Learning Disabilities: Health and Care Services

Debate between Earl Howe and Baroness Cumberlege

Wednesday 3rd December 2014 Lords Chamber

[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: Midwives

Debate between Earl Howe and Baroness Cumberlege

Tuesday 22nd July 2014 Lords Chamber

[Earl Howe]

My Lords, helping commissioners to reduce unwarranted variation in service delivery is one of the key roles of maternity and children strategic clinical networks, which are being established and supported by NHS England. We know from experience that these networks have a tremendously beneficial effect in ironing out inequalities in access.

[Baroness Cumberlege (Con)]

My Lords, will my noble friend rejoice with me that independent midwives now have professional indemnity? Does he agree that they make a very valuable contribution to maternity services, especially for vulnerable women?

[Earl Howe]

My Lords, we naturally applaud the professionalism of independent midwives. I agree with my noble friend that it is a positive step forward that all healthcare professionals in this country have professional indemnity insurance. We must think of the patient always and, should something go wrong, it is right that every patient is protected by indemnity or insurance.

Health Care and Associated Professions (Indemnity Arrangements) Order 2014

Debate between Earl Howe and Baroness Cumberlege

Monday 30th June 2014 Grand Committee

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

My Lords, in July 2010 the four UK health departments accepted the recommendations of the Finlay Scott review, which recommended that all regulated healthcare professionals should be required to hold appropriate insurance or indemnity cover as a condition of their registration when carrying out work as a regulated healthcare professional.

The Government are committed to requiring all practising regulated healthcare professionals to hold indemnity or insurance cover, and have been for some time. The Government are also required to implement Article 4(2)(d) of the EU directive on patients’ rights in cross-border healthcare, which reinforces that direction of travel and further commits us to legislation. The purpose of this policy is to ensure that people have access to appropriate redress in the unlikely event that they are negligently harmed during the course of their care. All patients should have that by right. The overwhelming majority of regulated healthcare professionals will be unaffected by the proposals because they already have insurance or indemnity cover. For employees in the NHS or independent sector, cover is already in place because of an employer’s vicarious liability for the negligent acts or omissions of their employees. Personal cover is required in relation only to self-employed practice.

The order makes provision that all practising regulated healthcare professionals must hold an appropriate insurance or indemnity arrangement as a condition of their registration—and, in the case of medical practitioners, a licence to practise—with the relevant regulatory body. It will be for individual healthcare professionals to assure themselves that appropriate cover is in place for all the work that they undertake. Unless healthcare professionals, who are practising or intend to practise, can demonstrate to the satisfaction of the regulatory bodies that such arrangements are or will be in place, they will be unable to be registered as a healthcare professional and will be unable to practise. I commend this order to the Committee, and beg to move.

[Baroness Cumberlege (Con)]

I declare an interest as a fellow of the Royal College of Obstetricians and Gynaecologists, a vice-president of the Royal College of Midwives and a patron of the National Childbirth Trust and Independent Midwives UK. I have other interests that are in the Lords’ register. I thank my noble friend for introducing this statutory instrument so clearly and for meeting the noble Lord, Lord Hunt, and myself, when we discussed the issue of independent midwives.

Draft statutory instruments are not usually a very gripping subject, but this one is because it affects the livelihood of so many people. It is therefore being introduced as an affirmative resolution. Not many statutory instruments, when enacted, will ensure that a professional is denied the right to practice—denied their livelihood. However, I start from the premise that every practitioner should have professional indemnity insurance. Some independent midwives are possibly the only group reluctantly acting without it but not only do they recognise the need for it, they want it and are prepared to go to great lengths to achieve it. This statutory instrument has concentrated minds and focused on the practicalities to achieve it, and from that point of view I welcome it.

It has been a struggle because insurance bodies draw no distinction between midwifery care and obstetric care, and of course the service given by each profession is very distinct. Obstetric treatment is very often a high risk activity, whereas midwife care is much less so. Successive Governments have adopted a policy that women should have choice—choice in healthcare but particularly choice in maternity services. This policy has been very widely welcomed by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the National Childbirth Trust, which have listened to women and have fought fairly long and hard to achieve this choice. All the evidence that they and others have gathered shows that women and their partners want choice. After all, there is nothing more important in life than giving life and bringing up the next generation.

