Abortion (Sex-Selection) Bill

Earl Howe Excerpts

Tuesday 16th December 2014 Lords Chamber

[Baroness Knight of Collingtree]

To ask Her Majesty’s Government what action they intend to take following the First Reading of the Abortion (Sex-Selection) Bill in the House of Commons on 4 November.

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

My Lords, abortion is traditionally an area where there is a free vote on Private Members’ Bills. We have made it clear on numerous occasions that abortion on the grounds of gender alone is illegal. We take this issue very seriously and will continue to monitor birth ratios and consider any evidence that comes to light.

[Baroness Knight of Collingtree (Con)]

My Lords, did my noble friend note that at the end of the First Reading debate on the Bill 181 MPs voted for it and only one voted against it and the tellers counting the vote against insisted that their votes be counted in favour of the Bill? Does he consider that this indicates acceptance of the evidence that abortion for gender reasons is going on and is causing very grave concern? Even a Minister saying in this House that this is illegal does not make it so: only a parliamentary Bill can do that. If gender equality means anything at all, surely the protection of the lives of baby girls is a matter of urgency.

[Earl Howe]

My Lords, the legal position is not in doubt. It is illegal to abort a foetus based solely on its gender. The Abortion Act states that two practitioners have to be,

“of the opinion formed in good faith”,

that the woman had grounds for an abortion. It is for doctors, in line with any guidance from their professional bodies, to satisfy themselves that they are in a position to give the opinion and to defend it if challenged. We refreshed the guidance in May of this year to make the position crystal clear.

[Baroness Thornton (Lab)]

My Lords, anyone who seeks an abortion on the basis of wrong gender is perpetuating a practice that is not only morally repugnant but illegal, as the noble Earl said. Sex-selection abortion is banned in the UK under the Abortion Act 1967. Does the noble Earl agree that because this practice happens in certain places in the world it may be taking place illegally in those communities in the UK? What are Her Majesty’s Government doing to identify whether this is the case?

[Earl Howe]

My Lords, our latest analysis of data by country of birth and ethnicity, which we have done for a second year running, found no evidence of sex selection taking place in the UK. Without exception, the wide variation in birth ratios was within the bounds expected. Any termination wilfully failing to meet the requirements of the Abortion Act will render those performing such procedures liable to prosecution under other legislation.

[The Lord Bishop of St Albans]

My Lords, given that many are concerned that we may not be protecting the most vulnerable in our society in this area, we need to understand the full extent of sex-selection abortion in this country, if indeed it is taking place. We need to collect and collate data. In the light of that, will the Minister tell the House what Her Majesty’s Government are doing to require the registration of the gender of foetuses using forms such as HSA4 or something similar so that we can actually have the evidence?

[Earl Howe]

My Lords, we are not moving in that direction partly because it is frequently not possible to determine the sex of the foetus after an abortion.

[Lord Steel of Aikwood (LD)]

Does the Minister agree that sex-selection abortion is not just illegal, as he says, but totally abhorrent? Does he further agree that, as the BMA has said that in some rare medical cases it may be necessary, it is really up to his department to issue clearer guidance as the Bill to which my noble friend referred is a 10-minute rule Bill that is not going anywhere? It is up to the department to issue guidance on this matter.

[Earl Howe]

My Lords, we issued guidance in May of this year. It sets out the expectations around the procedure to be adopted by the two doctors involved: certifying that an abortion meets the criteria set out in the Act by considering the individual circumstances of the woman and how they reached their decision. The guidance also reaffirms our position that abortion on the grounds of gender alone is illegal.

[Lord Alton of Liverpool (CB)]

My Lords, is the noble Earl aware that in China there have been 34 million abortions on the grounds of the one-child policy and that that has led to a distortion in the population of 34 million more males than females? Similar policies in India using ultrasound scanning tests have also led to the targeting of little girls. Given that some of these policies have been financed directly or indirectly through development funds from our own Department for International Development, will the noble Earl undertake to speak to his colleagues in that department to ensure that no British taxpayers’ money is used for these purposes?

[Earl Howe]

I am sure that noble Lords around the House will form their own conclusions on the information provided by the noble Lord, Lord Alton, but I do give that undertaking.

[Baroness Scotland of Asthal (Lab)]

My Lords, is not one of the difficulties being faced by the practitioner the fact that the guidance talks about “alone”, whereas we know that the psychological issues which arise among women who are put under pressure to have only boys may count towards the rationale that produces the abortion? What, if anything, do the Government intend to do to address this issue?

[Earl Howe]

My Lords, coercion and violence is of course an issue that is taken very seriously. Every woman who is being seen for a possible abortion has the opportunity to speak to a healthcare professional on her own. Those healthcare professionals are trained to be alert to the signs of coercion and violence and will take appropriate action.

[Lord Anderson of Swansea (Lab)]

My Lords, it is clearly counterintuitive to say that there is no linkage of the practice to certain ethnic communities. As the practice is clearly illegal, can the noble Earl tell us how many prosecutions there have been, how many of them were successful, and whether he believes that any sanctions are sufficient?

[Earl Howe]

My Lords, to my knowledge there have not been any successful prosecutions in this area, but the decision by the Crown Prosecution Service not to prosecute two doctors involved in recent allegations led to the call for my department to reissue the guidance on this matter, which, as I have said, we did earlier this year.

NHS: Medical Staff

Earl Howe Excerpts

Monday 15th December 2014 Lords Chamber

[Lord Fowler]

To ask Her Majesty’s Government how many medical staff working in the National Health Service today, including doctors and nurses, were trained in Africa.

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

My Lords, in 2013, the latest year for which figures are available, there were 6,472 doctors working in the NHS—that is 4.4%—who gained their primary medical qualification in Africa and 13,969 nurses on the Nursing and Midwifery Council’s register who trained in Africa. In that same year, 12,203 professional clinically qualified staff working in the NHS—that is 1.8%—held nationality with an African country.

[Lord Fowler (Con)]

My Lords, I pay tribute to the job that these people do for the National Health Service, but is not the lesson of the Ebola crisis that many of the health services in Africa are seriously underresourced? Can it be justified that not only Britain but other countries in Europe and the Middle East are taking much needed doctors and nurses away from Africa? Could we look at our own training policies to see how that position can be improved?

[Earl Howe]

My noble friend makes a very important point. As he will know, the UK signed the World Health Organization code of practice on the international recruitment of health personnel. My department worked together with the Department for International Development to produce a definitive list of developing countries—based on economic status and the availability of healthcare professionals—that should not be targeted for recruitment. He may like to know that the WHO is planning an assessment of the implementation of that code of practice and is due to report in 2016. However, we are mindful of the point made by my noble friend. Particularly with the Ebola crisis, it is important that we are sensitive to the serious issues that pertain in Sierra Leone in particular.

[Lord Hunt of Kings Heath (Lab)]

My Lords, given that, and given the Health Select Committee’s recommendation that although the contribution of overseas staff to the NHS should be celebrated, we should not be dependent on significant flows of trained staff from overseas, does the noble Earl still agree with the decision in 2012 to reduce the number of medical school training places by 2%? Does that not need reviewing?

[Earl Howe]

My Lords, as the noble Lord is aware, we rely on Health Education England to determine the number of training places that the NHS needs going forward, looking at not just the short term but also the medium to long term, informed by the work of the local education and training boards. That is as good a system as we believe we can get. Health Education England is properly funded to do that and we must rely on its expertise.

[Lord Crisp (CB)]

My Lords, I understand that the NHS in recent years has made it harder to employ people coming from poorer countries in Africa and elsewhere to work here. However the NHS, as the Minister has already stated, has a large number of people working within it from those backgrounds. I have two questions. First, what are the Government doing to aid countries to train more people in their own countries? Secondly, what are the latest figures for the international medical graduate scheme for people coming from Africa training in this country?

[Earl Howe]

The international postgraduate medical training scheme is only just starting and we hope to launch it very soon with one particular Middle East country. As regards the noble Lord’s first question—he will have to remind me of it.

[Lord Crisp]

I hope I can remember it. It was very simply: what are we doing from the UK to support the training of people in their own countries, where they will often stay longer than if they come and train here?

[Earl Howe]

I beg your pardon, my Lords. DfID has a number of programmes designed to support the health economies of developing countries. They have been in place for many years. They can take the form of training, not just of doctors but of all healthcare professionals. I am aware that DfID is extremely supportive of those programmes.

[Baroness Brinton (LD)]

My Lords, 10 years ago there were more Malawian doctors working in England than there were in Malawi and the Royal College of Surgeons, working with CBM UK, a disability charity, set up the College of Surgeons of East, Central and Southern Africa. In that time the number of African-trained surgeons has substantially increased through this joint practice. Are other royal colleges following their example in setting up similar projects?

[Earl Howe]

I am not aware of the answer to that question but I can tell my noble friend that the UK has been moving towards self-sufficiency for a number of years. For example, there was a 27% decrease in the number of registrations of non-European Economic Area nurses from April 2010 to March 2014, continuing a longer-term trend. The number of doctors in the NHS with a primary medical qualification from outside the EEA has remained relatively static over the last four years despite the full-time equivalent number of doctors increasing by more than 5% over the same period. I think we can take heart from those figures, mindful, of course, of the need to adhere to the World Health Organization code of practice.

[Baroness Wall of New Barnet (Lab)]

My Lords, I am sure the whole House will join in the sentiments expressed by the noble Lord, Lord Fowler, about the tremendous work that these nurses and doctors do in our NHS. I declare an interest as chairman of Milton Keynes Hospital NHS Foundation Trust. As I am sure the noble Earl is aware, many of the hospitals now are encouraging some of the African nurses to go back and have an opportunity to train the skilled and unskilled nurses who are already in their own countries. Despite the fact that things are obviously very challenging for us here, it is very important that they are able to do that.

