Health: NICE

Earl Howe Excerpts

Wednesday 14th July 2010 Lords Chamber

[Lord Naseby]

To ask Her Majesty’s Government whether they plan to review the management and procedures of the National Institute for Health and Clinical Excellence to ensure that patients suffering from the most prevalent conditions of cancer and Alzheimer’s disease are properly treated.

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

My Lords, our White Paper, Equity and Excellence: Liberating the NHS, published on 12 July 2010, sets out our commitment to renew the National Institute for Health and Clinical Excellence and, through primary legislation, to re-establish it as an executive non-departmental public body. Legislation on NICE will be included in a health Bill in the autumn.

[Lord Naseby]

The Minister’s Answer is extraordinarily welcome. So far as concerns those suffering from cancer and similar problems, is he aware that according to a report called Exceptional Progress?, published in March this year, fewer than four out of nine of the drugs put forward were refused by NICE, which left 16,000 patients with nowhere to go, whereas if they had been French or German those drugs would have been available? Furthermore, is he aware that there is currently great criticism of the processing, structures and methodology used by NICE and that, against that background, his news that the organisation is to be totally reformed is enormously welcome?

[Earl Howe]

My Lords, I am grateful to my noble friend. It is important for me to state that the Government respect the independent expertise provided by NICE and we think that it should be allowed to continue to issue guidance free from political interference. That is a point of principle. However, we also think that there are failings within the wider system regarding drug pricing and drug access. We are determined to address that but we are clear that NICE plays a vital advisory role.

[Baroness Finlay of Llandaff]

My Lords, how will the Government ensure that the research, which NICE requires to provide the data on which it can make informed decisions, will be supported in the newly reorganised NHS? The NICE document published today, with its review of Alzheimer’s drugs, has as a major recommendation: co-ordination of research to provide good, long-term, end-of-life care studies of the effects of these new drugs in patients.

[Earl Howe]

My Lords, the noble Baroness will have seen in the White Paper the emphasis placed on research. A number of paragraphs in it will be of interest to her, as they emphasise the key role that research and research funding play in the long-term agenda of the NHS and as regards the interests of patients.

[Baroness Howe of Idlicote]

My Lords, does the Minister agree that, if early treatment benefits and enhances the lifestyle of those suffering from dementia, and if the cost of granting such treatment is very low, not only would that enhance the life of the individual, it would give added value to carers, as their caring role and their role in employment and in the exercise of their skills would continue to benefit society and all of us for much longer?

[Earl Howe]

My Lords, the noble Baroness makes a very important point about dementia. She will be aware that when the Alzheimer’s drugs were appraised by NICE some years ago, there was disquiet that the role played by carers had not received adequate attention in the appraisal process. It is an issue of great importance to many people, but it is very complex. Given the finite, overall health budget, if we give greater weight to one factor, such as carers or getting people back to work, we automatically, by default, give less weight to others, such as people at the end of their lives. We need to look at this, but it is complex. We shall not let it go, but I cannot give the noble Baroness a definitive answer today.

[Lord Dubs]

My Lords, I wonder whether the Minister can do better than the Prime Minister did in Prime Minister’s Questions earlier today, when he declined to give a guarantee that the 14-day period, within which cancer patients should receive hospital treatment, would be upheld. Can he confirm that the Government will stick to the 14-day period?

[Earl Howe]

My Lords, that target of a 14-day referral period has a definite clinical underpinning. There are certainly no plans to abolish it.

[Lord Alderdice]

My Lords, the treatment of such disorders—particularly cancer, but it is also true of Alzheimer’s disease—requires not just biological but psychological and social interventions. Although the biological research is often funded by pharmaceutical companies, NICE has great difficulty in finding the funding for research for psychological and social treatments. Can my noble friend indicate whether there is any way in which NICE can be assisted to be more broad-ranging in its understanding of a bio-psychosocial approach to treatment of these disorders by facilitating more funding for research in the psychological and social areas?

[Earl Howe]

My Lords, I am sure that my noble friend will accept, as I hope I made it clear the other day, that the Government are wholly committed to improving the quality of care for people with dementia and their carers. We are standing fully behind the dementia strategy, instituted by the previous Government. That strategy contains a specific objective of improving the quality of dementia care in hospitals. I take on board what my noble friend says about the absence of adequate research in the psychosocial domain. I shall discuss that point with NICE over the next few weeks as I am aware that it is one of its concerns.

[Baroness Thornton]

My Lords, I welcome the statement that the Minister has made about keeping NICE as an independent voice. That is vital. Will the Government still support NICE in its work not just in medical research, but as regards the broader aspects of disease, social conditions, social care and so on, as mentioned by the noble Lord, Lord Alderdice? NICE has broadened its brief and has taken a much more holistic view about the conditions on which it issues guidance. Will the Government still support it in doing that?

[Earl Howe]

My Lords, as the noble Baroness will know, in 2005, the then Government charged NICE with producing public health guidance as part of its work. As we establish a more integrated and effective public health service, we will look actively at how NICE can contribute to that agenda, and, in particular, how it can contribute to integrated care provided by health and social care combined.

Health: Diet

Earl Howe Excerpts

Tuesday 13th July 2010 Lords Chamber

[Lord Krebs]

To ask Her Majesty’s Government what plans they have for improving the dietary health of the population.

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

My Lords, we believe it is for individuals to take responsibility for their health, including healthy eating. The Government can put in place ways to make this easier and support people. We are developing our proposals to achieve this.

[Lord Krebs]

My Lords, I thank the Minister for that reply and declare an interest as a former chairman of the Food Standards Agency. The Minister will be aware that dietary ill health contributes to about 100,000 deaths per year in this country and that during the past 10 years the three major initiatives to improve dietary health have been instigated by the Food Standards Agency: improved labelling, restrictions on the marketing of food to children, and the reformulation of processed food. Why does the Minister think the dietary health of the population will be improved by moving responsibility from the Food Standards Agency to the Department of Health, which has so far shown no interest in this matter? I understand health officials have calculated that it will be more costly to consolidate this responsibility in the Department of Health rather than the Food Standards Agency.

[Earl Howe]

My Lords, first, I pay tribute to the noble Lord’s distinguished chairmanship of the Food Standards Agency. The Government recognise the important role that the agency plays, and a robust regulatory function will continue to be delivered through the FSA. As part of our wider drive to increase the accountability of public bodies, and reduce their number and cost, we are also looking at where some of the functions of the FSA sit best to ensure that they are delivered most efficiently. No decisions have yet been taken, but we are examining the matter carefully.

[Baroness Gardner of Parkes]

My Lords, does the Minister agree that one major problem with diet is far too much liquid in the form of alcohol? Is he aware that in the other place, at afternoon tea between 4 pm and 6 pm, many groups hold an event to which many of us are invited, and frequently we are not even offered the option of tea but encouraged by the catering department to have alcohol at four o'clock in the afternoon? Does he not think that we could do something about that, closer to home?

[Earl Howe]

My Lords, I have no doubt that my noble friend is correct. I am sure that she will wish to place the correct representations in the right ear, and I will assist as best I can.

[Lord Cunningham of Felling]

My Lords, one of the principal reasons for the creation of the Food Standards Agency was to remove such decisions from political and ministerial control. This came about because of the loss of trust of the British people in guidance and statements from Ministers following things such as BSE and other terrible food infections across the country. In the light of that, is not what the Government are now considering a completely retrograde step?

[Earl Howe]

My Lords, as I said in answer to the noble Lord, Lord Krebs, we fully recognise the important role that the FSA plays. I identify myself fully with his remarks about the reasons why the FSA was created. I speak as a former junior Minister in the department that he led in such a distinguished way, and I realise fully the force of what he said.

[Lord Alderdice]

My Lords, given that the Government, directly and indirectly, are one of the largest employers in the country, and therefore the provider, directly or indirectly, of lunch and other meals, is there anything they can do to ensure that the meals provided and the diet available to employees, direct or indirect, of the Government are improved in line with what the noble Lord asked?

[Earl Howe]

My Lords, there is, and I am grateful to my noble friend. He will know that the healthier food mark initiative is one thing that the Government can do to enable the public sector to lead by example, in schools, hospitals and care homes. The healthier food mark has been developed over the past two years as a benchmark to raise the level of nutrition and sustainability of food served in the public sector. It sets clear guidelines on healthier and more sustainable food and recognises achievement, so I hope that it will lead the way.

[Baroness Coussins]

Will the Minister explain why the Government are scrapping the extension of free school meals when there is such a clear link between nutrition and academic performance? Would it not be better and more cost-effective in the long run to make sure that as many children as possible from low-income families get at least one nutritious meal a day?

[Earl Howe]

My Lords, the school fruit and vegetable scheme is continuing. However, future responsibility for running it will no longer lie with central government; it has been devolved to primary care trusts.

[Baroness Thornton]

They are being abolished. I declare an interest as a former unpaid trustee of the Fifteen training restaurants. Does the Minister think that it was wise of the Secretary of State to attack Jamie Oliver's school meals campaign, particularly given that he was incorrect in saying that the take-up of school meals had gone down when it had gone up? Will the Minister join the rest of the country in applauding Jamie Oliver's campaign to improve the quality and nutrition of school meals?

[Earl Howe]

My Lords, I do not know whether the noble Baroness saw my right honourable friend on television recently talking about this issue, but this is a good opportunity for me to put the record straight. He has not criticised Jamie Oliver’s work on school meals: on the contrary, he has applauded Mr Oliver and the many people who have worked very hard to improve the standard of school meals. The point that he made was that a very important initiative started by Jamie Oliver to make people more aware of what healthy eating is all about turned into a kind of prescriptive, top-down management process from Whitehall—and that is counterproductive.

[Lord Rea]

My Lords, how will the Government ensure that the principles of openness, independence and scientific accuracy in their pronouncements and advice, developed by the noble Lord, Lord Krebs, when he was the chair of the FSA, will be continued by whatever successor bodies are appointed to carry on the tasks of the FSA?

[Earl Howe]

My Lords, the noble Lord is assuming that the Food Standards Agency is going to disappear. I have seen those reports but do not recognise the stories at all. As I have told the noble Lord, Lord Krebs, and others, no decisions have been taken about the future of various functions within the Food Standards Agency, but we are clear that there has to be a role for a body setting standards objectively in the way that he has described.

Nanotechnologies and Food: Science and Technology Committee Report

Earl Howe Excerpts

Tuesday 13th July 2010 Lords Chamber

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

My Lords, this has been an extremely useful debate. I congratulate the noble Lord, Lord Krebs, and his fellow committee members on their excellent report.

