we felt mattered were preventing people dying prematurely; enhancing the quality of life of patients with long-term conditions; supporting people to recover from acute episodes of ill health and following injury; ensuring people have a positive experience of care; and, finally, treating people in a safe environment and protecting them from avoidable harm. Those domains get very close to what most of us would regard as a synoptic view of what good outcomes mean.
The noble Lord, Lord Turnberg, spoke about the need to achieve integrated care across primary and secondary sectors. I agree with him. The purchaser and provider split that the White Paper refers to must not be seen as a reason or excuse for GP consortia not to seek the advice, support and collaboration of clinical expertise on the provider side to ensure that the best possible services are commissioned for patients.
The noble Lord, Lord Mawson, asked how we can ensure that GPs will work across the community and public sector generally. Health and well-being boards have a critical role to play in co-ordinating a strategic patient-centred approach at a local level. GPs, local community representatives and democratically elected councillors will be tasked with making sure that they act on behalf of their patients and communities to deliver integrated services. A board will have a formal duty to involve and consult local people.
The noble Lord, Lord Beecham, asked in particular how GP consortia will work with local authorities. We have proposed that local government should have an enhanced responsibility for promoting partnership working and integrated delivery of services across the NHS, social care, public health and other services. It will be important for GP consortia to work in partnership with local authorities—for example, contributing to joint assessments of the health and care needs of local people and neighbourhoods, and ensuring that their commissioning plans reflect these needs.
Lord Beecham
What steps will be taken to ensure coterminosity between consortia and the relevant local authorities?
Earl Howe
This is obviously an issue that is in the minds of those of us in the department as well as those in the health service more widely. It is difficult to give the noble Lord a clear answer at this stage. Coterminosity does help; I agree with him. However, it is too early for me to tell him exactly how consortia will be configured. We can return to that issue.
As part of the consultation exercise, we specifically asked GP practices to begin making stronger links with local authorities and to see how they can best work together. We are currently reviewing the responses that we have received on this.
My noble friends Lord Alderdice and Lady Hussein-Ece spoke well about having informed and engaged patients. This goes back to what I was talking about a moment ago—“no decision about me without me”. That principle is a critical plank of our policy. Shared decision-making means patients jointly working with clinicians to ensure better outcomes and higher satisfaction. As my noble friend Lady Fookes said, the idea is to make the NHS genuinely patient-centred.
My noble friend Lady Hussein-Ece made the vital point that our need to focus on outcomes must reach well beyond simply measuring clinical outcomes. We need to measure patient-reported outcomes as well as patient experiences. Our proposed outcomes framework, as I have just outlined, seeks to do this. However, it is not all about measurement. It is critically important that all parts of the system, whether providers or commissioners, listen to and engage with patients, patient groups and the public more widely about their concerns and ambitions. That is exactly why we have set out proposals to strengthen the patient voice in the new system. The design of HealthWatch draws on the best of previous models of patient and public engagement.
With great respect to the noble Lord, Lord Rea, I fundamentally take issue with his point that all the major health think tanks disagree with our reform proposals. Most, if not all, agree with the vision of a health service judged against outcomes with the patient at the centre of commissioning and provision. The questions they have asked—they are natural ones—are mainly around the implementation. We have consulted on the implementation and will publish our response to these consultations. I look forward to debating the details of our proposals with him and the noble Baroness, Lady Armstrong, when the Health Bill reaches the House. I say to the noble Baroness, Lady Thornton, that that is likely to be in the spring of next year, although I hope that she will not hold me to a precise date.
The noble Lord, Lord Rea, asked us to rethink the whole idea of GP commissioning. I say to him that reform is not an option but a necessity if we are to sustain and improve our NHS. The fundamental problem is that PCT commissioning is remote from patients and does not have sufficient involvement of GPs and clinicians, who are those closest to patients and whose referrals and decisions incur the expenditure of the NHS budget. They are the people who can do much to improve the quality of care, but it needs to be clearly understood that our proposed model does not mean that all GPs have to be actively involved in every aspect of commissioning. A smaller group of primary care practitioners is likely to lead consortia.
I could address many other matters and I am sorry that I do not have time to do so. As I say, I will write to noble Lords. I apologise to them in that the clock is against us. I hope that we can come back to these matters. Suffice to say now that we are living in a financially constrained environment. An extra penny spent on new cancer drugs is excellent. We have the luxury of being able to spend those extra pennies within the confines of a protected budget and of being able to plan on the basis of stable finance over the next three years, unlike colleagues in some other departments. We also have the luxury of being able to plan for higher quality, integrated, patient-centred, outcome-focused health services led by clinicians and patients. I look forward to doing that. Leadership is about making hard choices in difficult times. The choice we have made is to put health first, and the way to do that can be put very briefly—we need to trust the NHS.