[Earl Howe]

I agree with the noble Baroness. It is important to underline that the medical training initiative, which is the means by which we can present an offer to foreign doctors—that is, postgraduate medical specialists—to come to train here, is a fixed-term arrangement for up to two years. It seeks to promote circular migration so that participants in a scheme can return to their home country and apply the skills and knowledge developed during their time in the UK. That is very valuable for those individuals and those countries.

[Baroness Chisholm of Owlpen (Con)]

My Lords, during my career as a nurse, I had the privilege of working with nurses from all over the world, including the African continent. They showed enormous compassion and dedication to their work. Does my noble friend feel that it is important that, when these nurses come to England, they are given all the support and training possible so that they reach the high standards that our nurses reach in their training here?

[Earl Howe]

My Lords, I do. My noble friend will be aware that the Nursing and Midwifery Council has established standards which ensure that the quality of the nurses whom we get from overseas is absolutely up to that of home-trained nurses. Support for those nurses while they are in this country is of course an essential ingredient if we are to keep them here for a reasonable length of time.

Learning Disabilities: Health and Care Services

Earl Howe Excerpts

Wednesday 3rd December 2014 Lords Chamber

[Baroness Hollins]

To ask Her Majesty’s Government, in the light of the report Winterbourne View—Time for Change, what steps they are taking to address the care of people with a learning disability whose behaviour challenges services.

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

My Lords, the Government’s report into Winterbourne View included actions for government and partners to provide safe, high-quality care for people with behaviour that challenges. Time for Change acknowledges that the report identified the key steps clearly. We and NHS England will look carefully at the further recommendations in Time for Change.

[Baroness Hollins (CB)]

I thank the Minister for his reply. Providing day-to-day support for people with learning disabilities whose behaviour challenges services is a complex task which requires specialised skills. Given the difference that the Dementia Challenge has made to raising knowledge and skills across the health and social care workforce, and the Prime Minister’s public endorsement of Sir Stephen Bubb’s report last week, will Her Majesty’s Government consider introducing a learning disability challenge, and will the Minister give his personal support to campaigning and encouraging the setting up of such a challenge?

[Earl Howe]

My Lords, that is a very interesting idea; the noble Baroness is right to draw attention to the Dementia Challenge programme, which has been hugely successful. At this point, once we and the system have delivered on our Transforming Care and concordat commitments we will consider how the lessons learnt from the Dementia Challenge programme might be applied in the next programme delivery phase, and indeed in other policy areas as well.

[Baroness Gardner of Parkes (Con)]

My Lords, I declare an interest as I have a grandson in this position. Is the Minister aware of just how extremely difficult it is to get any action at all in these cases? When someone in their early 20s who is no longer a child has to give up whatever educational establishment they have been at, parents find themselves confronted by a situation where everyone is saying, “Yes, you need mental health services”, but none are available. Do I understand correctly that the suggestion made by the noble Baroness might help that situation? If so, I strongly support it.

[Earl Howe]

My Lords, the report contains a number of important recommendations which we will consider. This report was commissioned by NHS England for NHS England, to make recommendations for a national commissioning framework under which local commissioners would secure community-based support for people with learning disabilities and/or autism. It is an important report, it is right that we take a bit of time to digest it, and, together with NHS England, we are looking carefully to do just that.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the noble Earl clarify something? He knows that NHS England set a target of June 2014 to stop placing people with learning disabilities in inappropriate in-patient facilities. It appears that that has not been followed through by clinical commissioning groups. Can he confirm that, and say whether the Government will discuss with the regulator, the Care Quality Commission, whether a moratorium on the approval of new registrations for inappropriate in-patient facilities will be considered as part of the reforms that need to take place?

[Earl Howe]

The noble Lord is quite right that progress has not been nearly as swift as we, or indeed anyone, would have liked. NHS England has stated its ambition to achieve a 50% reduction in the number of people who were in in-patient beds on 1 April this year by March 2015. Although the latest data for November shows that some 2,600 people were in in-patient settings, the number of people with a transfer date has gone up by more than 1,100 in the last three months, so progress is being made. On CQC registration, the CQC may at any time decline to register or indeed cancel the registration of a provider where it is failing to comply with the registration requirements set out in law. That includes the new duty of candour and the fit and proper persons requirement, which came into effect at the end of last month.

[Baroness Campbell of Surbiton (CB)]

My Lords, in preparing a response to Winterbourne View—Time for Change, will the Minister ensure that the needs of this group of people with learning disabilities and their carers are not confined within a joint commissioning framework, dominated by NHS England and CCGs, but are instead assessed within the provisions of the Care Act so that they benefit fully from the well-being principle, which is a more holistic, social model approach, with good entitlements and safeguards? They must not again be subjected simply to a medical model approach, or the same will happen.

[Earl Howe]

I can give the noble Baroness that assurance.

[Baroness Barker (LD)]

My Lords, the report recommends that the Government should respond to the Bradley report five years on, which deals with how the criminal justice system treats people with learning disabilities and autism. Could the Minister say whether the Government will respond to that report—and, if so, when?

[Earl Howe]

My Lords, the Bradley report, which was a seminal report, was subject to a five-year review earlier this year. We will consider reports of progress and further recommendations in that report in conjunction with the Ministry of Justice, the Home Office and NHS England with regard to future policy development.

[Baroness Cumberlege (Con)]

My Lords—

Health: Lesbian, Bisexual and Trans Women

Earl Howe Excerpts

Wednesday 3rd December 2014 Lords Chamber

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

My Lords, I begin by thanking my noble friend very warmly for securing a debate—the first one, in my experience—on the important issue of the health of lesbians, bisexual and trans women. These are women who may face discrimination by the NHS because of prejudice or, as we have heard, a lack of understanding about the particular health needs that they may have.

The noble Lord, Lord Cashman, spoke eloquently about the duties and principles of a civilised society in relation to minority groups of people such as these. The NHS constitution is our way of enshrining those principles in relation to the National Health Service. It commits the NHS to providing a comprehensive service available to all, irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity, or marital or civil partnership status. The service is designed to diagnose, treat and improve both physical and mental health. It has a duty to each and every individual whom it serves and it must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.

However, despite this we recognise that discrimination still takes place. In my comments, I will highlight some of the work that we are taking forward to combat such discrimination. The Department of Health is funding a number of organisations to help tackle some of the challenges that lesbians, bisexual and trans women face when seeking to access health services. First, the department has awarded Stonewall £235,000 over three years for its Health Champions programme. This supports 20 NHS organisations a year to improve their knowledge and awareness of the health needs of lesbian, gay and bisexual people—if noble Lords do not mind, I will use the acronym LGB—and helps them to deliver a more personalised health and care service.

Secondly, the department is funding the Lesbian & Gay Foundation to carry out two projects over three-year periods. The first, with a grant of up to £140,000, focuses on the recruitment, training and empowerment of LGB community leaders, enabling them to engage with NHS structures. The second project, with a further £108,000, is its Pride in Practice project, which aims to increase LGB people’s access to appropriate healthcare.

Thirdly, the department is funding the National LGB&T Partnership with a grant of £186,000 this year. The partnership is made up of a number of organisations, and this funding enables them to work with Public Health England to ensure that LGBT people’s needs are included in their business plan priorities; with the Department of Health to produce an LGBT companion to the adult social care outcomes framework; and with NHS England on the future of gender identity services for adults.

The noble Lord, Lord Cashman, and the noble Baroness, Lady Gould, expressed concern about the classification of trans people. It is universally accepted that gender nonconformity is not a mental disorder. However, specialist services in this country are commissioned from mental health trusts, and input from psychologists and psychiatrists, among others, is essential to offer advice and assessment for people affected by concerns regarding their gender identity. Some patients will not require or wish to receive any hormonal, physical or surgical treatment, but improvement in the patient’s self-perceived psychological and emotional well-being is a key goal of treatment for all patients. I will be happy to write to noble Lords expanding on that.

I turn to my noble friend’s concerns, in particular about lesbian and bisexual women. She spoke of insensitivity by general practitioners towards lesbian and bisexual people. I am sorry to say that the experiences she recounted resonate with some of the briefing that I have received. In September this year, a study funded by the Department of Health saw experts examine data from over 2 million responses to the general practice survey of 2009-10, including 27,000 responses from people who identified themselves as gay, lesbian or bisexual. It found that lesbian, gay or bisexual people were up to 50% more likely than heterosexuals to report negative experiences with the GP services that they received. Admittedly, the figure was 1.7% of lesbian, gay and bisexual people who reported their overall experience with their GP as very poor, compared with 1.1% of heterosexual people: nevertheless, that is a statistically significant difference. All patients deserve high-quality care from their GP regardless of their sexual orientation. Patients expect their GP to offer the best care, so if ever there were an example of how important it is for GPs to use the results of the GP Patient Survey to improve the services that they offer, surely this is it.

With regard to training and asking the appropriate questions, which is clearly part of all this, we have asked Health Education England to ensure that the recruitment, education, training and development of the healthcare workforce generally results in patients, carers and the public reporting a positive experience of healthcare, consistent with the values and behaviours identified in the NHS constitution. The quality of care is as important as the quality of treatment. We also asked Health Education England to ensure that there is an increased focus on delivering safe, dignified and compassionate care in the education and training of healthcare professionals.

In response to my noble friend’s point about mental health, Public Health England recognises the increased risk of suicide and self-harm among lesbian, bisexual and trans women. As part of its response, it is developing a professional toolkit for nurses with the Royal College of Nursing on youth suicide prevention among lesbian, gay, bisexual and trans youth in order to ensure that young people get better support.

My noble friend asked about the possibility of a strategy and what we were doing to monitor data. Public Health England recognises the health inequalities affecting all three groups of women. Many of these issues were clearly set out in the lesbian, gay and bisexual and trans companion document to the public health outcomes framework, published last year by the National LGB&T Partnership. I do not have time to read out some of the key points from that, but it is worth studying because it presents a very good way forward.