Nanotechnology is a fascinating new field of science. However, it can also be difficult for the lay person—I include myself in that category—to grasp its implications, given its potentially wide range of applications and the difficulty of visualising what it is and how it works. That makes the committee's achievement all the more impressive. It has sifted through a great deal of written and oral evidence to produce a readable and extremely interesting report—one that, I understand, has already been widely cited as a source of authority.

I followed with great interest all the contributions made during the debate, and I will return to some of the specific points raised in a few moments. Nanotechnologies and nanomaterials are clearly important issues for the Government. As I hope noble Lords will understand, we are still in the process of formulating our detailed policies in this area. As the House may know, the previous Government published a UK nanotechnologies strategy this March. Current Ministers, including me, will carefully consider the degree to which we will continue with that strategy. The report of the Science and Technology Committee makes a number of sound and sensible recommendations. For the reasons that I have just given, it would be premature for me to give a formal response on behalf of the Government on all of them. However, the majority of the recommendations fall within the remit of the Food Standards Agency, whose advice remains unchanged. Indeed, work is already under way within the agency to implement relevant recommendations. I shall say more about that in a moment.

My noble friend Lord Selborne speculated about the glittering prizes that may be attained in the future from this technology. The Government keep an open mind about the likely benefits of the use of nanotechnologies and nanomaterials in food. Proponents, as we have heard, point to a range of potential benefits such as improved packaging, better delivery of vitamins, lower-fat foods that have improved taste and texture, and reductions in food spoilage and food-borne disease. While all this sounds promising, the products themselves are very much at the research and development stage, and it remains to be seen how many will actually bear fruit commercially. However, many noble Lords have pointed out that what is clear, and what history tells us, is that unless consumers have full confidence in the safety of the end products, the benefits from innovation will be lost. This requires a combination of informed consumers and an appropriate, proportionate and fully transparent system of regulation.

The report addresses the need for better communication with the public about nanotechnologies in food. Members of the public rightly expect to have access to accurate and balanced information about issues that affect them and their families. This is particularly the case in relation to food, and the Food Standards Agency will work to ensure that information about nanotechnologies is made available in easily accessible ways.

The committee emphasised the importance of transparency. Of course the Government must play their part, but industry must also be open about the nanotechnology-enabled products that are being developed and used. The noble Lord, Lord Krebs, was absolutely right to point out that we know from previous experience with genetically modified foods that innovation cannot be forced on an unwilling or sceptical public. It is therefore in everyone’s interest to promote consumer confidence. This is particularly the case if, as some claim, nanotechnologies can help to tackle major challenges such as healthy eating and waste reduction.

The noble Lord, Lord Krebs, asked what the Government would do to ensure that the food industry is more transparent about its research on nanotechnologies, a question that was echoed by my noble friend Lord Selborne. The Food Standards Agency will work with industry and other stakeholders to ensure that as much information as possible is shared. That will be done, for example, by setting up a nanofoods stakeholder group and through a public list of products containing nanomaterials. Where I hesitate is over the committee’s recommendation of a mandatory reporting system for food products that are under development. As I have indicated, the Government have not agreed their detailed strategy on nanotechnology in general, or on the fine detail of the committee’s recommendations, but I could not but be struck by the arguments advanced by the Food Standards Agency in the previous Government’s response to the report: namely, that mandatory reporting could be counterproductive as it could well have the effect of driving research out of the UK, making it even more difficult to keep abreast of developments. There could be other and less dirigiste ways of achieving the committee’s aims in this area.

In answer to the direct question posed by the noble Lord, Lord Krebs, the noble Baroness, Lady O’Neill, and my noble friend Lord Methuen, I can only repeat what I said earlier in the day about the Food Standards Agency. A robust regulatory function will continue to be delivered through the agency. The Government fully recognise the important role that the agency plays, but we are examining whether some—I emphasise the word “some”—of the functions of the FSA could more sensibly and cost-effectively sit elsewhere. But again, as I indicated earlier, no decisions about that have been taken.

There is a need to co-ordinate and collect information, and I can tell my noble friend Lord Crickhowell that the Food Standards Agency is in the process of setting up a nanofoods stakeholder group, as recommended by the Select Committee, and will consult this group before establishing a register of foods that are currently being manufactured with the use of nanotechnologies later this year.

My noble friend asked about REACH. As far as I am aware, there is no further news to report. However, I will gladly ensure that he is kept informed of any developments.

Food products in the UK must meet the highest safety standards. As the committee concludes, different nanotechnologies raise different questions and so evaluation needs to be conducted on a case-by-case basis. For example, low fat mayonnaise made with a nanoemulsion of oil and water requires a different approach from insoluble nanoparticles of silver in a food supplement or embedded in food packaging.

The existing regulatory system for food ingredients provides a good level of control over new nanomaterials. The legislation will evolve, as it should, and I can say to the noble Lord, Lord Krebs, that the committee’s recommendations about clarifying the legal position of nanomaterials and drawing up appropriate definitions will be taken forward in the relevant fora in Brussels. The aim must be to provide clarity and safeguards against the introduction of new or altered food ingredients that have not undergone an independent safety assessment. This is important. In fact it has already happened in the area of food additives, and other revisions are under way in novel foods and food contact materials.

The noble Baroness, Lady O’ Neill, urged the Government to ensure that regulation should be based on functionality and not only on size. The point is well made and the Government will take it fully into account in our discussions in Brussels. In fact, recent changes to legislation on food additives are not tied to a particular size threshold but to changes in properties due to any change in particle size.

The committee’s report is one of several that highlight the gaps in our knowledge of nanomaterials. There is clearly a need to fill these gaps in order to assess and manage any potential risks effectively. We need to be able to ask the right questions and to draw the right conclusions from the data. The work that is currently under way, with funding from government departments and the research councils, will help to fill these gaps. In that context it is important to note that the various funding bodies do not operate in isolation but collaborate whenever possible. They also form part of a cross-government nanotechnologies research strategy group. This group has recently updated its list of research priorities, which will help to direct research funds in an effective way.

The noble Lord, Lord Krebs, asked specifically about the committee’s concerns relating to the proposed definition of engineered nanomaterial in the amended novel foods regulation proposal. I have touched on this already but I should add that the proposal for an updated EU regulation on novel foods is still under discussion. If a definition is adopted, then the Food Standards Agency will work with the Commission and other member states in monitoring and updating the definition to take account of technical advances and to reflect any international developments.

On the issue of risk assessment, the European Food Safety Authority is producing a guidance document for risk assessment of nanomaterials which will provide practical recommendations on how to assess applications made by industry for the use of engineered nanomaterials. This would apply to food additives, enzymes, flavourings, food contact materials, novel foods, food supplements, feed additives and pesticides. A first draft is due to be completed by July 2010 and will be subject to public consultation before it is finalised.

The noble Lord, Lord Krebs, mentioned that two products are known to be on the UK market. This was true in 2009 but I understand that one product became outlawed in January this year with changes to the law on food supplements.

My noble friends Lord Crickhowell and Lord Selborne questioned whether the research councils were sufficiently proactive in tackling the knowledge gaps in relation to the safety of nanomaterials. The relevant research councils have all taken measures to stimulate research into the safety of nanomaterials. A number of projects have been funded in recent years and these efforts are being intensified. For example, a programme on environmental exposures and human health has been launched jointly by the MRC and the Natural Environment Research Council working with the Department for Health and Defra. The programme specifically highlights nano-scale materials as an area of interest. It will fund four to six strategic collaborative consortiums to a value of £8 million to £10 million. The research proposals are currently under review and it is anticipated that the grants will be awarded in August 2010.

My noble friend Lord Selborne emphasised the importance of better research co-ordination to address gaps in knowledge and, as I have indicated, the cross-government research group has recently updated its priorities for nanotechnology research. A list of priorities was published after the committee report in March 2010 and provides a new focus for publicly funded research to fill the gaps that we fully acknowledge.

My noble friend Lord Crickhowell asked about progress on international collaboration of research. Government officials continue to work with the OECD programme on the safety of manufactured nanomaterials and I am informed that the underpinning research that has been commissioned with the help of the research councils is progressing well. At EU level the Technology Strategy Board is exploring further interactions with EU counterparts through involvement in a new research network focusing on the safe implementation of innovative nanotechnologies.

We have had a most valuable and constructive debate and I will take away the many points made. In conclusion, I emphasise the Government’s commitment to fostering a responsible attitude towards innovation and in creating the space for new developments, such as nanotechnologies, while ensuring the right level of regulatory oversight. Many have spoken of the importance of transparency. There is much that the Government can do to help the UK to benefit from innovation but none of this will matter if the public are not properly informed or are suspicious of the motives of those who seek to market new and innovative products. That underlines the critical role of transparency if the benefits of nanotechnology are to be realised. The Government, industry and the research community must all play their part.

NHS: White Paper

Earl Howe Excerpts

Monday 12th July 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 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 the future of the National Health Service. The NHS is one of our great institutions and a symbol of our society’s solidarity and compassion. It is admired around the world for the comprehensive care it provides and for the quality, skill and dedication of its staff. I begin today by paying tribute to the staff of the NHS and the commitment they show to patients.

This Government will always adhere to the core principles of the NHS; a comprehensive service for all, free at the point of use, based on need not ability to pay. This principle of equity will be maintained, but we need the NHS also consistently to provide excellent care. The NHS today faces great challenges: it must respond to the demands of an increasing and ageing population, advances in medical technology and rising expectations; it remains stifled by a culture of top-down bureaucracy, which blocks the creativity and innovation of its staff; and it does not deliver outcomes in line with the best health services internationally—many of our survival rates for disease are worse than those of our neighbours. The NHS must be equipped to meet these challenges—we believe it can do much better for patients—so today I am publishing this White Paper, Equity and Excellence: Liberating the NHS, so that we can put patients right at the heart of decisions made about their care; put clinicians in the driving seat on decisions about services; and focus the NHS on delivering health outcomes that are comparable with, or even better than, those of our international neighbours.