Over the years, choice has been eroded thanks to the closure of maternity units, but in some places midwife-led units or birth centres have replaced them. They are often under threat as well. I welcome midwife-led units because they are another form of choice but I regret the diminution of home births because that is a choice denied. I ask my noble friend: how many home birth services in the NHS are on temporary hold and how many have closed? I know that they are very detailed questions and I would welcome a written reply if that suits my noble friend better than responding now. I am asking these questions because Independent Midwives UK provides for home births. That is a government policy and one that has been strongly endorsed by NICE. Independent Midwives UK provides continuity by a named midwife throughout antenatal care, birth and postnatal care—another government policy. Throughout the NHS this has proved to be pretty unachievable because community midwives are drawn into the acute services whenever there is a shortage, and because there is frequently a shortage it happens frequently.

The department’s new definition of continuity is co-ordination. A named midwife should co-ordinate the care, as my noble friend said previously. We should ask women what they think. Is co-ordination the same as continuity? Of course it is not, when in extremis women cannot even get their co-ordinator on the telephone 24/7 but they can with an independent midwife. Do they build a relationship with the co-ordinating midwife, assisting at that seminal moment of giving birth? No, because she is not there; she is too busy co-ordinating.

Independent midwives in all their forms—as social enterprises, employee-owned organisations, provident industrial societies with “bencom” status and so on—want to provide choice, continuity and care for women both in the independent sector and for the NHS. They are based in their communities and many provide services for vulnerable women, asylum seekers, those with mental health problems and so on, on a pro bono basis, but like the rest of us they cannot live on fresh air. They are seeking commissions with clinical commissioning groups. They are working towards direct referrals from GPs who welcome the continuity of knowing the midwife responsible for a mother who needs advice and support. Can my noble friend suggest ways in which the Government could support independent midwives, who are the professionals who not only support the Government’s policy but are the professionals who actually carry it out?

The NHS mandate, which sets the agenda for NHS England and which my noble friend and his ministerial colleagues shape, is an opportunity to ensure that alternative choices are there for women and their partners. Will he encourage the ministerial team to focus on this issue and enable independent providers of services to thrive, thereby enhancing government policies, giving women choice and providing the continuity that they seek?

In closing, I pay tribute to the Nursing and Midwifery Council, which has taken a very measured view of this statutory instrument, has listened and has tried to meet the needs of all concerned, amending its guidance as necessary. I look forward to my noble friend’s reply, in writing if necessary.

--- Later in debate ---

[Earl Howe]

My Lords, I am grateful to all noble Lords who have spoken. I shall endeavour to answer all questions that have been put to me as fully as I can. To the extent that I cannot, I shall of course write to noble Lords after this debate.

The centre of attention in noble Lords’ contributions has been independent midwives. Independent Midwives UK is the body which has expressed most concern about the regulations. I am the first to say to my noble friend Lady Cumberlege that continuity of care and service in the NHS is important, and that is part of the mandate to NHS England. We fully accept the value of independent midwives. NHS England will refresh the maternity commissioning guidance to CCGs over the summer to support the plurality of providers and to help social enterprises get NHS commissions.

However, as my noble friend is aware, we are dealing here with self-employed, independent midwives. It is therefore important to look at the factors which pertain to that group of people in particular. My noble friend suggested that the order effectively puts certain independent midwives, the self-employed practitioners, out of business. I do not see it in that way at all. We recognise that self-employed independent midwives may be required to change their governance and delivery practices to comply with an indemnity policy, and it is for the individual practitioner to determine a suitable operating model under which they are able to continue to practise. Social enterprises are the obvious route to that.

The suggestion that independent midwives have not received the fullest attention from officials in my department is seriously misplaced.

[Baroness Cumberlege]

I have never said that. The department has really helped independent midwives keep up to date with what has been going on. Nor am I opposed to the order. I said earlier that I start from the premise that every practitioner should have professional indemnity. Perhaps the noble Baroness, Lady Emerton, did not hear that.

[Earl Howe]

I fully accept my noble friend’s statement on that score. It has been said that the Government have not been sufficiently supportive of the attempt by IMUK to overcome these obstacles, and I welcome my noble friend’s recognition of those efforts.