Improving the quality of the data is an important aspect of this. Public Health England recognises the challenges involved in understanding at a population level the health of these women because of the lack of routine data collection. It and NHS England are working together with the National LGB&T Partnership to integrate sexual orientation monitoring alongside other demographic data collection across the NHS.

The noble Baroness, Lady Gould, spoke very powerfully, as she always does, about the position of trans people and, in particular, about waiting times. NHS England acknowledges that there are some system delays at both gender identity clinic level and surgery level. It has set up, as she mentioned, a task and finish group to look at the issue of delays and has engaged with the three surgical providers to discuss options. It is under no illusions about this. I am well aware that Healthwatch England has made its opinions very clear to NHS England, and I pay tribute to it for that.

In general in this area, NHS England has created a gender identity clinical reference group which has developed a new service specification and clinical commissioning policy. It has also established a transgender network designed to hear the views of people and to influence the strategic direction of services. It is organised and facilitated by the NHS England patient and public voice team.

The noble Baroness also mentioned the workforce. NHS England has confirmed that the number of surgeons contracted to provide feminising gender reassignment surgery is currently 1.5 whole-time equivalent. It hopes there will be an additional 0.8 whole-time equivalent available by the autumn of next year. Two surgeons are currently training to perform gender reassignment surgery and are employed by the NHS. There is another one whole-time equivalent capacity available, but this is not currently contracted by NHS England. Clearly, surgery of this kind is highly specialised. It takes at least six months’ additional training to learn these particular techniques, and trainees would normally be established consultants in neurology, gynaecology or plastic surgery.

As regards hormonal treatment, oestrogens are not authorised, licensed or regulated for the use of trans women. Consequently, GPs may refuse to prescribe them. Specialist clinics make recommendations for the prescribing and monitoring of these therapies but do not directly prescribe them or provide physical or laboratory monitoring procedures for patients. It is true that there are no preparations of oestrogen licensed for the treatment of gender dysphoria. NHS England’s specialised services circular 1417 sets out arrangements for prescribing and monitoring medications.

GPs undoubtedly have an important role in the healthcare of people with atypical gender identity development, not only around the time of their transition to a social role and physical development congruent to their gender identity but for the rest of their lives when they no longer have a need for specialised gender identity services. If I can expand on those remarks, I would be happy to write to noble Lords.

The noble Lord, Lord Cashman, asked what actions had been delivered from the actions plans. The Department of Health has delivered on all its commitments in the trans and LGB action plans. The Government Equalities Office will shortly publish a report on all the work carried out by government in this area.

Responsibility for improving the health of the nation lies with Public Health England and NHS England and I am pleased to say that both organisations are working to improve the health of these groups of women. My noble friend mentioned cervical screening. Public Health England’s NHS cervical screening and breast screening programmes are offered to all women irrespective of their sexual orientation although Public Health England is working with the Lesbian & Gay Foundation to support screening for lesbian and bisexual women. This is especially necessary in respect of the cervical screening programme, which encourages lesbians to be screened despite the common misconception that this is not necessary.

Public Health England also recognises that there are health inequalities which are common across all three groups of women, such as the significantly increased risk of mental ill health, self-harm and suicide and also issues specific to gender identity, such as the ease of access to gender identity clinics. Many of these issues have been clearly set out in the companion to the public health outcomes framework published by the National LGB&T Partnership. The partnership is also developing healthy living guides for trans people which cover a wide range of topics including sexual health, mental health and well-being, physical activity and diet. Public Health England acknowledges the challenges involved in understanding, at a population level, the health needs of these women because of the lack of routine data collection, about which I have already spoken. Therefore they are working together with stakeholders to integrate sexual orientation monitoring alongside other demographic data collected across the NHS.

As part of its response to the increased risk of suicide and self-harm among these groups, Public Health England is developing a professional toolkit for nurses with the Royal College of Nursing on youth suicide prevention among LGBT youth to ensure they get better support. That builds on previous work by the department to support young people’s mental health. In addition, Public Health England has been working in partnership with the Royal College of General Practitioners to raise awareness of sexual orientation through a new e-learning resource.

I turn briefly to the work that NHS England has been taking forward in respect of gender reassignment. Since April 2013, NHS England commissioned gender identity services, as the noble Baroness mentioned, and soon after this it established a gender identity clinical reference group, which comprises clinical staff, patients, carers and representatives of professional bodies. In June last year the group embarked on the development of a new service specification and clinical commissioning policy. A transgender network has been established to support that work, and now has more than 100 members. The network is designed to hear the views of stakeholders and to influence the strategic direction of services, and is facilitated by the NHS England patient and public voice team. In recognition of the time required to develop the new service specification, an interim gender protocol was adopted in July 2013, based on the NHS Scotland gender reassignment protocol.

Finally, I know there are concerns in the trans community about waiting times for treatment—I have covered those in my earlier remarks. However, I emphasise that once within a gender identity clinic, patients should receive appointments with the team at an interval appropriate to their need. NHS England is aware of the situation and has set up a task and finish group specifically to address issues around delays. As I have indicated, any delays before gender reassignment surgery are related to capacity problems among surgery providers. I understand that around 455 patients are waiting for surgery, at various stages of clinical readiness. The positive thing is that in future, NHS England will be in a better position to monitor that, as it will hold the data centrally.

In summary, although the legal framework is in place to make discrimination on the grounds of gender, sexual orientation and gender reassignment unlawful, and despite the fact that equality is enshrined in the NHS constitution, we acknowledge that discrimination sometimes still takes place. What we need to do now, building on the legal framework, is to strive to change hearts and minds to eradicate prejudice. However, of course, that is not just a role for government; surely we all have a role to play in that endeavour. Each one of us needs to be honest about our own prejudices, and work to establish a more equal and fairer society for all.

House adjourned at 7.33 pm.

Nursing and Midwifery (Amendment) Order 2014

Earl Howe Excerpts

Tuesday 2nd December 2014 Lords Chamber

Moved by

[Earl Howe]

That the draft order laid before the House on 13 October be approved.

Relevant document: 9th Report from the Joint Committee on Statutory Instruments, considered in Grand Committee on 27 November

Motion agreed.

Hospitals: Voluntary Sector and Emergency Readmissions

Earl Howe Excerpts

Monday 1st December 2014 Grand Committee

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

My Lords, I begin by thanking my noble friend Lady Scott for tabling this important topic for debate and for introducing it so ably. The Government appreciate, as all speakers have acknowledged, that voluntary and community sector organisations make a substantial contribution to the delivery of high-quality local health and social care services. They have a strong track record of designing, providing and supporting services, based on their insight into people’s needs, and they are often well placed to respond in a flexible way to those needs. Their unique understanding of local communities also means that they are ideally placed to reach those vulnerable and sometimes hard-to-reach groups that statutory organisations might struggle to reach.

Moreover, social action and volunteering contribute to every sphere of health and social care and are fundamental to building strong and resilient communities. For example, the Royal Voluntary Service—mentioned by my noble friend Lady Thomas and the noble Lord, Lord Bradley—is a charity that supports older people to live well at home, in the community and in hospitals. With a network of more than 40,000 volunteers nationally, the Royal Voluntary Service uses its strong community links as a platform to deliver a range of services that improve the hospital experience for older people and their relatives, reduce hospital readmissions by linking hospital and home-based services, contribute financially to patient and community services, and provide people with practical and accessible information about local services. These types of schemes can help to avoid unnecessary emergency readmissions.

The report mentioned by a number of noble Lords makes very interesting reading. The conclusion of the report is that, in the RVS’s estimation, this support could save tens of millions of pounds in public money. That needs testing, as the noble Lord, Lord Bradley, indicated, as there are a number of important assumptions underlying the figure that it quotes. Nevertheless, it points the way to the usefulness and value of the voluntary sector in all the areas that I have mentioned. There are many other voluntary sector organisations that do similar work—for example, Age UK.

I shall now set out the range of actions that the Government are taking to improve integration of care to ensure that people can receive the care that they need and avoid emergency admissions and readmissions, including through use of the voluntary sector. The better care fund is a £3.8 billion pooled budget between health and social care, with areas choosing to pool £1.5 billion extra to bring the fund to £5.3 billion. The vast majority of this is being spent on social care and out-of-hospital community health services, which aim to keep people out of hospital and support them to leave safely as soon as they are well enough to do so.

Underlying the new approach are improvements in seven-day working across health and social care to help quicker, more appropriate discharge from hospital. One of the metrics for the fund is the number of people supported to remain at home at least three months after discharge from hospital. Plans project that, over two years, 11,860 older people will be supported to remain at home at least three months after discharge from hospital. This equates to a 33.7% increase over two years. Schemes in plans typically focus on things such as increasing capacity in reablement or intermediate care services, or multidisciplinary emergency response teams, which focus on avoiding unnecessary admissions to hospital.

We know that the voluntary sector can also play an important role in providing advocacy to people who need it. One of the drivers for the better care fund is to stop people having to undergo multiple assessments and telling their story repeatedly. Having someone to represent them and to help them navigate their way through often confusing health and care services can be invaluable. For example, in Greenwich the hospital ward support scheme trains volunteers to engage with people in hospital to support them to do practical things such as maintaining hygiene or engaging in conversation. The scheme prepares people for discharge, with volunteers on hand to support those identified as socially isolated who will be leaving hospital. Doncaster’s better care fund plan sets out a comprehensive falls prevention programme, through which Age UK Doncaster is being commissioned to help increase physical activity levels in older adults to increase strength, stamina and flexibility. That reduces the risk of falls and fractures, which are a major reason for hospital admissions and readmissions.