For too long, processes have come before outcomes as NHS staff have had to contend with 100 targets and more than 260,000 separate data returns to the department each year. We will remove unjustified targets and the bureaucracy which sustains them. In their place, we will introduce an outcomes framework to set out what the service should achieve, leaving the professionals to develop how. We should have clear ambitions, and our approach to this will be set out shortly in a consultation document. For example, our aims could be: to achieve one and five-year cancer survival rates above the European average; to minimise avoidable hospital-acquired infections; to increase the proportion of stroke victims who are able to go home and live independently—in short, care that is effective, safe and meets patients’ expectations. The outcomes framework will be supported by clinically established quality standards, and the NHS will be geared across the board towards meeting them. We will do this by rewarding commissioners for delivering care in line with quality standards; strengthening the regulatory regime, so that patients can be assured that services are safe; and reforming the payment system in the NHS, so that it is not just a driver for activity, but also for quality, efficiency and integrated care.

Patients will be at the heart of the new NHS. Our guiding principle will be, “no decision about me, without me”. We will bring NHS resources and NHS decision-making as close to the patient as possible. We will extend personal budgets, giving patients with long-term conditions real choices about their care. We will introduce real, local democratic accountability to healthcare for the first time in almost 40 years by giving local authorities the power to agree local strategies to bring the NHS, public health and social care together. Local authorities will also be given control over local health-improvement budgets. This will give an unprecedented opportunity to link health and social care services for patients.

We will give general practices, working together in local consortia, the responsibility for commissioning NHS services, so that they are able to respond to the wishes and needs of their patients. This principle is vital, bringing together the management of care with the management of resources. With commissioning support, GPs collectively will lead a bottom-up design of services.

In addition, we will introduce more say for patients at every stage of their care, extending the right to choose far beyond a choice of hospital. Patients will have choice over treatment options, where clinically appropriate, and the consultant-led team by whom they are treated. They will have the right to choose their GP practice. And they will have much greater access to information, including the power to control their patient record.

We must ensure that patients’ voices are heard, so we will establish HealthWatch nationally and locally, based on local involvement networks, to champion the needs of patients and the public at every level of the system.

To achieve these improvements in outcomes, we need to liberate the NHS from the old command-and-control regime. So all NHS trusts will become foundation trusts—freed from the constraints of top-down control, with power increasingly placed in the hands of their employees; and we will allow any willing provider to deliver services to NHS patients, provided that they deliver the high-quality standards of care we expect from them.

Our aim is to create the largest social enterprise sector in the world. But it is not a free-for-all. Monitor will become a stronger economic regulator to ensure that the services being provided are efficient and effective, and that every area of the country has the NHS services it needs to provide a comprehensive service to all. The Care Quality Commission will safeguard standards of safety and quality.

An independent and accountable NHS commissioning board will be established to drive quality improvements through national guidance and standards to inform GP-led commissioning. The board will allocate resources according to the needs of local areas, and lead specialised commissioning.

In the coming weeks, detailed consultation documents will enable people to comment on the implementation of this strategy, leading to the publication of a Health Bill later this year.

I recognise that the scale of today’s reforms is challenging, but they are designed to build on the best of what the NHS is already doing. Clinicians are already working to facilitate patient choice—giving patients the information they need to make an effective decision. GP consortia are already established in some areas of the country, and ready to go. Local authorities in some areas are already working closely with local clinicians to co-ordinate health and social care, and improve public health. Payment by Results already gives us a starting framework for building a payment system that really drives performance. Foundation trusts are already using the freedoms that they have to innovate.

We will build on this progress, not dismantle it. With this White Paper, we are shifting power decisively towards patients and clinicians. We will seek out and support clinical leadership. That means simplifying the NHS landscape and taking a further, radical look at the whole range of public bodies. We will reduce the Department of Health’s NHS functions, delivering efficiency savings in administration costs. We will rebalance the NHS, reducing management costs by 45 per cent over the next four years, and abolishing quangos that do not need to exist, in particular if they do not meet the Government’s three tests for public bodies—shifting more than £1 billion from the back office to the front line.

Form will follow function. As we empower the front line, so we must disempower the bureaucracy. After a transitional period, we will phase out the top-down management hierarchy, including both strategic health authorities and primary care trusts. Later in the summer, we will be publishing a report setting out how we see the future of NHS-related quangos. I can say now that this will mean a reduction of at least a third in the number of such bodies. This is part of the wider drive, across government, to increase the accountability of public bodies and reduce their number and cost. The dismantling of this bureaucracy will help the NHS realise up to £20 billion of efficiency savings by 2014—all of which will be reinvested in patient care.

Today’s reforms set out a long-term vision for an NHS which is led by patients and professionals, not by politicians. It sets out a vision for an NHS empowered to deliver health outcomes as good as any in the world. I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

My Lords, I am sure that the House will be grateful for the noble Baroness’s questions, although I have to express considerable disappointment that she finds so little to commend in the White Paper, which to me is a very exciting document, and one which builds in many important respects on the structures which her Government put in place. Lest it be thought otherwise, I am the first to knowledge the improvements in the health service which the previous Administration effected. They did so with the benefit of a great deal of extra public funding and no doubt we should be grateful for that. The problem that we perceive is that despite the progress that was undoubtedly made during the 13 years of the Labour Government, one thing did not keep up with funding: the outcomes that we saw emerging from that increased investment. The fact is that we are not matching the performance of our counterparts in Europe in a number of respects: in cancer survival rates and an array of other conditions. That has to change. We have asked ourselves how we can best deliver those outcomes and the quality of care that the noble Lord, Lord Darzi, envisioned in his strategy when he became a Minister. We want to build on the work of the noble Lord, Lord Darzi, and we believe that this programme of action will do that.

Our plans for GP consortia are very much based on practice-based commissioning arrangements and clusters. Our plans for economic regulation build on the work of Monitor. Currently, many of the functions of the NHS commissioning board already exist within the Department of Health. We are carving them out and slimming them down by stripping out avoidable layers of management. We have always been clear that we want to have GP commissioning, and our plans are the logical extension of that.

I must comment on the noble Baroness’s first remarks about the leaks to the press. I very much regret them. We do not know where they came from and are making the kind of investigations that she would expect. Our policy and our aim are always to make announcements of this kind to Parliament in the first instance. I am sorry that that has not happened in some cases. The press coverage has not been accurate in all respects.

I hope that when the noble Baroness digests this White Paper, she will come to view it rather more favourably than she has indicated. She suggested that our proposals are ideologically driven. There are only two pieces of ideology here: the desire to continue the quality agenda that the noble Lord, Lord Darzi, started and a desire to bring health and social care much closer together. The proposals for the role of local authorities will achieve that and, at the same time, they will introduce a greater degree of democratic accountability. Accountability will operate on several levels, and the noble Baroness asked me about it. There will be accountability to Parliament through the Secretary of State via the NHS commissioning board, which will hold GP consortia to account for the money they receive. At a local level, there will be accountability through HealthWatch and local authorities. That dimension of local authorities’ remit to enable them to have a say in the planning and configuration of services at a local level is a very important development because it will enable public health, social care and the NHS to be looked at in the round.

The noble Baroness asked whether we envisage any limit on the use of the private sector by GP consortia. The principle that we will adopt is that GP consortia should take on as much responsibility as they wish. The national commissioning board will support them in developing the necessary expertise but, if they want to, we are proposing that they should be able to seek support from elsewhere, including the private sector, within their budgets. In no sense are we proposing a privatisation of the NHS. In particular, lest anyone should think otherwise, our proposals for foundation trusts do not do this. I refer noble Lords to paragraph 4.21 of the White Paper, which makes this unequivocally clear.

There are certainly risks in managing the transition. Indeed, managing risk is not a new problem in the health service—it has happened since time immemorial—but the NHS chief executive and Ministers are extremely mindful of the need to control and manage risks, particularly during the transition. David Nicholson has set out the framework for implementation, with clear plans to minimise risk such as shadow-running bodies for a period of time.

It will take time for these changes to become fully embedded. That is a good thing. We recognise that not all GPs will be able to go at the pace of the fastest, and those who are not in the vanguard will be supported appropriately, but we are clear that GP commissioning is the way forward. It will align decision-making for clinical care with decision-making for financial flows. These are segregated at the moment. If you bring them together, commissioning is much more likely to be cost-effective and in the better interests of patients. While I recognise that the noble Baroness has anxieties, I hope that my colleagues and I can reassure her over the weeks and months ahead that this is a programme to be excited about, rather than the reverse.

--- Later in debate ---

[Lord Walton of Detchant]

Will the Minister say whether he believes that abolishing all regional planning is absolutely right? I believe that it could be dangerous.

[Earl Howe]

My Lords, I am grateful to the noble Lord for his questions. He will know that our plans do not constitute reorganisation for its own sake. The only purpose of the reorganisations that we are proposing is to embed higher-quality practice and better outcomes for patients, and for no other reason.

The noble Lord asked several questions about GP commissioning. As he will know, the previous Administration introduced practice-based commissioning more than five years ago. Some consortia are doing an excellent job, but many GPs have been frustrated by not having clear responsibility and control. They find very often that PCTs get in their way rather than help them. I think that it will be music to their ears that they will be able to create structures and management systems for themselves that will help them rather than get in their way. We are going to enable them to learn from the past. We are engaged in talks with the profession about how we implement the change, which will, I emphasise, be bottom up.

The noble Lord also referred to GP fund-holding, which as the House will know was a policy introduced by the Conservative Government. There were good points and bad points about fund-holding. The good points were that it empowered GPs and, in many cases, delivered good quality care. But the criticisms revolved around high transaction costs, bureaucracy and, in many ways, inequalities that resulted. We want to avoid those pitfalls. The support that GPs will get will not be prescribed from the centre. A range of support is already available for commissioning, including PCT teams, local authorities and independent commissioning support organisations. There will be no shortage of help out there.

[Baroness Northover]

My Lords, perhaps I may remind the House, as invited, that this is a brief Statement. We have 20 minutes all together and we are already five minutes in. Many people want to intervene on this extremely important Statement, so if people can be brief we will be able to cover as much as possible.

[Baroness Morgan of Drefelin]

My Lords, the Minister talked about an NHS that was stifled by top-down bureaucracy. Given the impressive outcomes that we have seen with improvements in cancer treatment, I do not think that many people would recognise that story. Does the Minister accept that medicine is a fast-changing field where innovation needs to be translated into practice on the front line as quickly as possible? Does he further accept that there needs to be leadership in a complex system like this if patients are to have access to the improvements in innovation and care? How does he see that leadership working?

How will patients be represented throughout the system? For example, how will they be represented at the NHS board? How will GPs ensure that they can access fairly and without bias the views of all their patients, not just those they see regularly? How will GPs translate those patient perspectives into commissioning in line with this new strategy that the local authorities will be responsible for developing? I want to hear the Minister answer that important question in some detail.