Independent Midwives UK made an application, as my noble friend knows, for government funding for its proposal. That was considered, but the conclusion reached after independent expert advice was that the proposed insurance model was not feasible and would not provide long-term protection to pregnant women.

Alongside that, we were mindful that the creation of any government scheme specifically for Independent Midwives UK would effectively position the Government as the underwriter of the independent sector. My noble friend is as aware as anyone of the sensitivity of that. That would have undermined any private sector solution, which in turn would reduce the onus on midwifery service providers to demonstrate financial responsibility in what is undoubtedly a high-risk area of clinical practice—that is, it would reduce the onus on them to be responsible for showing an underwriter the appropriate steps being taken to mitigate risks. So, for a number of reasons, we were not able to take those proposals forward.

However, we explored a number of routes. One was that a corporate body should be formed that would be eligible to join the clinical negligence scheme for trusts, although that would not cover non-NHS work. We made funds available via our Social Enterprise Investment Fund to support the development of social enterprise solutions where the market does not offer affordable indemnity to individuals. That was not seen as a viable route either, although a new social enterprise called Neighbourhood Midwives was set up through that route and is now offering maternity care in the private sector with appropriate indemnity cover in place. Its business model is a 100% employee-owned mutual providing management and support to small, community-based neighbourhood practices.

My noble friend Lady Brinton asked about the insurance sector. From the start of the discussion in 2010, dialogue has been in progress with the Association of British Insurers, individual insurers and insurance brokers, who have indicated that insurance would be available for corporate bodies employing midwives to deliver NHS or non-NHS services. It would be necessary for corporate bodies to demonstrate the robustness of their governance systems to provide adequate assurance to an indemnifier. Where providers can demonstrate safe outcomes as well as good risk management processes, this would affect the price that was quoted, making it more affordable. There are also other factors that can be varied, depending on the appetite for financial risk, and which can reduce the price, such as excess provisions. This concurs with the independent research commissioned by the NMC and the Royal College of Midwives that suggests that independent midwives would be able to obtain insurance as employees within a corporate structure. As I say, some independent midwifery providers have secured insurance by fulfilling the above principles.

I heard my noble friend Lady Cumberlege say that the order effectively deprives certain individuals of the right to work. I do not share that view. The right of an individual to practise their profession is not an absolute right; the state may impose certain conditions provided by law that an individual must satisfy in order to practise their profession. Those conditions should be both proportionate and justifiable.

The bottom line here is that we believe it is unacceptable, as the noble Baroness, Lady Emerton, emphasised, for individuals not to have recourse to compensation where they suffer harm through negligence on the part of a registered healthcare professional. The NHS constitution in England reinforces this by including,

“the right to compensation where you have been harmed by negligent treatment”.

In requiring all practising regulated healthcare professionals to hold an indemnity arrangement as a condition of registration, the order does not make the practice of independent midwifery illegal—far from it. Midwifery outside the NHS will still be accessible in the ways that I have already described. I note that Independent Midwives UK is advertising insurance as a benefit of its membership, so I wonder whether any self-employed midwives will in fact have to stop practising.

My noble friend Lady Brinton hit the nail on the head when she expressed her welcome for the EU directive and the principles that underlie it: that all patients across the EU should be treated by healthcare professionals who have insurance or indemnity cover.

The noble Baroness, Lady Emerton, touched on the issue of compensation. As she knows, compensation for negligence can be very high indeed. It is for this reason that the Royal College of Midwives no longer offers insurance. Its scheme was stopped after an issue involving an independent midwife.

If we distil the arguments to their most basic, the implication behind a number of criticisms of this order is that choice in natal care should trump other considerations. I am afraid that the Government take a different view. Our policy is that patients should have recourse to redress if they are harmed, and the most cost-effective and proportionate way of achieving that is by requiring all practising regulated health professionals to hold appropriate cover.

Having said that, we lay great emphasis on choice, as my noble friend is aware. The policy set out in Maternity Matters: Choice, Access and Continuity of Care in a Safe Service, published in 2007 but endorsed by the current Government, aimed to introduce by the end of 2009 four main areas of choice in maternity. The choices are: how to access maternity care, whether via a GP or directly through a local midwifery service; the type of antenatal care—depending on the circumstances, midwifery care or team care with midwives and obstetricians; the place of birth, depending on the circumstances, supported by a midwife at home or in a free-standing midwife-led unit in a hospital, or supported by a maternity team including obstetricians in a hospital; and where to access postnatal care, at home or in a community setting.