As well as providing services directly, we know that the third sector is represented at the strategic decision-making level in better care fund planning, with Nottingham and Southwark being just two examples of the many areas with voluntary sector representatives as members of their integrated care programme boards, as well as the health and well-being board itself.

The £2 million social action fund has delivered improved engagement with the independent, voluntary and community sectors. Eight schemes are being funded, aimed at supporting frail and elderly people. The aim is to scale up and robustly test interventions that use social action to reduce demand on hospital services, with funded projects making their impact over the course of winter 2014-15. We hope to be able to mainstream the most successful interventions down the line, and all evaluations and learning will be shared widely with the sector. The projects will help develop the potential of services that use social action to help older people stay well, manage their conditions or recover from illness or injury, thereby reducing growing pressure on hospitals. Currently, such services are small in scale and piecemeal, and often are not robustly evaluated. By March 2015, the aim for each project will be to contribute to a significant impact in the local area over the winter of 2014-15, develop a robust evidence base on its effectiveness through evaluation by the Nuffield Trust, and lay the foundations for the service to continue and grow on a long-term basis.

I am conscious that I have mentioned only a very few of the many voluntary sector organisations that are relevant to this issue, focusing primarily on the generic services provided. There is also a wide range of different, more condition-specific services provided by the voluntary sector—for example, some of the support provided by charity helplines that enable people to manage their conditions at home. There are also the very important services provided by voluntary sector hospices that support people at the end of their life within their homes, thereby avoiding unnecessary hospital admissions.

I shall highlight one particular example of where I have observed fantastic contributions made by the voluntary sector. Last month, I visited a medical practice in Hertfordshire to see how the role of developing well-being services within local NHS communities works. The Wellbeing Service was developed in order to support patients’ physical, psychological and social needs through improved health and well-being. The practice has engaged with a number of voluntary organisations to help prevent readmissions. I was particularly struck by the help that the volunteers give patients in navigating their health journeys, and I commend their tremendous work on this.

The noble Lord, Lord Bradley, asked whether there would be any spend on the voluntary sector from the additional £700 million of winter funding. Planned spend by system resilience groups identified for voluntary sector organisations is approximately £3.9 million. Approximately 110 independent and voluntary sector schemes are planned across the country, covering the expansion of capacity to provide care at home, hospital-to-home aftercare, out-of-hours cover and beds in care homes, the community and hospices. These plans include voluntary sector providers referenced in plans, such as Age UK, the British Red Cross and various hospices and smaller providers. Many schemes are focused around helping with improved hospital discharges, support for patients on return to their homes, community care provisions, and longer-term work to reduce readmissions and prevent admissions in the first place. I think we can be encouraged by that picture.

I conclude by saying that I recognise that the voluntary and community sectors make a substantial contribution to the health and care system. This has been an excellent short debate. Like my noble friend, I regret that there have not been more speakers, but the issues raised by those who have spoken have brought to light what value is available from the voluntary sector in a range of fields in health and social care. I thank my noble friend for having given us this opportunity to look at those areas. I encourage commissioners to engage with voluntary sector organisations to understand the kind of support that they can deliver to prevent emergency admissions, looking at some of the excellent examples that we have heard about this afternoon.

Committee adjourned at 5.02 pm.

HIV: Late Diagnosis

Earl Howe Excerpts

Monday 1st December 2014 Lords Chamber

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

My Lords, late diagnosis of HIV in the UK is declining, but 42% of people were diagnosed late in 2013. This is still too high and that is why we continue to include it in the public health outcomes framework.

Implementation of the sexual health improvement framework in England will help to reduce late diagnosis. The Department of Health funds HIV Prevention England, which continues to promote HIV testing, including leading on National HIV Testing Week and piloting the use of self-sampling tests.

[Baroness Prosser (Lab)]

I thank the noble Earl for that reply. Even in areas of high prevalence of infection, research has found that only 30% of patients are being tested for HIV in line with national testing guidelines—for example, when registering with a GP or being admitted via a hospital’s general medical admissions. Will the Minister have discussions with the Local Government Association—the body, as he no doubt knows, which is now responsible for public health—and agree a strategy to increase routine HIV testing in those high-prevalence areas, in line with those guidelines?

[Earl Howe]

My Lords, local authorities have an important part to play in the battle against HIV and AIDS. They are mandated to commission open access sexual health services, and that means that people can self-refer to the service of their choice, regardless of its location. However, as the noble Baroness will know, this is an issue that goes beyond local authorities. The key message from National HIV Testing Week, which was last week, was that we should all take responsibility for reducing HIV transmission, and that those who feel they may be at risk should take an HIV test.

The testing taking place in sexual health clinics in 2013 was up on the year before. We are seeing very good work with, for example, African faith leaders, and we have also piloted national HIV self-sampling services, which undoubtedly have a great utility for those who are too embarrassed to go to a clinic.

[Baroness Manzoor (LD)]

My Lords, geographically the highest rates of late diagnosis of HIV were in the Midlands and the east of England with 52%, followed by the north of England with 42%, the south of England with 41% and London with 35%. In light of the announcement that was expected later in the week but which was made at the weekend by the Chancellor of the Exchequer—that there will be an additional £2 billion for the NHS—can my noble friend say whether community testing for HIV will be part of the money being spent?

[Earl Howe]

It is far too early for me to say how the new money will be spent. In any case, that has to be a decision for commissioners weighing up the healthcare priorities that face them. But the new money is excellent news for the NHS, and there will be a Statement later today about that.

[Baroness Masham of Ilton (CB)]

My Lords, how many undiagnosed people with HIV does the Minister think there are? Would it not be beneficial to have testing of HIV, TB and hep C all together to save money and to pick up more infections?

[Earl Howe]

I shall have to take advice on the second question posed by the noble Baroness, which I do not know the answer to. But in answer to her first question, an estimated 107,800 people were living with HIV in the UK in 2013, of whom 24% were unaware of their infection, remain at risk of infecting others and are unable to benefit from effective treatment. That is why it is so very important that we target the at-risk communities to urge them to get tested, either in a clinic or through self-testing kits, which are now legal.

[Baroness Scotland of Asthal (Lab)]

My Lords, I wonder if the noble Earl can help me as to what work is being done in relation to women who are suffering from partner violence. Your Lordships will know that 12% of those involved in intimate romantic relationships have HIV through partner violence. Will the noble Earl say what the Government intend to do about that?

[Earl Howe]

The noble and learned Baroness is absolutely right. Those who are at risk of partner violence are of course at greater risk of contracting a sexually transmitted disease. We know this to be true particularly in countries overseas. The work to combat domestic violence, which the noble and learned Baroness is very familiar with, continues. It is vital, not just in this area of work but more generally in the field of mental health, to ensure that women at risk of violence—particularly women—have a place of refuge and a source of advice.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that the new money would be even more welcome if it had not consisted of quite a lot of old money rebadged. The noble Earl referred to the three-year HIV prevention campaign, which promoted testing and condom use. Perhaps I might ask him about how the campaign will go forward. Are the Government going to fund such a campaign and for how long, and can he say what proportion is going to be spent in the future compared with the past?

[Earl Howe]

My Lords, the Terrence Higgins Trust is the vehicle through which we conduct campaigns. Terrence Higgins has a three-year contract, which ends in March next year. We have yet to finalise all our spending commitments from April 2015. We expect that the funding for Terrence Higgins will have to be pared back by some measure because of the current funding constraints, but we are in discussion with Terrence Higgins about that.

HIV: Stigma

Earl Howe Excerpts

Monday 1st December 2014 Lords Chamber

[Baroness Gould of Potternewton]

To ask Her Majesty’s Government what plans they have to develop a campaign to address HIV stigma along the lines of the “Time to Change” campaign on mental health stigma.

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

My Lords, the Department of Health funds the Terrence Higgins Trust for the HIV Prevention England programme, which helps to tackle stigma by social marketing programmes and by working closely with HIV voluntary organisations. Implementation of the department’s framework for sexual health improvement, 2013, will help reduce the stigma associated with HIV and sexual health issues. Public Health England is supporting the development of the “People Living with HIV Stigma Index” in the UK.

[Baroness Gould of Potternewton (Lab)]

My Lords, maybe I shall not start by asking the question that might be asked, which is: what is the Minister’s secret? I could ask that in the name of Prince Harry, who wants to know what everybody’s secret is, in order to try to encourage people to be able to say, “Yes, I am HIV positive”. But that is not the question I am going ask the Minister.

I thank the noble Earl for his reply, and yes, there are some activities going on—activities which, I have to admit, are not extremely well funded. It seems to me that the success of the Time to Change campaign, which I am delighted by, shows that anti-stigma campaigns can be, and are, very successful. Does the Minister agree that HIV is the other health condition consistently faced with stigma and discrimination? Why has there not been proper resourcing and funding so that we can have a similar anti-stigma campaign, to ensure that there is prevention and a reduction in the number of people who have HIV?

[Earl Howe]

My Lords, there is certainly still too much stigma, although I believe opinion has moved in the right direction generally. The campaigns in the 1980s played a key part in providing information to the general public about AIDS and later HIV, but for some years it has, I think, been widely accepted that campaigns targeting groups at increased risk of HIV are more effective. That is why, for many years, my department has funded the Terrence Higgins Trust for targeted HIV prevention. HIV Prevention England, the unit set up by the Terrence Higgins Trust, is leading that, and is delivering innovative social marketing campaigns, including some mainstream advertising, on things like condom use and testing. There is also a DH-funded national programme, which has been successfully piloted with Public Health England.

[Lord Fowler (Con)]

My Lords, do we not need to fight stigma and discrimination overseas as well as at home? Around the world, some 18 million people have HIV and are untested, many because of their fear of discrimination. Given that many of them are in Commonwealth countries, should we not use all our influence to persuade such countries to follow policies of equal and fair treatment for all minorities?