[Earl Howe]

My Lords, the noble Baroness makes an important point about innovation. We are clear, as is the White Paper, that driving innovation through the system will remain an extremely important part of what we mean by quality. The QIPP agenda is alive and kicking. For those noble Lords who are not familiar with the acronym, QIPP stands for quality, innovation, productivity and prevention. The innovation part of that will be driven in several ways, not least by the NHS commissioning board, which will have access to sources of advice from NICE, the NHS quality board and many other sources. But we also plan to put in place incentives in the tariff, which will drive innovation and high-quality care. Our proposals for those will be forthcoming.

The noble Baroness asked about patient representation. She was absolutely right about clinical leadership, but she was also correct to say that we need to ensure that the patient’s voice is heard at every level of the health service. At the local authority level, there is no doubt that Health Watch will have a presence as the voice of local patients. We are also creating a national Health Watch, which will act as the national voice for patients, feeding directly into the Care Quality Commission so that assessments of quality can be informed by patient experience on the ground. We are not planning in any way to dilute the duty under Section 242 of the 2006 Act to involve patients in the configuration of services. It is important that local people feel that they have a say in the way that services are developed. Our proposals for this will be laid out in an engagement document that is to be published in a short while.

[Baroness Barker]

My Lords, I welcome the Statement repeated by the noble Earl, and in particular the fact that it builds on many of the best innovations developed by the previous Government such as the commitment by the noble Lord, Lord Darzi, to clinical excellence as the lead factor in the development of services. What I also welcome is that, unlike under the previous Government, the default position is that power will be vested in local communities rather than with the Secretary of State, particularly the commitment to ring-fenced funding for public health and, even more so, having a public health strategy that includes mental health.

I have two questions for the Minister. The first concerns the choice of provider. A large section of the paper emphasises the right of patients to choose a provider. Is it not the case that, in order for there to be a choice of provider, there has to be overcapacity in the system? Can the noble Earl tell us what estimate the department has made of that, given that the White Paper also talks about the challenging financial position in which these plans will go forward? The second question concerns a statement in the papers that the Government intend to create the biggest social enterprise sector, which no doubt will be welcomed by the noble Baroness, Lady Thornton, as doing such a thing was also a policy of her Government. Can the noble Earl explain whether that means that many, if not most, of the existing providers of health services will cease to be providers of those services in the future?

[Earl Howe]

My Lords, I am grateful to the noble Baroness for her positive comments. On public health, she will see in the White Paper that we will be publishing a further White Paper later in the year specifically about public health. Quite deliberately, there is only limited information on that subject in this White Paper. As regards choice of provider, she will see in the White Paper that our policy is clear: it is a policy of “any willing provider”. That means that any provider who is able to provide services to the NHS at the right level of quality and at or below the tariff will be allowed to do so. However, as I said in the Statement, this will not be a free-for-all because providers, if they provide services to the NHS, will be subject to the scrutiny of Monitor, and there will be a joint licensing system between Monitor and the CQC in respect of financial systems and quality, so that those providers who offer their services to the NHS will be regulated on a level playing field. I shall take away the concern she raised at the end of her question, and if I have not covered it adequately in my answer, I will write to her.

[Lord Snape]

Does the Minister accept that this is not a reorganisation of the National Health Service being proposed by the Government, but a balkanisation of that service? Did he not notice the lack of enthusiasm for these proposals of those on the Benches behind him, particularly his junior partners in this alliance? Where is the sense in taking away powers from primary care trusts and strategic health authorities and giving them to individual GPs—ironically, to those in the one group who are not employees of the National Health Service? How will it be possible to continue with a unified National Health Service throughout the United Kingdom if hundreds, if not thousands, of GP practices all promote their own ideas in their own specific areas? These proposals will kill the National Health Service, as the Government well know. Why their allies are supporting them, only they will know.

[Earl Howe]

My Lords, I am not sure what the noble Lord’s question was but I profoundly disagree with his analysis of the proposals before the House. Far from killing off the National Health Service they will give it added life. What is the National Health Service about? It is there to serve patients. If we take as our guiding principle that patients matter more than anyone else—more than the system and more than PCTs—and that we want to take care of patients in the best possible way, we need to enable doctors and patients, working together, to take ownership of the patients’ state of health and to take decisions together. If you arrive at that conclusion, the structures that we are proposing are the logical outcome. The noble Lord’s concerns are for the system, which has often got in the way of patient care. The whole point of these proposals is to remove those obstacles. I hope he will have cause to change his mind as he reads the White Paper.

[Lord Newton of Braintree]

My Lords, I preface my three questions by declaring that I am the chair of an NHS trust. First, does the Minister think there is scope for organisational reconfiguration, to use an awful phrase, to contribute to the achievement of the Government’s objective of higher quality in a cost-effective way? Secondly, if he does, does he think—as I do—that such experience as there is suggests that the road to such reconfiguration is strewn with bureaucratic obstacles, delays and unnecessary costs? Thirdly, if he agrees with that, will he do something about it?

[Earl Howe]

My Lords, I agree with my noble friend. There is no doubt scope for reconfiguration but we are not going to prescribe it from Whitehall. The structures that we propose in the White Paper will facilitate reconfiguration in a much more coherent and structured way on a local level because, with the buy-in of patients, local authorities will have a major say in the way in which services are configured, as will GPs, acting in consortia, jointly. The key issue is whether reconfiguration makes sense from a clinical perspective. Politicians are not in the best position to decide that. Having said that, there will be occasions when people will be unable to agree at a local level and we have plans to cater for that situation: ultimately, the Secretary of State will stand as arbiter in such difficult cases. However, in the majority of cases, we see decisions as properly lying at a local level.

[Baroness Finlay of Llandaff]

I have two brief questions. First, in the Statement the Minister referred to outcomes. Given that secondary care sometimes has patients—sadly too often—referred late because of delayed diagnosis in primary care, how is the clinical care of the general practitioner going to be held to account in this system? My second question relates to the Minister’s mention of “any willing provider”. What security will there be to ensure that a provider cannot introduce a loss-leader service with clearly defined boundaries in order to gain a market share, and to prevent complex and difficult cases not covered by that provider being dumped on the NHS? This has been the experience with some private practices where patients are in private hospitals but, when things become too complicated, they are shipped down the road to the local NHS intensive care unit.

[Earl Howe]

My Lords, the noble Baroness identifies two particularly important issues. How will GPs be held to account for the clinical care that they provide? The data emanating from their performance will be transparent and published. The consortia will monitor the performance of each practice. They will identify outliers, whether good or bad, and act accordingly. We do not have those information systems sufficiently in place—I hope that, over the next 18 months or so, there will be time to develop the systems needed for consortia to do this—but it is vital that GPs are held to account for their performance and they will be incentivised in their remuneration to provide high quality.

The noble Baroness made an important point about loss leaders among providers. The NHS commissioning board will license a provider only if it is satisfied that the quality of care delivered by that body is of an adequate standard. I think that the board will look with great care at the practice of introducing loss-leader services and rule out, if there is any doubt at all, quality being compromised in the process.

[Lord Warner]

My Lords, I warmly welcome some of those ideas in the White Paper that build on the previous Government’s reforms such as choice and competition. However, is the Minister aware—as am I from my own experience as a Minister—that many in the NHS do not wish to be liberated? What will be his approach to those areas where GPs’ consortia do not live up to the standards required of the commissioning board? What will he do to ensure that we do not lose the benefits of regional specialised commissioning, which it has taken many years to bring to the level of quality that exists today?

[Earl Howe]

My Lords, I shall be brief because time is against us. I agree with the noble Lord that we must not lose the gains that we have made in specialised commissioning following the Carter reforms. He will see that the national commissioning board will retain responsibility not only for national specialised commissioning but for regional specialised commissioning. That will safeguard the quality of those services.

The noble Lord referred to GPs who do not wish to commission or who are in some way found wanting in their performance. Our experience to date—a number of consortia have been formed around the country, all of which are working encouragingly well—suggests that those GPs within the consortium who are in the lead and are the most go-ahead are best placed to bring up to standard their colleagues who are perhaps struggling. We have witnessed that in a number of instances. Those GPs who are incapable of being brought up to an adequate standard may be subject to a question over their future. In certain consortia, we have seen GPs retiring from NHS service.

[Baroness Wall of New Barnet]

My Lords—

NHS: Pain Management Services

Earl Howe Excerpts

Wednesday 7th July 2010 Lords Chamber

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

My Lords, this has been an excellent debate. I begin by expressing my gratitude to the noble Lord, Lord Luce, for calling it and congratulating him on the eloquent way in which he has introduced a topic which I know is close to his heart.

Chronic pain can be a devastating condition, as many of your Lordships have testified. It affects a large proportion of the population, especially those of advancing years. The noble Lord has already quoted a number of relevant statistics; let me just add another. Data from the Health Survey for England suggested that more than half of the total impact of disease on quality of life is due to pain.

There are examples of really effective, joined-up, multidisciplinary pain services providing support to patients as and when they need it. As the noble Baroness, Lady Pitkeathley, said, that is how it should be. But, all too often, patients do not get the support and the treatment that they need.

In his 2008 annual report, the then Chief Medical Officer, Sir Liam Donaldson, described how the system was failing to give sufficient priority to chronic pain. A key response from the previous Government was to agree funding for a national pain audit. We are maintaining support for this initiative, which is led by the British Pain Society in collaboration with Dr Foster. More than 200 pain clinics are already signed up to provide data. The work is being piloted and data collection will begin later this year. We are expecting a report in the early part of 2012. The audit will not only assess the organisation of local services—location, staffing and equipment—but also assess the quality of patient care across NHS providers by measuring activities and outcomes.

What can the Government do? Our vision for the NHS is for a transfer of power away from the centre down to the people who really understand what is needed: to patients, GPs and other front-line health professionals. It is only by doing that that we will fashion a health service that is truly patient-centred. This is why we intend to devolve budgets to GP commissioners, working in small local consortia. They are best placed to understand their patients’ needs and to prioritise and commission appropriate services, including multidisciplinary pain management services.

On average, someone with chronic pain will have direct contact with a health professional for only around three hours a year. The rest of the time they care for themselves. Patients therefore need to be informed. By our educating people about their condition and ensuring that they have access to support from others in a similar situation, people’s health can be significantly improved. This also helps to reduce the number of GP visits and prevent unnecessary hospital admissions as well as reducing the length of any hospital stays.