I hope my noble friend will concede that maternity has been a major focus for the current Government. We have invested heavily in training additional midwives. There is a record number in training at the moment. We have invested large sums in improving and refurbishing birthing units, as well as introducing specialist mental health midwife training so that every birthing unit will have a specially trained clinician available by 2017. This is a major part of our agenda.

I think I have said as much as I can in answer to questions. I will, however, respond in writing to the points that I have not adequately covered, including my noble friend Lady Cumberlege’s question about how many home births might be on hold or suspended as a result of this order. I beg to move.

National Health Service: Nursing Staff

Debate between Earl Howe and Baroness Cumberlege

Monday 16th June 2014 Lords Chamber

[Earl Howe]

My Lords, the figure that I have is in fact a decrease of just over 3,000 nurses in senior positions at bands 7 and 8, but that is more than made up for by the increase of over 7,500 nurses at bands 5 and 6 on the front line. On the noble Baroness’s second point, the figures that I saw emanating from the Royal College of Nursing should be looked at with some caution; the RCN has included exit packages for executive directors but not for nurses. In fact, the latest independent evidence shows that for the third year running there was no increase in median executive board pay. It is important to compare like with like there, and the figure of 6.1% as a rise for executive directors is not one that we recognise.

[Baroness Cumberlege (Con)]

My Lords, does my noble friend agree that one of the most encouraging aspects of the nursing profession is the number of senior nurses who have gone on to be chief executives and board members in the NHS, bringing all the skills of nursing to the leadership of hospital trusts and clinical commissioning groups?

Health: Midwives

Debate between Earl Howe and Baroness Cumberlege

Wednesday 5th March 2014 Lords Chamber

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

My Lords, the Department of Health has been working closely with Independent Midwives UK, which represents self-employed sole-practitioner midwives, to explore possible options to secure insurance for its members. Independent Midwives UK has presented a business plan to the department seeking government funding, which has been carefully assessed. As any solution must be applicable across the UK, discussions have also taken place with the UK devolved Administrations. A decision regarding Independent Midwives UK’s proposal is imminent.

[Baroness Cumberlege (Con)]

My Lords, I thank my noble friend for that Answer and declare my interests as listed in the register. It has occurred to me that the first person to see your Lordships in the nude is a midwife. Midwives are very special people, and independent midwives are equally so. It is a travesty that independent midwives will not be able to practise if they cannot get clinical indemnity. As my noble friend said, Independent Midwives UK has worked very closely with the department but, unfortunately, there is still a gap of £1 million, the initial pot required to get midwives clinical indemnity. Will my noble friend work very hard to ensure that he and his colleagues fund that £1 million? I have to say that, in the context of the NHS budget, which is £110 billion, it is simply short change.

[Earl Howe]

My Lords, I hesitate to correct my noble friend but Independent Midwives UK submitted a business proposal to the department which would require the Government to provide a £10 million grant to support the inception of an insurance scheme for its members to provide full maternity care. We have considered two options, either of which would deliver that result. The creation of any government scheme specifically for Independent Midwives UK would effectively position the Government as the underwriter of the independent sector. That is something that we have hitherto found difficult to consider.

NHS: Foundation Trusts

Debate between Earl Howe and Baroness Cumberlege

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

I am not aware of any on Sir Bruce Keogh’s list which were planning to merge but, if I may, I will write to my noble friend with further details if that needs clarifying.

[Baroness Cumberlege]

My Lords, my interests are declared in the Register of Lords’ Interests. Complicated organisations, such as hospitals of every sort, need outstanding, in-depth leadership from all quarters. Does my noble friend agree that clinicians should provide that leadership but that if there is an overwhelming culture of retribution there is no incentive for them to take on these very demanding roles? What incentives can the Government introduce to ensure that the most talented doctors and nurses are attracted to lead the NHS and take on these very high risk jobs?