[Earl Howe]

My noble friend, with his immense knowledge of this subject, is of course absolutely right. The 2011 UN Political Declaration on HIV and AIDS specifically includes a goal to eliminate by 2015 stigma and discrimination against people living with and affected by HIV through the promotion of laws and policies which ensure that human rights and fundamental freedoms are protected. Progress towards universal access cannot be made unless stigma and discrimination are tackled. They are a particular barrier with regard to the criminalisation of gay men and women, transgender people and sex workers. DfID is a constant champion of these groups internationally.

[Baroness Brinton (LD)]

My Lords, Prince Harry’s brave statement today to declare his secret reminds me of mine. A dear friend died of AIDS three decades ago. I cannot speak his name because to this day his family do not know that he had it. The point made by the noble Lord, Lord Fowler, is important, but we have children and young people in this country who are suffering from HIV and AIDS. What education is planned specifically for young people who are at risk, along with their school friends?

[Earl Howe]

My Lords, sex and relationship education plays an important part in exposing young people to the whole subject. Guidelines are available that schools must follow. They include sections on HIV and sexually transmitted diseases generally. As I say, secondary schools must follow those guidelines.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, building on the question from the noble Baroness, Lady Brinton, does the noble Earl agree that stigma starts very young? It builds on attitudes that are adopted by young people. The importance of PHSE programmes in schools is therefore very great. In what ways are his department and the Department for Education working together to ensure that these programmes are delivered—not just that they are recommended, but that they are delivered? Does he further agree that it would be a good thing if they were a regular and statutory part of the curriculum?

[Earl Howe]

I shall expand on my previous answer. Sex and relationship education is compulsory in maintained secondary schools, although not in academies. All maintained schools and academies have a statutory requirement to have due regard to the Secretary of State’s sex and relationship education guidance, which dates from 2000, when teaching sex and relationship education. The guidance makes it clear that all such education should be age-appropriate and makes the following points about HIV and sexually transmitted infections:

“information and knowledge about HIV/AIDS is vital; young people need to understand what is risky behaviour and what is not; young people need factual information about safer sex and skills to enable them to negotiate safer sex … Young people need to be aware of the risks of contracting a STI and how to prevent it”.

They also need to know about the diagnosis and treatment of HIV and STIs.

[Lord Roberts of Llandudno (LD)]

My Lords, is this not the direction in which we need the devolved health commitment in Scotland, Wales and Northern Ireland to go? What co-operation is there between them and the English set-up through television programmes, advertising and in other ways? Is this not one of the areas where it is essential to have effective co-operation?

[Earl Howe]

Yes, indeed, my Lords. I can tell my noble friend that there is such co-operation and constant communication between the public health authorities in England and the devolved Administrations on this, as on many other matters.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Earl made it clear in answer to my noble friend that academies are not subject to the core nature of the curriculum as regards sex and relationship education. As he will know, there have recently been a number of inspections by Ofsted that have shown up defects in the approach of schools to sex and relationship education. Surely that gives rise to concern that the issue of stigma is simply not being addressed properly in some schools. Is his department willing to take this up with Ofsted?

[Earl Howe]

I would be happy to do that.

NHS: Five Year Forward View

Earl Howe Excerpts

Monday 1st December 2014 Lords Chamber

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

My Lords, I shall now repeat a Statement made earlier this afternoon by my right honourable friend the Secretary of State for Health about the NHS. The Statement is as follows.

“I wish today to make a Statement about the future of our NHS, one that I hope everyone in this House will welcome. In October, NHS England and its partner organisations published an ambitious Five Year Forward View that was welcomed across the political divide. Today, I will announce how the Government plan to implement that vision.

Our response has four pillars. The first pillar is to ensure that we have an economy that can pay for the growing costs of our NHS and social care system: a strong NHS needs a strong economy. Some have suggested that the way to fund extra cost pressures is through new taxes, including on people’s homes. However, through prudent economic policies, the Government can today announce additional NHS funding in the Autumn Statement without the need for a tax on homes. The funding includes £1.7 billion to support and modernise the delivery of front-line care, and £1 billion of funding over four years for investment in new primary care infrastructure. That is all possible because under this Government we have become the fastest growing economy in the G7.

The NHS itself can contribute to that strong economy in a number of ways. It is helping people with mental health conditions to get back to work by offering talking therapies to 100,000 more people every year than four years ago. But the NHS can also attract jobs to the UK by playing a pivotal role in our life sciences industry. We have already attracted £3.5 billion of investment and 11,000 jobs in the past three years, as well as announcing plans to be the first country in the world to decode 100,000 research-ready whole genomes. Today, I want to go further by announcing that we are establishing the Genomics England Clinical Interpretation Partnership to bring together external researchers with NHS clinical teams to interpret genomic information so that we go further and faster in developing diagnostics, treatments and therapies for rarer diseases and cancers. Too often, people with such diseases have suffered horribly because it is not economic to invest in finding treatments. We want the UK to lead the world in using genetic sequencing to unlock cures that have previously been beyond our reach.

The second pillar of our plan is to change the models of care to be more suited for an ageing population, where growing numbers of vulnerable older people need support to live better at home with long-term conditions like dementia, diabetes and arthritis. To do that, we need to focus on prevention as much as cure, helping people to stay healthy without allowing illnesses to deteriorate to the point where they need expensive hospital treatment. Some have argued that to do that we need to make clinical commissioning groups part of local government and force GPs to work for hospital groups. Because this would amount to a top-down reorganisation, we reject this approach. We have listened to people in the NHS who say that more than anything the NHS wants structural stability going forward, and, even if others do not, we will heed that message.

We have already made good progress in improving out-of-hospital care. This year, all those aged 75 and over have been given a named GP responsible for their care, something that was abolished by the previous Government. From next year, not just over-75s but everyone will get named GPs. Some 3.5 million people already benefit from our introduction of evening and weekend GP appointments, which will progressively become available to the whole population by 2020. The better care fund is merging the health and social care systems to provide joined-up care for our most vulnerable patients. Alongside that, the Government have legislated, for the first time ever, on parity of esteem between physical and mental health. To deliver world class community care, we will need much better physical infrastructure. Today, I can announce a £1 billion investment fund in primary and community care facilities over the next four years. This will pay for new surgeries and community care facilities in the places where people most want them: near their own homes and families. These new primary care facilities will also be encouraged to join up closely with local jobcentres, social services and other community services.

Additionally, from the £1.7 billion revenue funding we are also announcing, we will make £200 million available to pilot the new models of care set out in the Five Year Forward View. To deliver these new models, we will need to support the new clinical commissioning groups in taking responsibility, with partners, for the entire health and care needs of their local populations. So as well as commissioning secondary care, from next year they will be given the opportunity to co-commission primary care, specialist care, social care, through the better care fund and, for the first time, if local areas want to do it, public health. The NHS will therefore take the first steps towards true population health commissioning, with care provided by accountable care organisations.

A strong economy and a focus on prevention are the first two pillars of our plan. The third pillar is to be much better at embracing innovation and eliminating waste. We are making good progress in our ambition for the NHS to be paperless by 2018, and last month the number of A&E departments able to access summary GP records exceeded a third for the first time, while from next spring, everyone will be able to access their own GP record online. However, today, I want to go further: £1.5 billion of the extra £1.7 billion revenue funding will go on additional front-line activity. To access this funding, we will ask hospitals to provide assured plans showing how they will be more efficient and sustainable in the year ahead and deliver their commitment to a paperless NHS by 2018.

We also have to face the reality that the NHS has often been too slow to adopt and spread innovation. Sometimes this is because the people buying healthcare have not had the information to see how much smart purchasing can help contain costs, so from next year CCGs will be asked to collect improved financial information, including per-patient costings.

The best way to encourage investment in innovation is a stable financial environment, so I can today announce that the Government, in collaboration with NHS England, will give local authorities and clinical commissioning groups indicative multiyear budgets as soon as possible after the next spending review. We expect that NHS England and Monitor will follow this by modernising the tariff to set multiyear prices and make the development of year-of-care funding packages easier.

The NHS also needs to be better at controlling costs in areas such as procurement, agency staff, the collection of fees from international visitors and reducing litigation and other costs associated with poor care. I have announced plans in all these areas and we will agree the precise level of savings to be achieved through consultation with NHS partner organisations over the next six months. That will lead to a compact signed up to by the department, its arm’s-length bodies and local NHS organisations, with agreed plans to eliminate waste and allow more resources to be directed to patient care.

The final pillar of our plan is the most important and difficult of all. We can find the money, we can support new models of care, and we can embrace innovation, but if we get the culture wrong, if we fail to nurture dignity, respect and compassionate care for every single NHS patient, we are betraying the values that underpin the work done every day by doctors and nurses throughout the NHS. We have made good progress since the Francis report, with a new CQC inspection regime, six hospitals being turned round after being put into special measures, 5,000 more nurses on our wards, the My NHS website and 4.2 million NHS patients being asked for the first time if they would recommend to others the care they received.

In the next few months, however, we will go further, announcing new measures to improve training in safety for new doctors and nurses, launching a national campaign to reduce sepsis and responding to recommendations made in the follow-up Francis report, tackling issues around whistleblowing and the ability to speak out easily about poor care.

Under this Government, the NHS has, according to the independent Commonwealth Fund, become the top-ranked healthcare system in the world. In 2010, we were seventh for patient-centred care, and we have now moved to top. Under this Government, we have also become the safest healthcare system in the world. But with an ageing population, we face huge challenges.

How we prepare the NHS and social care system to meet those challenges will be the litmus test of this Government’s ambition to make Britain the best country in the world to grow old in. We are determined to pass that test and today’s four-pillar plan will help us to do just that. Our plan will need proper funding, backed by a strong economy, so I welcome yesterday’s comment by Simon Stevens that when it comes to money,

‘the Government has played its part’.