I recognise that some patients cannot take decisions for themselves or express themselves, among whom are children, as my noble friend Lord Alderdice rightly pointed out. The detection of children's pain can, however, be improved by strategies to facilitate their expression of pain in ways that are appropriate to their cognitive development and that can be understood by the adults caring for them. So there is work going on in this area.

Good management of chronic pain takes account of the whole person. People agree goals and actions to be taken in a personalised care plan. This allows people to make choices about the care that they receive. The issue of choice was rightly mentioned by a number of noble Lords. It puts people at the centre of any decisions about their care. As my right honourable friend the Secretary of State put it recently,

“no decision is made about me, without me”.

Information from care plans can also help commissioners consider how to use funds most efficiently to support people to self care and identify services that are successfully meeting patients’ needs and expectations. It also enables them to recognise gaps where there is unmet need. This is an important way for the patient voice to have direct influence over the design and commissioning of services in a particular locality.

Of course, devolving decision-making in this way does not mean that the Government are devoid of responsibility. There are a number of ways in which the Government and other organisations can support patients and front-line staff, ensuring that funding is spent on appropriate and effective services. First, we can ensure that clinicians and commissioners have up-to-date, evidence-based clinical guidance. The National Institute for Health and Clinical Excellence plays a key role here. As the noble Lord, Lord Luce, mentioned, NICE issued a clinical guideline last year on lower back pain and has more recently published a guideline on neuropathic pain. Over time, NICE will create a library of quality standards that support NHS organisations as they look for evidence on how to improve outcomes for patients.

Secondly, we can promote the development and diffusion of ideas on the service models that work best for patients. Patients with long-term conditions want services that are based in the community and which support and affirm their ability to manage their own conditions. They want to be referred to secondary and tertiary care only when really necessary. That requires excellent co-ordination between all levels of the system. One of the workstreams of the quality, innovation, productivity and prevention programme is focused on delivering this approach for people living with long-term conditions such as chronic pain.

Thirdly, we can promote the development of indicators of the quality and outcome of services. Outcome indicators will help patients to exercise choice and hold providers to account. They will help service providers to benchmark their performance against their peers and improve the services that they offer. They will help to ensure that any serious failure in quality is identified quickly and action taken to ensure the safety of patients.

An aim of the national pain audit will be to measure patient outcomes using the brief pain inventory scale—an accepted pain management assessment tool. This, combined with an assessment of patients’ outcomes using other patient-reported outcome measures, will make for a comprehensive review of the quality of care. The audit will help to identify indicators that could be suitable for routine use.

Finally, we can ensure that the right financial incentives are in place. The tariff system already ensures, in broad terms, that money follows the patient and that providers are rewarded for delivering best practice. We will build on that by increasing the proportion of provider income that is responsive to the quality, not just the quantity, of care provided. It is just worth adding that in due course, patients with long-term conditions may be able to influence their choice of treatment and provider even more directly through the use of personal health budgets, which are being piloted at the moment.

My noble friend Lady Morris spoke about acupuncture. Use of acupuncture in the NHS is quite limited. The National Institute for Health and Clinical Excellence provides guidelines to the NHS on the use of treatments and it currently recommends that acupuncture is considered as a treatment option for lower back pain. However, it is often used to treat musculoskeletal conditions and a wide variety of pain conditions. Unfortunately there is an absence of clinical evidence in this area. We simply do not have the evidence base to be sure that it works for many of the conditions for which it is often used. More scientific research is undoubtedly needed to establish whether acupuncture is effective against many conditions.

My noble friend also referred to the problem of gaining access to hospital appointments at weekends. There is an important case for services such as pain control to be provided outside working hours. We would encourage local commissioners to continue to develop services such as this to meet the needs of the working public. The noble Baroness, Lady Greengross, with her wide experience, pointed out that the elderly frequently suffer worse treatment than those in other age groups. Those who commission services locally clearly have a duty to ensure that the needs of the whole community are met, with particular attention given to vulnerable older people. The multidisciplinary nature of teams is pivotal in making pain relief available to all age groups in society.

The noble Lord, Lord Luce, asked whether we would consider a national strategy for chronic pain or indeed a tsar. I am not persuaded at the moment that a tsar or a national strategy for chronic pain over and above our current policies for improving the quality of services is necessary. We need to liberate front-line staff as a first priority to enable them to work with their patients to improve the quality of services that they provide or commission. We need to ensure, too, that they have access to the guidance that is available. As I mentioned, there is a wealth of available guidance, including a commissioning pathway published by the Department of Health, and guidance for secondary care and primary care has been published by the British Pain Society, as he will know.

The noble Lord and the noble Baroness, Lady Emerton, asked whether a pain score should become part of the vital signs that are monitored for patients in hospital. Current guidance from NICE recommends that all patients admitted to hospital should be assessed and a decision made on which clinical indicators should be monitored. A pain score is one of the indicators that should be considered.

The noble Baroness, Lady Emerton, referred to nurse prescribing and how that might be improved in this area. In prescribing medication it is essential that the right person gives the right medication at the right time and that stands to reason. Nurse prescribing is a welcome development that can benefit patients significantly. She would agree that services should continue to look at what professional mix can best deliver safe, timely and effective treatments for patients. She also referred to the need for risk assessment among nurses. I have every sympathy with that point. Back pain among nurses as a result of injury at work is a great concern, both for the nurses and their families. Local employers also have a duty of care to provide safe working environments and prevent unnecessary and avoidable harm.

The noble Lord, Lord Tunnicliffe, asked about investment in services at a local population level. We share a commitment to improve health and healthcare. This is our driving principle and our proposals for reconfiguration of the NHS will drive the improvement for all patients.

I conclude by reassuring noble Lords that I should be happy to meet the noble Lord, Lord Luce, and the Chronic Pain Policy Coalition to discuss these issues further.

Health: Spending Cuts

Earl Howe Excerpts

Wednesday 30th June 2010 Lords Chamber

[Lord Harrison]

To ask Her Majesty’s Government what is their response to the report in the British Medical Journal on the effect of spending cuts on public health.

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

The Government are committed to improving the prevention of ill-health and will publish detailed proposals later this year. The determinants of public health are complex and we welcome this research. The spending review will set budgets for the years ahead and, in making savings, we will ensure that services work collaboratively and that the wider impacts of spending cuts are considered to avoid false economies.

[Lord Harrison]

Does the Minister acknowledge that it is impossible to ring-fence NHS spending from the surrounding cutpurse policies of this increasingly cut-price Government, as illustrated in the recent report? Will he tell his friends in the Treasury that decent jobs, decent housing, proper programmes for family welfare and protection of pensioners are integral to a proper and comprehensive health policy in this country? Will he slam the back door on these insidious back-door cuts?

[Earl Howe]

My Lords, the Government are conscious that the health and well-being of the population are affected by a number of factors outside the strict confines of the healthcare system. At the same time, we should not underplay the role of the NHS in tackling health inequalities, and not least the role of primary care. In that context, my department is privileged in being able to look forward to a budget that is not going to be cut over the course of this Parliament.

[The Earl of Listowel]

My Lords, we know very well the health inequalities among looked-after children in public care. Will the Minister look very carefully at the specialist mental health services provided by local areas to children in public care and ensure that they are sustained as far as possible? He may recall that, in 2004, 68 per cent of children in residential care were found to have a mental disorder. Will he look especially carefully at children’s homes and ensure that, wherever there are partnerships with the mental health services, those partnerships are sustained?

[Earl Howe]

My Lords, I acknowledge the noble Earl’s continuing interest in this area, about which I know he is extremely well informed. The Government are committed to improving the health and well-being of children and young people in whatever setting, especially the most vulnerable and disadvantaged. We are conducting a thorough review of the programmes that my department funds. There is nothing sinister in that; we want to ensure that, as part of the spending review, our programmes and policies have the strongest evidence base and represent the best value for money.

[Baroness Barker]

My Lords, does the Minister agree that the BMJ research makes a compelling case for the integration of local authority work and NHS work on public health? Will the work that his department is doing explicitly include those two groups as well as the voluntary sector, which plays a tremendous part in preventive health measures, which are very effective?

[Earl Howe]

My Lords, as so often, my noble friend is right. Local authorities will have a major role to play in the prevention agenda, as will third sector organisations. I can tell her that we are having extensive discussions at the moment with many such organisations.

[Lord Campbell-Savours]

My Lords—

[Lord Ashley of Stoke]

I wonder if the Minister will also say that I am often right, like the previous speaker. He always says that the Government intend to improve the health service, but he says in the same breath that they intend to go ahead with cuts. How can this illogical stance be repeated time and again?

[Earl Howe]

My Lords, as I have just indicated, the Department of Health is very fortunate to be protected from cuts in its budget during this Parliament, but at the same time we have a duty to spend every pound wisely and to obtain value for money. The spending review is still ahead of us. The only cuts that I can predict are those to bureaucracy and administration, to enable us to direct more money into front-line healthcare.

[Baroness Finlay of Llandaff]

Will the Minister provide an assurance to those highly specialised secondary care services that are fearful that GP commissioning may be at too small a population level to ensure that those with complex conditions, which may need complex early diagnosis and management, will be adequately managed? I declare an interest as a member of the BMA ARM at the moment.

[Earl Howe]

My Lords, the noble Baroness is right to draw attention to this issue, of which I am very conscious. Where we have commissioning, it is important that the population base for a given condition is sufficient for that commissioning organisation to contend with. With regard to specialised conditions, I am working hard to ensure that the model we propose will take them fully into account.

[Baroness Thornton]

My Lords, Hamish Meldrum from the BMA said:

“We urge the government and NHS organisations to focus on those areas where they can truly eliminate waste and achieve genuine efficiency savings rather than adopt a ‘slash-and-burn’ approach to health care with arbitrary cuts and poorly thought-through policies”.

For example, I understand that there is a 50 per cent cut in the communications budget of the Department of Health. Does this include public health information programmes, and are they being dropped? Will they include programmes on smoking cessation, stroke, obesity and various other public health issues? I would have thought that those would have been a priority for this coalition Government.

[Earl Howe]

My Lords, public health is indeed a priority for the coalition Government. However, we are subject to a government-wide constraint on marketing and communications expenditure. That means that every programme of communication or marketing has to be justified by the evidence that it will do some good. That is a good and proper control. It does not mean that we will stop all spending, but we have to justify what we do.