[Earl Howe]

My noble friend makes a vital point. If we are to strive for excellence in the health service, leadership is essential. That is the reason why the NHS Leadership Academy has been established—to encourage not only managers but clinicians and nurses to take leadership roles in the health service for the very reasons that my noble friend states.

Care Quality Commission: Morecambe Bay Hospitals

Debate between Earl Howe and Baroness Cumberlege

Thursday 20th June 2013 Lords Chamber

[Earl Howe]

I am grateful to the noble Baroness. In fact, the trust has taken significant action in response to the concerns raised by the CQC and Monitor. In addition to responding specifically to the three warning notices issued by the CQC, there have been significant leadership changes at the trust. Sir David Henshaw was appointed as interim chair and Eric Morton as interim chief executive. The trust appointed four new non-executive directors and a new chief operating officer and recruited a new obstetric consultant and additional midwives. There have been other appointments as well. It has established a programme management office, as requested by Monitor, to oversee the implementation of programmes of work to bring about lasting improvements across the trust—and it has recruited a number of posts to the programme office to take that work forward. So I am encouraged that it is taking the position as seriously as it should in the circumstances and that, again, there is a refreshed team at the top of that organisation.

[Baroness Cumberlege]

Very often, when we have these inquiries, they are initiated not so much by the people who work within the trusts but by members of the public who feel very concerned about the quality of care being given within a hospital or service. Very often, those people who bring up these concerns, who are dubbed colloquially as whistleblowers, get very victimised by other people within the population but also within the hospital. Is there any support or help that we can give those people who bring to the attention of the NHS some of the problems that exist?

[Earl Howe]

My noble friend raises a key issue, which successive Governments have wrestled with. We all know how life works. Whistleblowers are treated badly because their message is often very uncomfortable. That is why local Healthwatch could potentially be a very important part of the puzzle here, by ensuring that people have a place to go to that they can trust and that can raise concerns without necessarily naming the person who has initiated those concerns.

More and more, we need to encourage providers of care to take ownership of their performance. They have to be candid with themselves and accept criticism where it is laid. Boards of directors have to look systematically and regularly at the complaints made against them—whether rightly or wrongly—to make sure that they are as open as possible with themselves. Only by instilling a culture of that kind can we move forward.

Health: Midwives

Debate between Earl Howe and Baroness Cumberlege

Monday 10th June 2013 Lords Chamber

[Baroness Cumberlege]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I declare the interests that are on the Lords’ register and, in this instance, the unremunerative position as patron of Independent Midwives UK.

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

My Lords, a 12-week consultation on the legislation to require regulated healthcare professionals to hold indemnity or insurance closed on 17 May. We are now analysing the responses to assess how the issues might be addressed, including those affecting independent midwives—that is, self-employed individuals in the private sector. This includes consideration of different models of service. Officials are also facilitating meetings between NHS England and representatives of independent midwives to discuss emerging commissioning issues.

[Baroness Cumberlege]

My Lords, I thank my noble friend for that Answer. On 26 October, when the European directive comes into force, it will preclude around 170 independent midwives from practising, and this at a time when we have a burgeoning baby boom. Many of these midwives actually work within the NHS. Is my noble friend aware that many of these independent midwives are seeking a solution but they require help, advice and support from the department and, above all, a revision of the tariff for maternity services? Will my noble friend ensure that this issue is a priority for urgent action by his colleagues, the Department of Health and the other agencies involved?

[Earl Howe]

My Lords, as my noble friend knows, work has been going on for a number of years, including going back to the previous Government, to see whether there are viable ways of ensuring that this small group of independent midwives can obtain suitable indemnity or insurance cover. One of the difficulties we have had is the absence of information on the potential barriers to independent midwives moving to alternative governance and delivery practices in order to obtain that cover—hence the consultation I have spoken about. As I said, we are now analysing the responses. However, I do not agree that there is no way through. We know that some independent practitioners have opted for a corporate or social enterprise model as a way of gaining insurance cover. We are trying to understand what the barriers are to that among those who are resisting the idea.