However, we also need ambitious reforms to the way we deliver care, focusing on prevention, innovation and a patient-centred culture that treats every single person with dignity and respect—proper reforms not as a substitute for proper funding but as a condition of it, with a long-term plan for the economy and a long-term plan for the NHS. I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

My Lords, I normally thank the Opposition spokesmen for their comments, but that was an absurdly negative response, if I may say so. It does the noble Baroness no credit to do that amount of shroud-waving. She knows perfectly well that the case that she has put is grossly overegged. Yes, of course, the NHS is under pressure; we all know that. There is rising demand on a scale that we have never seen, but it ill befits the party opposite, which agrees that more money is needed for the NHS, to take issue with the money that we are announcing today. I would have hoped that she would have welcomed that, but she has not.

I shall answer the noble Baroness’s questions about where the money has come from. We never pretended that the whole £1.95 billion was new money. Some £550 million comes from reprioritised programme work that we have reallocated from the department; £150 comes, similarly from work that NHS England has reprioritised. So the Treasury is providing an additional £1 billion of funding; the department, as I say, is doing its bit; and the Treasury is also providing additional funding of £1 billion over the next four years, to support investment in out-of-hospital infrastructure and facilities. The £700 million that the Treasury is not providing as new money is made up of savings from a number of programmes which come to a natural end in 2014-15. There are back-office savings and there is contingency funding which is no longer needed. These savings have been found without impacting on existing front-line services, so this funding provides a genuinely additional boost to the NHS.

As for the Treasury’s new money, £1 billion from the forex fines will fund the £1 billion fund over four years to invest in out-of-hospital infrastructure, but the Government’s tight financial management has seen departments continue to exceed savings targets. Historical underspends have been quite considerable. The largest were generated by the Ministry of Defence, the Department for Education and the Department for International Development. These underspends demonstrate the Government’s firm grip of the public finances and continued improvements in spending control and financial management. They allow us to be confident in reallocating spending within the overall totals for 2015-16 to priorities in the health service.

The noble Baroness mentioned mental health. We remain committed to investing in mental health services. The Deputy Prime Minister will be making a full announcement soon, outlining how we will invest an additional £45 million on mental health services. As for the current year, to which she also referred, we have already made significant additional funding available for the NHS this year to support winter and system-resilience planning and to tackle long waits for operations. Robust plans are in place to maintain and improve NHS performance through the rest of this year and we are confident that the NHS will live within its budget this year.

The noble Baroness also mentioned social care and the pressures on those services. Through the better care fund we are moving to a position where we see health and social care no longer as separate budgets and services, but rather as the same thing—a position the patient and carer have been in for a number of years. Any investment in the NHS will provide benefit to social care and, as the Five Year Forward View sets out, the NHS will take decisive steps to break down the barriers in how care is provided between health and social care. This funding will help kick-start that.

As for the noble Baroness’s final barb about the Government’s reforms, I put it to her that the NHS is now set fair to work with the system that we have established. In other words, we have established a system that has health and well-being boards looking at the health priorities of a whole area, with clinicians embedded in that prioritisation process, commissioning for the health needs of an area, and public health centred on local authorities, which many regard as its natural home. We have clinical leadership in those clinical commissioning groups, something we did not have before these reforms, and we have saved a packet of money. The noble Baroness referred to the £3 billion cost of the reforms. That figure is fiction, as I am sure she knows because I have said it many times. The gross cost of the reforms was roughly £1.5 billion. During this Parliament, we will be saving, net, £4.9 billion as a result of the reforms, with £1.5 billion recurring year after year. This is a massive boost to front-line capacity in the NHS and nobody should forget that. This was a set of reforms designed to benefit patients and, by that measure, I put it to the House that it has succeeded in spades.

[Lord Willis of Knaresborough (LD)]

I thank my noble friend for repeating the Statement. I echo the point that, while many of us on all sides of the House may have disagreed with some of the structural changes in the Health and Social Care Act, the last thing the health service wants is another structural reorganisation. The plan by the party opposite to scrap the Health and Social Care Act is a real worry to many professionals. I say to my noble friend that no matter how much money the Chancellor promised today, it will not be enough to meet the demands of a changing healthcare system, where we are seeing, year on year, because of the success of the NHS, people living longer and with lots of different comorbidities.

I have a concern about the Statement. I actually think that Simon Stevens’s report is an excellent report and one that should have united this House rather than dividing us. After all, his pedigree comes from working with the Labour Party on the early reforms in the last Parliament. What really worries me is that neither in Simon Stevens’s report, nor in the Statement, is there a mention of the other crucial element, which is the workforce. The workforce and, indeed, the work of Health Education England, is not even worth a mention in the Statement—yet it is the 500,000 nurses and the 1.4 million care workers who bind the health and care system together and who will deliver the integrated health and social care which all of us in this House want to see.

Will my noble friend make it clear today that no savings will be made by reducing Health Education England’s budget? Will he state clearly that there will be investment in the skills of our staff in order that Simon Stevens’s plan actually works and that we can make it a realisation rather than a hope?

[Earl Howe]

My noble friend is absolutely right. One of the critical elements of the Five Year Forward View is to ensure that we have the right number of staff with the right qualifications in the right places. While Health Education England is the body charged with ensuring that that happens, it is up to us in government to ensure that there is adequate funding to enable it to do that. I can assure my noble friend that Ministers are very clear that Health Education England should be fully supported to deliver the programme that it has mapped out for itself. That programme is an exciting one. It involves more doctors and nurses in training over the next few years. Our ambition is to see by 2020 an extra 10,000 people working in primary care, for example—and that is only one detail.

As a result of the Government’s reforms to the health service, we have been able to afford a large number of extra posts in front-line care, including doctors and nurses in both primary and secondary care. We have done that by reducing the number of administrators in the system—20,000 fewer than there were in 2010. My noble friend is right to draw attention to this issue; it is one that is very much in our focus.

[Lord Liddle (Lab)]

My Lords, pursuing the point about the integration of health and social care—I declare an interest as a member of Cumbria County Council—we in Cumbria face a situation where already our budget has gone down by over £100 million, we face another £80-odd million of cuts in the next four years, and this does not take account of the cost of the tax reductions that the Conservative Party is promising. The numbers of staff will have declined by 2,500 from 2010 to 2017, out of a staff of about 8,000. In this situation, it is impossible to protect social care. It is interesting that the Government are promising a longer-term perspective on health funding. Does this perspective apply to social care funding as well? What guarantees are the Government able to give that they will continue to fund local councils adequately in order to meet the rapidly growing demands of social care?

[Earl Howe]

My Lords, the noble Lord makes a very good point. It is for precisely that reason that we have looked at the mechanism that we have called the Better Care Fund to bring together budgets for health and social care. It will amount in practice to a transfer of funding into social care from the NHS. We are clear that that is the best way in which we can realise the vision that we have set, which is a preventive one for people—in other words, to forestall admissions to hospital.

Local government is feeling the strain—I do not seek to deny that—but so are many other areas of our national life. Up to now, the Better Care Fund aside, we have found an extra £1.1 billion from the NHS budget to bolster local authority budgets, and we are maintaining public health allocations at the same figure as before, so no cuts there. I realise that the strains are considerable and that local authorities are having to find ingenious ways of moving forward, but I am encouraged by the Better Care Fund plans that are coming forward; they look credible and exciting in terms of the quality of care that local authorities are now looking at.

[Lord Walton of Detchant (CB)]

My Lords, it may be thought inappropriate that someone of my age should comment upon what is called a forward view but which is in fact a five-year plan. Having said that, I have listened carefully to the Statement repeated by the Minister with his characteristic lucidity and authority, and although I have heard many five-year plans discussed by Governments of all parties over the past 66 years since the NHS began, I think that there are features of this one that are quite important, not least the crucial importance of integration between medical and social care. Will the additional funding that the Minister announced be capable of introducing and maintaining a seven-day week in the NHS, in the community and in the hospitals, which has been long awaited? That is a very important point.

I welcome what the Minister said about developments in the training of healthcare professionals; that is a crucial point at this stage in NHS development. I also welcome what he said about developments in biomedicine. In what way are the Government going to be able to handle the many new orphan and ultra-orphan drugs that are now coming on stream for the treatment of rare diseases, as a result of research in the NHS, which are going to be extremely costly? Is this going to be handled by NICE or do the Government have any specific plans regarding that problem?

--- Later in debate ---

[Earl Howe]

My Lords, I thank the noble Lord, Lord Walton, for his welcome of the Statement and indeed of the Five Year Forward View, which I think commanded a great deal of support from many quarters. He asked about the seven-day working plans for the NHS. Part of the Better Care Fund plans involves local areas committing, in one form or another, to seven-day working. Unless we have seven-day working in hospitals, we cannot hope to achieve the smooth and timely discharge of patients. That means a change in approach by a number of professionals. It does not mean that every professional will need to work seven days a week—no one has ever suggested that—but it means a shift in approach by social services, and by consultants in hospitals, in a way that in some areas we have not seen. In other areas this is already happening, and we can build on those models.

On the noble Lord’s question on biomedicine and orphan drugs, he is of course as well informed as he always is on these matters. Orphan drugs, as and when they come forward, can indeed be expensive, particularly if they are termed a stratified medicine applicable to only a narrow cohort of patients. In those instances we will expect NICE to make an assessment of these high-cost, low-volume treatments under its new methodology for those drugs. NICE is already engaged in a number of work streams in those areas. It is right that we take that approach. We have to have some methodology that commands confidence, to ensure that the NHS receives treatments that are not only clinically effective but provide value for money.

[Lord Cormack (Con)]

My Lords, I thank the Minister and congratulate him on what he has said. However, does he not accept that at the end of five years, welcome though this new injection of money is, there will be even greater demands and greater needs? Will he reflect on the debate introduced last year by the noble Lord, Lord Patel, where almost every speaker from all sides of this House indicated that there is a need for a plurality of funding if our National Health Service is to avoid further problems and disasters? Will he therefore reflect on the wisdom of establishing, with all-party support, a royal commission on the funding of the NHS that can look at everything and rule nothing out? If we are to have a world-class service through this century, we cannot resort to sticking plasters from time to time; we must have a new model of funding.