Health: Stroke Treatment

Earl Howe Excerpts

Wednesday 30th June 2010 Lords Chamber

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

My Lords, I being by congratulating my noble friend Lord Rodgers on securing this debate and giving us the opportunity to discuss the important issue of treatment and care for people who have had a stroke. I found much to agree with in all that he said. Stroke is a devastating condition that has an enormous human cost. It is our third biggest killer. Every year some 110,000 people in England have a stroke. A million people have had a stroke and a third of them have moderate to severe disabilities as a consequence. It is the largest single cause of adult disability and often has shattering consequences for families and carers. There is also a major economic dimension to stroke since the cost to the economy runs into billions of pounds every year. Indeed, the National Audit Office, whose recent report we are considering, estimates that in 2008-09, stroke had direct care costs of £3 billion within a wider economic cost of about £8 billion.

The Government welcome the National Audit Office report of 2010 which identifies significant and positive changes in the provision of stroke treatment and care since its report in 2005. As my noble friend said, it shows that acute care is improving with specialist stroke clinicians now available in all hospitals, and concludes that action taken since 2005 has improved value for money. That is very welcome news. However, as has been pointed out by a number of noble Lords, the NAO also identifies areas for further improvement—for example, in post-hospital care to match the progress made in acute care. It is clear that there is still more to be done. My noble friend Lady Neuberger drew our attention to several key items on the agenda. Before coming to future work, I pay tribute to the multidisciplinary teams in the NHS and social care whose energy and commitment are making the stroke strategy a reality. Charities, too, such as the Stroke Association, Connect, Different Strokes and Speakability have contributed a great deal to the significant improvements that have been made.

What are we doing? We are working with NHS Improvement to develop the accelerating stroke improvement programme to achieve in this current year further, faster improvement across the whole care pathway. This will help address issues that the NAO highlights and will support the NHS and its partners to make the necessary improvements. Five strategic health authorities have held events to start implementing this programme and arrangements are in hand for the remaining five to do so.

One of the key components of stroke treatment is for all patients who require it to have timely brain imaging. The stroke best-practice tariff encourages this, and direct admission to a stroke unit also improves outcomes. A stroke-skilled workforce is vital. The department has supported development of the stroke-specific education framework which, through the UK Forum for Stroke Training, will contribute to assuring the quality of stroke training. More stroke-specialised physicians have been trained and we are planning more training places in the coming year. We continue to work with the Care Quality Commission, Skills for Care, NHS Improvement, the ambulance service and local government to develop systematic ways of enabling all staff who look after people who have had a stoke to be stroke skilled.

Working with the CQC, we will support action to improve training opportunities for those caring for stroke survivors in residential and nursing homes. Many more stroke survivors could benefit from high-quality early supported discharge, which can improve outcomes. Stroke care networks and local authorities need to work together with commissioners and provider trusts to ensure that this part of the pathway continues to develop. The accelerating stroke improvement programme will be supporting this.

Stroke is a vascular disease and, as well as smoking and high blood pressure, its risk factors include an irregular heart rhythm called atrial fibrillation, or AF, which can be detected from the pulse. Some 12,500 strokes a year are thought to be attributable to AF. Improved diagnosis and treatment would prevent around 4,500 of those strokes annually and work is in hand to raise awareness of AF in both primary and secondary care, and to explore opportunities to improve this situation.

Quality, as ever, is key, and the House may wish to know that the National Institute for Health and Clinical Excellence has today published a quality standard on stroke as advice for the Secretary of State to consider. NICE quality standards provide a description of high-quality care across a care pathway, and I very much welcome NICE’s work in this area.

My noble friend paid tribute to the Stroke Association, as do I, and asked whether Ministers will meet it. I understand that my honourable friend the Minister responsible for stroke, Mr Burns, is planning to meet the Stroke Association in the reasonably near future.

The noble Baroness, Lady Thornton, spoke very powerfully about the Act FAST campaign. It has been evaluated in some detail and has proved to be very effective in raising awareness of the signs of a possible stroke and the need to treat it as a medical emergency. In addition, analysis of calls to 999 found that in the first four months of the campaign there was a 55 per cent increase in stroke-related calls. Qualitative research among healthcare and social care workers found that the public campaign has done a very good job of educating them about the signs of stroke and the need for urgency. The noble Baroness raised concerns about the funding allocation for the Act FAST campaign. She knows that as part of the efficiency measures announced by the Government all communications activity has been frozen, but we will make the case for exemptions where we believe that we have robust evidence, can generate a strong return on investment—if I may put it that way—and achieve measurable benefits to the nation’s health. I am absolutely sure that my honourable friend Mr Burns will have this issue fairly near the top of his list for the reasons that she stated.

The noble Baroness and my noble friend Lord Rodgers expressed concern about reconfiguration. The Government are clear that they do not expect reconfiguration to stop, but wish to ensure that plans are locally owned by residents, patients and particularly clinicians. Some areas have chosen to implement the national stroke strategy through proposals for significant reconfiguration of stroke services. NHS London has developed detailed plans in this regard. Those proposals are due to be discussed at forthcoming meetings to ensure that all stakeholders agree with the approach. I also have a note here about Greater Manchester. If the noble Baroness would like the details, I will gladly write to her.

My noble friend Lord Rodgers and the noble Baronesses, Lady Pitkeathley and Lady Thornton, expressed worries about the premature ending of ring-fencing for the stroke grant and about the message that this sends. It is important to note that the funding itself has not been cut. For 2010-11 it has been protected, unlike that in many other areas of local and central government as we tackle the deficit. The decision to remove the ring-fencing is consistent with the approach of the Department for Communities and Local Government, of the Treasury and of local government itself. The decision to remove ring-fencing was not taken lightly. The Government's view is that in this very challenging period for public finances it is important to give local government flexibility in local decision-making and in the delivery of front-line services, including social care. The local authority circular that accompanies the grant describes clearly the kind of services that local authorities might want to commission and provide using this funding. Local authorities are required to make a return to the department confirming that expenditure of the money has been incurred under the terms and conditions set out in the local authority circular.

As I expected, the noble Baroness, Lady Pitkeathley, spoke powerfully about the role of carers. The Government recognise that being given breaks from caring is one of the top priorities of carers when it comes to the support that they want. We are committed to using direct payments to carers and better community-based provision to improve access to respite care in particular. The noble Baroness is absolutely right that experience has shown that involving stroke survivors and their carers from the outset in the development of services is essential if those services are to match individuals’ needs and expectations. The grants have provided local authorities with an opportunity to focus attention on a group of people in the community who have very specific needs. Enhancing the quality of life and degree of independence of stroke survivors indirectly supports their carers and families as well.

It has always been clear that the grant money was for a three-year period, during which local authorities would have the opportunity to put in place service provision for stroke survivors and their carers. We anticipate that local authorities will endeavour to incorporate approaches that are proven to offer value for money into their longer-term plans.

Time is against me and I will probably have to write to noble Lords whose questions I have not answered. I say to my noble friend Lady Neuberger, in response to the key point that she raised, that age discrimination, as with other forms of unfair treatment, has no place in the health and social care system. The National Service Framework for Older People published in 2001, explicitly rejected age discrimination in health and social care, and Equality Act will give legal force to this.

The noble Baroness, Lady Thornton, asked when we would respond to the PAC report. We will do so on 8 July.

Finally, I thank the Comptroller and Auditor General and his staff for producing their stroke care report. As it says, there are clear patient and economic benefits from having a fast emergency response and early access to stroke units. We intend to ensure that the improvements that the report acknowledges continue, and we will support further progress so that our stroke services become among the best in the world.

House adjourned at 6.59 pm.

Health: Primary and Community Care

Earl Howe Excerpts

Thursday 24th June 2010 Lords Chamber

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

My Lords, I begin by expressing my gratitude to the noble Lord, Lord Mawson, for the opportunity to reflect on the changes to primary care over the past decade. Perhaps I should start by confirming the basic principle that the Government will uphold the guiding values of the NHS; that it should be available to all, free at the point of need and based on need and not ability to pay.

For more than 60 years, our system of primary care—the local family doctor—has been the bedrock of the health service. When we are ill, our GP is our first and often only port of call. They are the prescriber, the referrer and the gatekeeper to the vast and often complex labyrinth that is the NHS. Few things are as local as your GP practice. By definition, GPs are of the community and perfectly placed to reflect and respond to the needs of the community. The problem that they face now is that they serve two masters; the patients whom they see every day and the targets imposed from above. However, we believe that, freed from central control, incredible things are possible, as we can see from the rise of the social entrepreneur.

Earlier this month, my right honourable friend the Secretary of State visited the extraordinary Bromley by Bow Centre, of which the noble Lord is the founder and president. Based in one of the most deprived parts of the country, it demonstrates what can be achieved with vision, determination and commitment. It helps people to overcome poor health and unhealthy lifestyles, to learn new skills, to find work and to create an enterprising community. It has been an inspiration to many in Bow and it is an inspiration to this Government.

The noble Lord, Lord Mawson, is right. By responding to local people and by being led by them, the Bromley by Bow Centre and other social enterprises are transforming communities in a way that the state cannot. This is the big society in action. Far from supporting them, however, the state has too often acted as a barrier to social entrepreneurs, limiting what is possible. This needs to change.

A damaging recent development has been the introduction of “preferred provider”; in effect, preferring adequate care delivered directly by NHS organisations over excellent care provided by others. We will encourage “any willing provider” to compete to provide the best outcomes for patients. We will give public-sector workers the right to form employee-owned co-operatives so that they can then bid for and deliver services themselves. We will support the creation and expansion of mutual organisations, co-operatives, charities and social enterprises. These will have a place, above all, in the provision of community services, with the quality of those services driven by innovative approaches to delivery.

Rather than preventing social renewal, government should be a catalyst to encourage and galvanise it; “putting the wind in people’s sails”, as the noble Lord, Lord Mawson, put it. As he said, there are some excellent examples of where the state already does this without working in silence. In Southend-on-Sea, the St Luke’s Healthy Living Centre, in partnership with a local primary school, local residents and a wide range of grassroots representatives, provides counselling services, an allotment and food co-operative, advice services and a business support unit. Another social enterprise is Open Door in Grimsby. Open Door works in partnership with local public services, voluntary organisations and Santander bank. Most of all, however, it works with those it supports—the homeless, drug users, refugees—to give them the help they want rather than the help that others assume they need. Both have enjoyed the support of the Department of Health’s £100 million Social Enterprise Investment Fund, one practical example of where the state can help. The noble Lord, Lord Crisp, mentioned the work being done by some PCTs under the triple aim barrier. Like him, I commend those initiatives.