Care Bill [HL]

Debate between Earl Howe and Baroness Cumberlege

Tuesday 4th June 2013 Lords Chamber

[Baroness Cumberlege]

Perhaps I may comment on what my noble friend has said in reply to the debate. I understand that under secondary legislation he is considering putting a registered nurse on the board. Some assurance on that would be very helpful. In my experience working with clinical commissioning groups, when they were appointed there had to be a nurse on the board, and the last person to be appointed in many cases was the nurse. There was a feeling that it was hard to find a nurse who would make such a contribution. Some very talented young nurses are coming on-stream, but when one talks about a clinical presence on a board, so often, it is interpreted as a medical person on the board. We seek to ensure that a working nurse will be on those boards. If my noble friend can reassure me that he will consider that very carefully when drawing up the regulations, I will be very pleased.

I am so sorry. I should have declared an interest. My interests are on the Lords’ Register.

[Earl Howe]

My Lords, I listened with care to my noble friend, whose experience we respect greatly. I can tell her that Health Education England’s board will need to have access to a cross-section of clinical expertise, as it does at the moment. Nursing representation will of course be very important. I assure her that we will prioritise that issue in developing the supporting regulations on membership. That is probably as far as I can go, but I recognise the force of everything that my noble friend said.

Health: Midwives

Debate between Earl Howe and Baroness Cumberlege

Monday 25th February 2013 Lords Chamber

[Baroness Cumberlege]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In so doing, I declare an interest as a fellow and vice-president of the Royal College of Midwives. My other interests are in the Lords register.

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

My Lords, there are some 1,381 more midwives in the NHS than there were in May 2010, and there are a record 5,000 in training. The Government have committed to ensuring that the number of midwives matches the needs of the birth rate. Most women already have choice and one-to-one maternity care, and we are working closely with the Royal College of Midwives to ensure that personalised, one-to-one maternity care is available for every woman across the country.

[Baroness Cumberlege]

My Lords, I thank my noble friend for that very encouraging reply. I suspect that every single Member of your Lordships’ House has been touched by a midwife. They are a remarkable and very committed profession. Is my noble friend aware that although there is what the Royal College of Midwives describes as a tipping point in the increase in the number of midwives attending women in labour, the real crisis is in postnatal care, where new mothers require advice, support and help in cherishing and feeding their newborn baby? Is he also aware that this requires continuity of a midwife? He has just told us that continuity is being carried through, but a recent survey shows that 40% of new mothers always see a different midwife. How does he propose that we put this situation right?

[Earl Howe]

My Lords, women should expect to have one-to-one care from a midwife during labour, birth and immediately after birth, and to continue to have the support of their midwife after the birth. This is especially important for those women who are susceptible to, or have, depression during pregnancy or postnatal depression. My noble friend is absolutely right about continuity. This depends on each woman having an individualised postnatal plan of care, taking into account her circumstances. To assist the NHS, the department has asked the National Institute for Health and Clinical Excellence to develop a quality standard for postnatal care, which it is anticipated will be published in July this year.

NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012

Debate between Earl Howe and Baroness Cumberlege

Tuesday 5th February 2013 Lords Chamber

[Baroness Cumberlege]

My Lords, I suspect that my noble friend has got the message now that we are not totally enamoured of these regulations. I think back to when we had the White Paper, which was published in July 2010. I remember, as my noble friend Lady Jolly has said, how excited I was then by the fact that in local Healthwatch we were to have an organisation that really would be the collective voice of patients. There was a mechanism so that it would have a very strong infrastructure at the local level.

So far so good, but throughout the passage of the Bill Members of your Lordships’ House fought strongly to get that policy enacted. We were given assurances, as noble Lords have said, and they were given in good faith. Yet now we have the regulations in this statutory instrument, we are not only disappointed but deeply concerned. I share the grave concern of the House’s Secondary Legislation Scrutiny Committee, which says that there is a very real possibility that local Healthwatch is in danger of being manipulated, but our concerns do not stop there.

The Government are right to want local people to have control of local Healthwatch but there is a genuine fear about it being subjected to such complex and draconian restrictions on what it will be able to say and do. It is not entirely clear to us what value local Healthwatch can add to the accountability framework of the NHS. This view is shared by Healthwatch England which, as the noble Lord, Lord Collins, has said, suggests that this could be dealt with by guidance. However, the trouble with guidance is that it does not have any statutory force. However, it could use its powers to sharpen the way in which local Healthwatch operates—as an independent champion through the trademark which all local Healthwatches must have and have to own. I have not given my noble friend any notice of this, but perhaps he might like to think about that and take it away.