[Earl Howe]

My Lords, my noble friend, as ever, has rightly identified the likelihood of greater and greater demands on our health service over the coming years. Certainly, building a non-partisan consensus is something to be desired regarding the way that we fund our health service. Having said that, I can tell my noble friend that there has been no thinking whatever on the part of Ministers to depart from the current model of funding for the NHS. We believe passionately that the NHS should be free at the point of use, regardless of ability to pay. That is one of the core principles on which the NHS has been founded since 1948 and it is paid for out of general taxation. While I take on board my noble friend’s desire to look afresh at this area, I think that we have some way to go before cross-party talks need to take place. We are clear that we can proceed on the current basis.

[Lord Davies of Stamford (Lab)]

The noble Earl has always taken a very serious attitude towards his ministerial responsibilities and he has just spoken about the desirability of moving to an all-party consensus on health matters. Does he not therefore rather regret, in retrospect, that the Government decided to spin this announcement, leaking it in advance of the Statement in the House of Commons and putting it about that there was £2 billion of new money for the NHS—the implication being that this was the result of more buoyant government revenues because of a higher growth rate? In fact, it is nothing of the kind as the noble Earl has now revealed to the House. It is roughly £1 billion being reallocated within the NHS budget and £1 billion being reallocated from other department budgets, including from defence where there has been underspend, which is very damaging to this country’s interest. Would it not have been better, and easier to develop a consensus in this country—to which the noble Earl quite rightly looks forward—if in fact the Government were slightly more straightforward and candid with the public over announcements of this kind?

[Earl Howe]

I do not think one can develop a consensus prior to a government Statement—that is probably wishing for the moon. The charge that the noble Lord levels against the Government is also, if I may say so, misplaced. We have never pretended that all the money being announced today is new money. I do not seek to suggest that, as I have already explained. As regards the timing, I think it is standard practice for key elements of the Autumn Statement to be trailed ahead of the formal announcement. However my right honourable friend the Chancellor will confirm everything we have said today in the Autumn Statement on Wednesday, and that is as it should be.

[Baroness Masham of Ilton (CB)]

My Lords, the Minister has not said anything about specialised units. I declare an interest as president of the Spinal Injuries Association. Spinal units are vitally important when patients need treatment, yet some spinal units have cut the services of physiotherapists and occupational therapists, who are vital for rehabilitation. The answer is always, “It is up to the trusts”. The trusts can be wrong and in this case they are. Can the Minister give an assurance that there will be enough trained doctors, nurses and therapists for the next five years in spinal units?

[Earl Howe]

My Lords, I will have to take advice about that question. What I can say is that we now have in place a system of workforce planning that is better than its predecessor. I do not think there can ever be such a thing as a perfect system of workforce planning. We now have a national body, Health Education England, that is responsible for making sure that we have adequate numbers of professionals with the right skills. However, we also have local education training boards whose members include representatives from the acute trusts. It is up to those boards to make clear what the requirements are for trained staff and feed those requirements up to Health Education England so that planning over the coming years can be done in a rational and sensible way. I would expect that spinal units should make their case in that fashion so that if there is a need for physiotherapists in spinal units, and those physios are—for any reason—not available, then they will come forward in adequate numbers in years to come.

[Lord Patel (CB)]

My Lords, the Minister started his Statement by saying that the Government recognise the importance of life sciences in both economic growth and in delivering mental health care. Of course, I would agree with that and I take it from the Statement that the Government therefore have no intention of cutting the budget of either clinical or medical research in the spending review to come. I welcome the suggestion that the Government will recruit more people to decode genetic information. Of course, we will need that if we are to develop better biomarkers or drugs for treatment, but the personalised medicine that would lead to is expensive and the budgets it will require will be far greater that what we have now.

I also welcome the idea that we integrate the care of patients and do not have a demarcation between primary care, community care and hospital care, but the model that he suggested might not quite do that. He might like to reassure us that the model he has in mind is of complete integration of care, otherwise we will not win the battle for better care for people suffering from long-term conditions.

The comment about future budgets requires a greater debate. I have read the review in detail and it is a bold statement to say we can conduct a five-year review of healthcare without any further restructuring. I, for one, do not mind some restructuring if it will lead to better delivery of healthcare.

[Earl Howe]

I think that the restructuring the Government believe is necessary is the restructuring of the delivery of care and the culture, as the Statement made clear. What we do not think necessary is a restructuring of the architecture of the National Health Service. That has been done and, as I have said, we are set fair for the future. As regards integration, will it be complete integration? “Integration” is a word that is bandied about and it will mean different things in different areas, depending on what is necessary. We are clear that the better care fund plans, for example, which focus on this idea of integration, should most definitely involve the acute sector and social care along with primary and community care, and in many cases other disciplines as well. Pharmacy, for example, has a major part to play in reducing unplanned hospital admissions and I could cite many other professional disciplines. It depends on what each area requires.

I cannot give an answer on the research budget in the next spending review because that spending review will be conducted by the next Government, whoever they will be. Meanwhile, we are clear that the research budget is an absolutely essential part of the NHS’s future ability to provide quality care for patients over the long term. As the noble Lord knows, we have protected that budget during this Parliament.

Nursing and Midwifery (Amendment) Order 2014

Earl Howe Excerpts

Thursday 27th November 2014 Grand Committee

Moved by

[Earl Howe]

That the Grand Committee do consider the Nursing and Midwifery (Amendment) Order 2014.

Relevant document: 9th Report from the Joint Committee on Statutory Instruments.

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

My Lords, the Government have identified improvements that can be made to the legislation within which the Nursing and Midwifery Council operates, to improve public protection and increase public confidence in the Nursing and Midwifery Council. Therefore, the department carried out a UK-wide consultation on proposed changes to the Nursing and Midwifery Order 2001, which is the Nursing and Midwifery Council’s governing legislative framework. The majority of respondents supported these amendments.

The first of the proposed changes is to enable the Nursing and Midwifery Council to appoint case examiners who will be given powers currently exercised by the investigating committee to consider allegations of impairment of fitness to practise, following an initial screening which has considered that an investigation is appropriate. Two case examiners—one lay and one registrant—will consider the allegation, following the procedure set out in amendments to the Nursing and Midwifery Council (Fitness to Practise) Rules, which are being developed in parallel to this order by the Nursing and Midwifery Council.

The case examiners will then agree their decision on whether or not the registrant has a case to answer—this is the same process used by General Medical Council case examiners—and whether the allegation should therefore be considered by the health committee or by the conduct and competence committee. If case examiners fail to agree on whether there is a case to answer, the allegation will be referred to the investigating committee for determination. The introduction of case examiners should lead to the swifter resolution of complaints and thereby improve public protection and the efficiency of the Nursing and Midwifery Council’s fitness to practise processes, as well as reducing the stress to registrants caused by lengthy investigations.

The second change is to introduce a power for the council to review “no case to answer” decisions made at the end of the investigation stage in fitness to practise cases, and to make rules in connection with the carrying out of such a review. This will bring the Nursing and Midwifery Council’s power in line with the General Medical Council’s power.

The third change is to introduce a power to allow the council to delegate this function to the registrar—the chief executive. The amendments to the fitness to practise rules being developed by the NMC will provide that the registrar may review a “no case to answer” decision where new evidence comes to light that has a material impact on the original decision or if it is considered that the decision may be materially flawed, and in both cases that it is in the public interest to review. Save in exceptional circumstances, a review of a “no case to answer” decision cannot be commenced more than one year after the date of that decision.

The fourth change is to revise requirements for the composition of the registration appeal panel by removing the requirements for a Nursing and Midwifery Council member to chair the panel, which is intended to establish a clear separation of duties between the operational and governance functions to avoid suggestions of perceived bias and conflict. Additionally, it will remove the requirement for a registered medical practitioner to be on the panel in cases where the health of the person bringing the appeal is an issue. It is intended that medical advice will be provided by independent medical witnesses and reports to ensure the panel remains detached from that part of the process, and therefore making the process more robust and transparent. This will also ensure more consistency between registration appeals and fitness to practise appeals.

The fifth element is to clarify existing legislation that the Nursing and Midwifery Council’s Health Committee or Conduct and Competence Committee has the power to make a strike-off order in a health or lack of competence case upon a review of a final suspension order or conditions of practice order, provided the registrant has been the subject of such a final order for at least two years. This is not a new power but provides clarification of the existing legislation to protect patients and the public by ensuring that those whose fitness to practise is impaired cannot continue to practise.

The sixth change is to introduce a power for the Nursing and Midwifery Council to disclose to a third party certain information relating to a person’s indemnity arrangements for the purpose of verifying that information for the Nursing and Midwifery Council’s purposes. This will enable the Nursing and Midwifery Council to verify the information it receives to ensure that indemnity arrangements are in place and provide sufficient cover against the liabilities that many be incurred by a practising nurse and practising midwife registrant.

The seventh change is to give the Investigating Committee a new power to also make an interim order after it has referred a case to the Health Committee or to the Conduct and Competence Committee if that committee has not begun its consideration of the case. At present, once the Investigating Committee refers a case, the power to make an interim order rests only with the Conduct and Competence Committee or the Health Committee. This will ensure that if new information is received which suggests that an interim order is necessary for the protection of the public after a case has been referred to another practice committee, but before the committee has started to consider it, the Investigating Committee will have the power to make an interim order.

The introduction of case examiners and the power to review “no case to answer” decisions, made at the end of the investigation stage in fitness to practise cases will bring the Nursing and Midwifery Council in line with the General Medical Council. The implementation of these recommendations requires a Section 60 Health Act 1999 order to amend the legislation governing the Nursing and Midwifery Council. I commend this order to the Committee, and I beg to move.