The crucial thing is what is delivered—the clinical outcomes and the benefits to patients and residents—not who delivers it. As the noble Lord, Lord Mawson, said, it is about doing, not just talking. This is all part of a massive redistribution of power and control away from the centre to individuals and local communities.

While at the Bromley by Bow Centre, the Secretary of State described our approach to healthcare. These principles are not plucked from thin air but, rather, are garnered from the experience of those parts of the NHS that already deliver truly excellent care. First and foremost, because decisions that include the patient lead to better clinical outcomes, we will place the patient at the heart of everything the NHS does. As the Secretary of State put it, there will be,

“no decision about me, without me”.

Secondly, because what matters most to people is that they receive the very best quality of care, not that their hospital can jump through bureaucratic hoops, the NHS will focus on constantly improving clinical outcomes. We will hold the NHS to account for what it achieves, not how it achieves it.

Thirdly, because there is a limit to the improvements that can be driven from the top down, and we have long ago reached that limit, we will empower professionals. Over the past decade, the NHS has been showered with money, which is marvellous. However, it has also been drowned in red tape and bureaucracy. The Government intend to set the NHS free, not shackle it with centrally imposed process-based targets.

Fourthly, preventing disease will be as important as curing it. What has really improved the nation’s health? Is it the National Health Service? Of course it is. Mass immunisation programmes and more recent things, such as the smoking ban, have also saved lives and helped well-being. Beyond a narrow focus on health, improvements in housing and sanitation have been just as important. Health cannot be placed in a silo. That is why public health will play a significantly greater role.

Fifthly, people do not differentiate between healthcare and social care—they just want help. Better social care can often prevent the need for expensive healthcare. For example, fitting a hand rail costing £70 can prevent a fall that would require a hip operation costing £7,000. Therefore, we must properly integrate health and social care, especially if we are to deal with the effects of an ageing population. These are the principles that will underpin our approach to healthcare, but to improve health outcomes we must bring these principles to life.

The Quality and Outcomes Framework initially helped to raise standards, especially in more deprived areas. However, it did so at significant cost and the improvements have now stalled. I was in considerable sympathy with much of what the noble Lord, Lord Rea, said about this. We will reform the QOF to reward GPs for improving health outcomes. We will also discuss with the profession how patients can help to shape the care they receive. We will also look again at the GP contract. Taxpayers must get value for money in return for the massive investment that they have made in primary care, and the contract must properly reflect and reward what we are asking GPs to do.

Whoever provides health services, high quality commissioning is essential and should be done as closely to the patient as possible. GPs and their primary care colleagues are in the best position to know what services their patients need and will have the power to commission them. In this way, they will also take ownership of the financial implications of their decisions, leading to better value for money. That is not something that they can do in the fullest sense at the moment. This requires leadership. As commissioners, GPs and their colleagues will become the leaders of a more autonomous NHS, supported nationally by a new NHS commissioning board.

Twenty-four-hour urgent care is currently unco-ordinated and of variable quality. We plan to overhaul that system. Nor should we overlook the role of the pharmacists. Every day millions of people visit their local pharmacy. With the right incentives and support, pharmacies can deliver both clinical and public health services. We will also build on the progress that has already been made in recent years.

The noble Lord, Lord Rea, in his excellent speech, pointed to the differential funding of primary care trusts and urged the Government to take account of differing health needs and deprivation. The noble Lord raises an important point. We are committed to ensuring a fair allocation of resources to the new GP commissioning consortium when it is formed. We also want allocations to be made based on the health needs of the registered population for these groups, so that those with the greatest need have their fair share of resources.

The noble Lord referred to the document produced by the Royal College of General Practitioners, which proposes GPs’ practices working together in a federation to support each other in the provision of care to serve the local population. These are sensible proposals and we want to build on them, for GPs not only to provide a wider range of care and services to their patients, but to commission wider health and care services for the population. It is right that GPs’ practices themselves decide on these federations. We are not prescribing those nationally from the centre.

This very much brings us to the concerns voiced by the noble Lord, Lord Crisp, and the noble Baroness, Lady Finlay, relating to the varying capabilities of GPs and how those who feel less confident and keen about commissioning can be supported. It is very much about GP collaboration. Everything that the noble Baroness said about this was absolutely right. The new GP commissioning system that we are proposing will be led by groups of doctors at a local level and overseen nationally by an independent NHS commissioning board. This is not about trying to turn GPs into managers; it is about placing the financial power to change health services in the hands of those NHS professionals whom the public most trust. Giving more responsibility and control over commissioning budgets should help GPs consider the financial consequences of their clinical decisions. This will lead to reducing waste and bureaucracy. Much will depend on the size of GP consortia, but I am confident that the necessary leadership will emerge from those consortia to facilitate the spread of best practice.

The noble Lord, Lord Crisp, sought clarification on the arrangements and the roles of GPs in commissioning services from primary care. We will be bringing forward proposals for change to the roles and responsibilities of GPs before the summer through a White Paper. Shortly after that we intend to publish a consultation document on GP commissioning arrangements. That consultation document will set out in a lot more detail the roles and responsibilities that we are proposing for organisations. We will welcome views and comments from all interested parties.

The noble Baroness, Lady Finlay, referred to the unintended consequences of change, the challenges posed by patients with complex conditions and the requirement to treat those patients in the right settings and along the right care pathway. She is spot on in all that she said. She referred specifically to payment by results acting as a barrier to integrated care. The work that we are doing to underpin our drive to an outcomes-based model of commissioning includes work to refine the tariff to embrace long-term conditions, co-morbidities and complex cases. This is a major undertaking but it is essential that we get there.

My noble friend Lord Alderdice remarked that there is a limit to managerialism. I am right with him on that. The Government are committed to a patient-led NHS, strengthening patient choice and patients’ management of their own care. That will involve pro-active, preventive and personalised care planning with a focus on shared decision-making. That will apply especially to the care of people with long-term conditions, a theme pursued very powerfully by the noble Lord, Lord Crisp, and one which brings us back to the wise advice of the noble Baroness, Lady Finlay, on the management of change. We are developing a national support programme aimed at accelerating improved long-term care management. The aim is to realise the benefits of improved quality and productivity more rapidly through a large-scale change management programme that will disseminate good practice.

Front-line staff are, of course, crucial to the delivery of personalised care planning. More needs to be done to support the wider culture change that empowers people with long-term conditions to take more control so we plan to support the workforce with guidance and training resources. There is a clear message here: personalised care planning underpins good management of long-term conditions. The care planning process is about involving people with long-term conditions in discussions about their own goals and outcomes for the way they want to live their lives and then agreeing a plan with them on how their care will be managed. It is about addressing their full range of needs: personal, social, economic, educational, mental health and others. That is the way that we will empower people and get them to understand what choice really means.

The noble Baroness, Lady Emerton, in a speech to which I cannot possibly do sufficient justice in the time available, referred to the essential role of community nurses. We are determined to address health inequalities and improve public health. Nurses are key to this, as are health visitors working with families, communities and Sure Start and school nurses working with school populations. They will make skilled and significant contributions to this. We are committed to increasing the number of health visitors in the workforce to provide the best health, well-being and support services for all children and families and to improve services for those who need additional support. The noble Baroness was right in all that she said about the skill set of nurses. Health visitors in particular combine a nursing or midwifery and public health education which gives them the ability to put together a medical and psychosocial knowledge with an understanding of the health system. That is a unique strength.

The noble Baroness, Lady Emerton, referred to the challenges to the nursing workforce and its role in providing community services. She will know that four years ago the Modernising Nursing Careers initiative was launched jointly by the four UK chief nursing officers, with clear priorities. Those priorities were developed to ensure that nursing careers supported health reforms. The programme developed national tools and levers to enable local transformation of the nursing workforce. We will follow that theme.

The noble Baroness, Lady Finlay, referred to a 24/7 service. We are committed to providing universal access to high-quality urgent care, whereby people can have the care that they need whenever they need it. I anticipate that we will shortly make further announcements on that theme.

The noble Baroness, Lady Thornton, asked about the LIFT initiative. I agree with her that much good has emanated from it, and it has the potential to continue delivering. There are a possible 144 new schemes in the pipeline, worth £1.2 billion in total. There are also two new express LIFT companies in procurement that are due to become operational in this financial year. She also asked about social enterprise. I hope that I have said enough to convince her that we are serious about this. A number of initiatives, including using funds from dormant bank accounts to establish a big society bank, will be helpful. This is also about training. We need a new generation of community organisers to support the creation of neighbourhood groups across the UK, especially in the most deprived areas.

My noble friend Lord Colwyn moved us to the subject of dentistry and specifically the regulation of the dental profession. Dental practices will be required to register with the CQC from April next year—the date set by the Health and Social Care Act regulations. I recognise the fear of overregulation that dentists may have and I am well aware of the importance of good morale. My clear understanding from the CQC is that it will look at evidence that outcomes are being met, rather than adopting a tick-box approach to compliance. Where possible, the CQC will use existing information held, for example, by the Dental Reference Service, to minimise the demands on dentists. The CQC is agreeing a memorandum of understanding with the General Dental Council. Perhaps I should point out that plans to include in the registration system primary care providers such as dentists were consulted upon in spring 2008, and the majority of respondents supported the decision—including the British Dental Association.

In view of the shortage of time, I will write to my noble friend about the HTM 01-05 guidance, because there is rather a lot to say about that. I have convinced myself in the past fortnight that we are on the right path. I know that there is a lot of concern among dentists about cost, but I believe and have been persuaded that the guidance is the correct way to go.

Primary care is the bedrock of the NHS. It provides some excellent services but is capable of so much more. The balance of power within the NHS will undergo a fundamental shift—away from central control and away from restricted provision. The noble Lord, Lord Mawson, asked: who will lead? It is probably obvious from what I have said that, above all, we want clinicians and professionals rather than the politicians to lead. My noble friend Lord Alderdice spoke powerfully about that. We will give the NHS the freedom to innovate and a mandate to achieve excellence. We need a new can-do and should-do attitude. We need a dramatic improvement in productivity and efficiency. Most important of all, we need to see a significant improvement in the health and well-being of patients.

NHS: Budget

Earl Howe Excerpts

Wednesday 23rd June 2010 Lords Chamber

[Lord Campbell-Savours]

To ask Her Majesty’s Government what assessment they have made of economies available within the National Health Service’s budget.