[Baroness Brinton (LD)]

My Lords, this amendment to the Nursing and Midwifery Order is to be welcomed. A regulatory body has to balance the respected traditions and structures of an informed 150 years of experience with the urgent needs of the current issues that the council faces when there may be rare problems with registered nurses and midwives. Much of what is proposed follows good practice. However, there is one area in which I have some minor queries and I wonder whether my noble friend the Minister can help.

The move away from independent consultants forming an investigation committee to having an in-house employed case examiner raises two minor concerns that are not reflected in the consultation response at paragraph 8.6 of the Explanatory Memorandum. Will the case examiners have extensive training in gathering the evidence that they will have to present to the quasi-judicial relevant committee considering each case? Will the benefits that other investigating groups such as Ofsted and local government inspectors have, given that at least one member of those teams comes in from outside, ensuring that there is always fresh challenge, be lost with this new arrangement?

Secondly, as employees of the council, will their job specification make it absolutely clear that they must conduct their role without fear or favour? It may be obvious when they are dealing with people outside the council but occasionally—very rarely—there may be a case where, for example, a decision not to have an interim suspension might have resulted in further injury or damage, and therefore members of the council themselves and other judgments might be being examined. The case examiners must be truly free to examine the council’s own processes and to feel no pressure from their own managers.

The no case to answer decision and the independent chair of the appeals panel are important and to be welcomed. However, given what I have just said about the case examiners, I find it slightly peculiar to remove the requirement for a registered medical practitioner to be on the panel, because that person in the past has provided that independent voice from the members of the council.

The points that I have raised are minor ones, and I welcome the order. However, I hope that I can have some reassurance on these points relating to the new role of case examiners.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, am very grateful to the noble Earl, Lord Howe, for explaining the details of the order so clearly. However, he did not mention the Law Commission proposals for legislative changes relating to all health regulatory bodies. I note that the Explanatory Memorandum says that the Government will publish a response in due course, but I have to say that there is huge disappointment among the regulators that no Bill appeared this Session—not even one for pre-legislative scrutiny. Essentially, we are now faced with a series of Section 60 orders dealing with the regulatory bodies in an individual and piecemeal way, without the consistency and modernisation of the regulatory landscape that was promised by the Law Commission work. I hope that the noble Earl will be able to say a little more about when the Government will publish their response to the Law Commission proposals and perhaps give a little more information about how he sees the pipeline for Section 60 orders coming forward.

In particular, he will know that, in relation to the NMC, part of the Law Commission proposals were that there would be a reduction in the number of public hearings that have to take place. That would reduce the cost to the NMC and the time it takes to deal with cases. Given that we are not having primary legislation, is it the Government’s intention to bring forward as quickly as possible a Section 60 order in relation to that? As far as the proposals in this order are concerned, they seem sensible and unexceptional. I hope that they will lead to the NMC being able to be more efficient in its processes.

Having read the consultation document, I would just like to raise a couple of points on it. First, I will follow up what the noble Baroness, Lady Brinton, said about case examiners. The consultation document refers to a small number of people who are unsure about this proposal. I am particularly worried that as case examiners will be employees of the NMC, they will be target driven rather than acting as independent professionals. The consultation response from the Government says this will not be the case. It states:

“Although employed by NMC, Case Examiners will be both registrant and lay (non-registrant) and experienced senior decision makers who are used to making independent decisions”.

I very much endorse the comments of the noble Baroness, Lady Brinton, on training and the need for people to be brought in to provide fresh challenges. However, this issue about targets is a very important one, and I wonder whether the noble Earl can give me a reassurance that there will not be targets—even unseen ones—in relation to cases and their outcomes. Can he just say a little more about how we can ensure that case examiners will be wholly protected when they carry out their duties? If they are in a managed organisation, they will be accountable to a manager, and we need to have some assurance that there is not going to be interference by the hierarchy of the NMC in case examiners’ decisions.

I would like to ask about another point raised in the consultation document. One response was about the need for more diversity on panels,

“in particular a point that black, minority and ethnic (BME) employees are disproportionally represented within the disciplinary systems of both employers and regulators”.

The consultation says:

“These comments have been fed back to the NMC to consider”.

Has the NMC now given consideration to that issue?

Turning to the Deregulation Bill, the noble Earl was present at our debate last week and will know that we have some concerns that, according to a list issued apparently by the Government, the Professional Standards Authority is subject to the economic growth duty within that Bill. I do not expect the noble Earl to answer me on that today. But, given that the Professional Standards Authority is to be involved, can I take it that by implication that duty will fall also to the NMC, the GMC and other professional regulatory bodies? Obviously, we will come back to this issue when the Deregulation Bill returns on Report but we are finding it difficult to find out the list of organisations that the Government consider should be encompassed within it.

Of course, the issue is that there may be an impediment to the non-economic regulators taking regulatory action because they now have to consider the economic growth duty. In the main, that will apply more to the CQC when dealing with organisations than it will to the individual regulatory bodies. But as the Government think that the PSA is encompassed within the Bill, I would be interested in a response from the Government.

Will the noble Earl say something about the overall performance of the NMC? He will know that this has been the subject of some concern and indeed scrutiny by the Health Select Committee. At the most recent accountability hearing in 2013, the Health Select Committee concluded:

“The NMC is an organisation with a recent history of poor performance, including lack of focus on its core regulatory activities, financial mismanagement and long delays in processing Fitness to Practise cases”.

The PSA’s 2013 performance review of the nine healthcare regulators it oversees, which was published in July this year, stated that the NMC,

“is not yet meeting eight of the 24 Standards of Good Regulation”.

I know that in the 2013 accountability hearing the Health Select Committee concluded that,

“the NMC has made progress”—

indeed, I pay tribute to the chief executive and the chairman, who have done a lot to ensure that this happens—but it also says that,

“more progress is required before the NMC can be regarded as an effective regulator”.

Would the noble Earl care to comment on that?

The Select Committee also looked at the issue of revalidation. Following the introduction of revalidation for doctors, the need for revalidation for nurses is self-evident. The Health Select Committee says that it welcomes,

“the commitment of the NMC to introduce revalidation for nurses and midwives from the end of 2015”,

but that,

“it does not believe the NMC yet has a workable plan to deliver this commitment”.

That is the 2013 report of the accountability hearing. The Select Committee has not yet had the 2014 hearing, which I think will take place in January. Will the noble Earl update the Committee on whether he now thinks that the NMC has a workable plan?

Overall, this is a sensible order. We need to do everything we can to help the NMC improve its processes. I express my thanks to the current leadership of the NMC and the work that it has done. It clearly needs to do more and Parliament needs to be prepared to help it. If we are not going to have a substantive Bill, I would have thought it a priority to bring further Section 60 orders in relation to the Nursing and Midwifery Council, particularly on the question of whether we can help it streamline its fitness to practise hearings.

[Earl Howe]

My Lords, I am grateful to my noble friend and the noble Lord, Lord Hunt, for their questions and comments. My noble friend Lady Brinton asked for reassurance about the case examiners. Under the proposals, the two case examiners will independently review the evidence and then agree their decision. This is the same process as used by GMC case examiners, and I am not aware of any particular difficulties that it has encountered in this connection. If the case examiners cannot agree the decision, the case will then be referred to the investigating committee for determination, as I explained.

My noble friend asked about training of the case examiners. Two case examiners, one lay and one registered nurse or midwife, will consider an allegation of impairment of fitness to practise, whereas three investigating committee members are required at present. Co-ordinating meetings of the investigating committee members is time-consuming due to panel members having other commitments or requiring refreshed training. A case examiner will be a skilled role. They will develop expertise that will lead to greater consistency when making decisions because they will be considering a greater number of cases on a regular basis than individual members of a large pool of investigating committee members. This will speed up the fitness-to-practise process and result in reduced costs.

My noble friend asked whether the job specification of case examiners, as employees of the council, must specify that they carry out their roles without fear or favour and be truly free to make comments. Case examiners will be employed by the NMC, whereas investigating committee members, who currently consider allegations of fitness to practise, are chosen from a pool of around 100 individuals who provide their services to the NMC as independent contractors. But, once again, there is no reason to suppose that, as professional people, they will feel inhibited from voicing their full and frank views whenever they feel the need to do so. Despite their being employees, it is more than any professional’s self-esteem is worth to feel inhibited in that sense. It is a very responsible role. While the individuals will need to be carefully chosen, I have confidence that this arrangement will work.

My noble friend asked about the removal of the requirement for a registered medical practitioner to form part of the panel where health is an issue. We consider it more appropriate for medical advice to be provided by independent expert witnesses and medical reports. Having an independent medical witness will ensure that the panel remains detached from that part of the process and is therefore more able to make an independent decision so making the process more robust and transparent. This would ensure consistency between registration appeals and fitness-to-practise appeals.

The noble Lord, Lord Hunt, expressed concern that case examiners might be target driven, and this was an issue raised in the consultation. We do not believe that this will be the case. Although they will be employed by the NMC, case examiners will be both registrant and lay; that is, a registrant nurse or midwife and a lay person. Their role will be distinct; they will be responsible only for making an assessment of whether a registrant has a case to answer against an allegation that is made to the NMC that their fitness to practise is impaired. They will make their decisions impartially and independently, and based solely on the information provided for the case, including any representations made by the registrant. Any such decision would be made by a pair of case examiners. The NMC will seek to appoint people to these roles who have demonstrated sufficient skills and experience to make robust decisions. The NMC’s case examiner resource will be sufficient to ensure that all decisions will be considered on their merits, without any undue time pressure. Case examiners will not be involved in undertaking the fitness to practise investigation itself, nor in presenting cases at any final hearing.