[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, it is clear that funding growth will be constrained and, in order to meet rapidly rising demands and to realise our ambitions for improved health outcomes, substantial improvements in economy and efficiency will be required across all areas of health spending. Full plans for delivering these improvements will be developed during the spending review.

[Lord Campbell-Savours]

My Lords, recognising the relationship between transparency and the economic use of resources, will the Government consider amending the National Health Service pharmaceutical regulations to require manufacturers of prescribed products and appliances to indicate on the label of the packaging the tariff price of a generic product or the manufacturer’s list price of a branded product? Can he refer this whole matter to the transparency unit that his Government have set up?

--- Later in debate ---

[Earl Howe]

My Lords, on an instinctive level, I completely understand the noble Lord’s concerns and I can tell him that the department has looked very carefully at this whole issue. The worry, based on research, is that labelling medicines with prices has a much more complex impact on patients’ attitudes towards their medicines than one might expect. A high or a low price on a medicine could lead to a patient doing the opposite of what one wants in terms of taking medication appropriately. Therefore, I am afraid that we have reached the conclusion that this is not something that should be pursued at the moment.

[Lord Walton of Detchant]

Does the Minister accept that for some years the National Health Service has been beset by the activities of an intolerable quangocracy? In fact, no fewer than 50 organisations have the right to inspect and assess the performance of health service bodies. In their proposed bonfire of the quangos, will the Government look first at whether it is necessary to continue with the mechanism of looking over the activities of the individual regulatory authorities? Is it necessary to continue with that supervisory body or with, for example, the National Clinical Assessment Authority? Have not these two bodies probably outlived their usefulness?

[Earl Howe]

My Lords, I am very much in tune with the noble Lord’s general theme. As I said in the House last week, it has to make sense for us to look at each and every arm’s-length body. We need to consider what it does and what it was designed to do, decide how critical those functions are and how well they are fulfilled and then decide whether we can achieve better value for money by doing things differently. I do not want to promise the noble Lord a bonfire, as I have not yet taken any decisions, but I assure him that I will be rigorous in my approach to this whole exercise.

[Baroness Gardner of Parkes]

My Lords, as a former chairman of a hospital trust, I know that when staff are consulted about the way in which savings can be made they come up with very constructive ideas. Could not the cumulative effect of many hospitals seeking the comments and advice of their staff lead to considerable savings and improved efficiency in running the hospitals?

[Earl Howe]

My noble friend makes an extremely good point. Much of the thrust of what we are trying to do is to achieve much greater local ownership by clinicians, staff and managers of the problems that we can all identify. The ideas that my noble friend has put forward already operate in many trusts, but they should be imposed more widely.

[Lord Warner]

My Lords, in his review will the Minister encourage his ministerial colleagues to enhance the coalition Government’s reputation for taking tough decisions by looking seriously at the number of acute hospitals that are failing financially and are unsustainable, especially in London? Is he willing to market-test the provider side of PCTs, which the Department of Health has identified as inefficient?

[Earl Howe]

My Lords, the noble Lord, with his knowledge of London, speaks with great authority and he will know that reconfiguration is high on the agenda in London. Efficiencies can be created, but we want to see local buy-in to those changes rather than any top-down prescription. On his second point, we are keen on the split between the commissioning and the provision of community services, so that we can get greater plurality of provision in community services.

[Baroness Barker]

My Lords, have the Government yet managed to conduct an assessment of the NHS IT budget? If so, what conclusions have they reached?

[Earl Howe]

My Lords, that work is ongoing and we have not yet reached any definitive conclusions.

[The Lord Bishop of Liverpool]

My Lords, I declare an interest in that the Church of England is a provider of sessional chaplains in the National Health Service. Given the importance of chaplains to the well-being and recovery of patients and given the value of their work with staff, especially those under stress, will the Minister encourage NHS trust hospitals to resist reducing those services?

[Earl Howe]

My Lords, as I hope was apparent from our debate in the House the other day, the Government attach great importance to chaplaincy in the NHS. The kind of encouragement that the right reverend Prelate speaks of is something that I will consider. I need to be sure in my mind of how best to do that, but his point is well made and I will take it back to the department to see what we can do.

[Baroness Wall of New Barnet]

My Lords, will the noble Earl assure the House that in looking for economies in the health service—I am sure that there are opportunities to do that—he will safeguard the vanguard policy of the last Government, which is fortunately retained by this Government, to ensure that patients’ experience comes first and foremost? Would he also perhaps take an idea from me to look at how we deal with patients who do not attend—DNAs, as we call them—despite having had prior notice? Failure to attend is costly and inefficient for the health service.

[Earl Howe]

The noble Baroness is quite right that patients who do not attend their appointments cost the NHS a great deal. How do we deal with the issue—I am sure that the previous Government wrestled with it, too—if we are to avoid charging patients for failing to turn up? I would resist the idea of charging because I do not think that it is a road down which we should be going in secondary or primary care. However, the ways in which we can encourage patients to turn up on time should attract greater focus in our efforts towards achieving efficiency.

[Baroness Masham of Ilton]

My Lords, will the Minister assure us that trained nurses, physiotherapists and occupational therapists will not be replaced by cheaper care assistants?

[Earl Howe]

My Lords, to ensure that the quality of NHS services continues to improve in a climate of constrained growth, we must achieve greater productivity, but that means designing services for better quality and value for money. It does not mean downgrading the quality of the services. It is for local NHS bodies to decide how services can best be delivered most efficiently. I would be very surprised if that kind of dilution of expertise formed a part of any such plans.

[Lord Campbell-Savours]

Would it not be quite wrong for the Department of Health to prejudge what the transparency unit might say on the price labelling of prescribed products?

[Earl Howe]

My Lords, I do not think that we have prejudged it because extensive work has already been done in the department. It found that if, for example, a medicine has a high price attached to it, people might be deterred from taking it because of their fear of being a burden on the NHS. Equally, if a medicine has a low price put on it, someone might wrongly perceive that the lower price was linked to lower quality. That is based on research. It is not simply civil servants reacting to an idea; there is a lot of work behind it.

NHS: Patient Targets

Earl Howe Excerpts

Wednesday 23rd June 2010 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government how they will ensure that patients will be seen in reasonable time by doctors and other primary care professionals following the publication of the revised NHS operating framework which removes NHS patient targets.

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

My Lords, the revised NHS operating framework stops central performance management of process targets that have limited justification. The NHS must be free to manage services at a local level, and will be accountable to the patients and the public it serves. To ensure this, we shall continue to collect data measuring access. Incentives for timely access such as through the quality outcomes framework, the NHS constitution and the contractual regime remain in place.

[Baroness Thornton]

I thank the noble Earl for that Answer. He will recall that in 1992 his Government launched their Patient’s Charter, in which the pledges for patients included:

“to be guaranteed admission for treatment by a specific date, no later than two years from the day when the consultant places the patient on a waiting list”.

I might add that his Government did not achieve that. I take it that the coalition Government’s objective is not that, but the House might like to know what they think is a reasonable waiting time. We got it down to 18 weeks. What does the noble Earl think it should be?

[Earl Howe]

My Lords, it is right for me to make clear that the previous Government achieved a great deal in bringing down waiting times—there is no doubt that that was a major worry for patients—and they are to be commended for that. The noble Baroness is concerned that we do not let the situation slip, and I fully share that concern. As I have indicated in brief terms, two main issues will prevent it happening. The first is that the legal duty on commissioners to commission services that comply with operational standards around the 18-week referral time still applies. The second is the NHS constitution, which contains the right to access services within minimum waiting times, as she knows. Those patient rights within the constitution have not been diluted.

[Baroness Pitkeathley]

My Lords, the noble Earl emphasises localism in the NHS, and that is very welcome, but is he aware that patients and their organisations have expressed great anxiety about not having enough people and structures to check how their local services are doing, especially—as patients and their organisations know very well—because there are some conditions for which early diagnosis is essential if cure is to be achieved?

[Earl Howe]

My Lords, the noble Baroness is quite right. For example, on the waiting time targets for cancer referrals, we have made no changes because there is a clinical underpinning to those targets. She is also right to say that there is often insufficient information for patients on which to base decisions. We are very keen to build and develop information channels so that patients can be better informed and are able to make better choices about their care.

[Lord Alderdice]

My Lords, is my noble friend aware that one of the difficulties with targets for waiting times was that clinicians were forced to ensure that all patients fitted into the waiting times, when they were aware that some were a great deal more urgent and some not so urgent at all? Can he reassure me that in devolving more power back to clinicians and more opportunities back to local people—patients and carers—those differences between people’s requirements will be taken full account of rather than simply some artificial and arbitrary time limit?

[Earl Howe]

My noble friend is right because, when all is said and done, many of the centrally imposed targets were quite arbitrary. For example, why 18 weeks, not 17 or 19? It is worth saying that the targets that clinicians and managers set themselves are often a great deal more stringent than the ones that politicians are likely to set.

[Lord Crisp]

My Lords, as the chief executive of the NHS in England from 2000 to 2006, I think that I had better declare an interest on this matter. Although what the Government announced recently were some minor and probably quite sensible changes to targets, they also sent a big message. The message is about localness, which is very welcome, but there is also a very risky message, which is that waiting no longer matters. I know that the noble Earl understands very well that the NHS listens to what Ministers say. How will he ensure that people in the NHS understand that waiting is still a very important issue?

[Earl Howe]

My Lords, the noble Lord is absolutely right. I believe that the message that he wants sent has been sent by the NHS chief executive in his letter to NHS bodies. It is certainly a message that the Government want to send. Timeliness is important. A great deal has been achieved. We do not want to squander that, but we think that clinicians should now be given the responsibility to prioritise patients and treatments for themselves, not have central performance management dictated from above.

[Baroness Wall of New Barnet]

Does the noble Earl agree that it would be appropriate for hospitals such as Barnet and Chase Farm to carry on with our internal stretch targets, which we do not declare anywhere, but which ensure that our patients are aware that it is a good hospital to go to? They are not arbitrary—trust me, they are not; they are real—and they make a big difference.

[Earl Howe]

I have always drawn—and I think that my ministerial colleagues do as well—the distinction between targets that are useful for internal management purposes and for patient decision-making and targets that are micromanaged from Whitehall. There is a distinct utility in the kind of targets that the noble Baroness is talking about because, as she knows, they are often very good proxies for outcomes.