Paragraph 36 of the regulations prohibits local Healthwatch from opposing or promoting changes to any national or EU law, any national policy, any policy by a local public authority—including both local authorities, the NHS or “any organ or agency” of either—and any planned or actual changes in any of these. In addition, it prohibits influencing,

“voters in relation to any election or referendum”.

These prohibited activities may be undertaken only if they are incidental to what could be called the core purpose of local Healthwatch—that is, giving people a say in local health and social care—unless that core purpose is incidental to the prohibited activities. This is mind-stretching. That seems to be something of a circular definition whereby X is allowed if it is incidental to Y, unless Y is incidental to X. This is pretty difficult. I have said that it is mind-stretching but I really fear that it will be unworkable. What is certain is that it will be incomprehensible to local people, who are expected to participate in local Healthwatch.

The impact of this provision is likely to have a chilling effect and to negate the aims of Healthwatch. Why should any committed volunteer get involved in local Healthwatch, giving freely of their time and energy to try to influence things for the better, if they risk being penalised for doing so?

I shall describe three situations to the Minister to test this with him, and I hope that he will reassure me on these points. First, say that there was a controversial policy to close an A&E department in order to save money. Would local Healthwatch be permitted to provide evidence to campaigners of how good the patient experiences had been at that threatened department? Would that be banned under Regulation 36 as the promotion of changes to a policy that a public authority proposes to adopt? If the Minister says no, how could local Healthwatch be confident that the local NHS decision-makers would share this view?

Secondly, could people who had been active in a national campaign to improve quality and accountability in the NHS be decision-makers in local Healthwatch? Would local Healthwatch have to avoid any connections to an organisation seen as intending,

“to affect public support for a political party”,

that was in power? Again, if the Minister says no, and decisions on such matters are to be delegated to local authorities, how could local Healthwatch be confident of that?

Thirdly, during a local election campaign, would local Healthwatch be subject to purdah, like democratically elected bodies such as local authorities or the Government themselves? Would that apply even if it discovered serious abuses of vulnerable people with learning disabilities in a residential home during this period? Such a discovery would not reflect well on the local authority commissioners, who are “an organ or agency” of local government under the regulations. Would the local Healthwatch have to keep such concerns secret or risk being penalised by that very same local authority?

The very fact that we have to ask these questions demonstrates that we do not have the right set of safeguards for the independence of local Healthwatch. The fact that local Healthwatch is funded and controlled by local authorities, which it is supposed to be scrutinising, is pretty uncomfortable. The added constraints of Regulation 36 threaten its freedom to speak and to act in the interests of patients and the population. These very complex restrictions seem designed to protect those in politics or in the provision of services who have something to hide. They impoverish the debate on health and social care, whether it is about controversial reconfigurations or a Baby P tragedy. Patients could not care less about politics and just want someone to speak up for them when they themselves cannot.

I urge my noble friend to consider modifying, redrafting or, if possible, removing these restrictions, or to find a mechanism to ensure that they are not implemented in the way that I have outlined and the way that I fear. To me, it is not clear whom they are really designed to protect, but I fear that it is certainly not patients.

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

My Lords, I thank the noble Lord, Lord Collins, for raising his concerns and other noble Lords for following in his footsteps in sometimes very trenchant terms. A number of concerns have been raised about these regulations during the course of the debate and I will now do my best to address them in turn. A number of noble Lords reminded us of the critical importance of lay involvement in local Healthwatch and questioned why the wording of the regulations does not therefore prohibit employees of a local authority or indeed of the NHS from taking roles in the leadership and governance of a local Healthwatch. Indeed, your Lordships’ scrutiny committee suggested that this might leave a local Healthwatch in some way vulnerable to manipulation or threaten its independence. That concern was picked up by one or two noble Lords. I can, I hope, provide reassurance on this. Indeed, I am sorry that despite the department’s clarificatory submission to the scrutiny committee, it still remains a source of concern.

We completely recognise the importance of local Healthwatch being truly local organisations that are led by local people and involve volunteers. That policy aim is reflected in the way the regulations are drafted. They impose explicit requirements relating to the involvement of lay persons and volunteers. Both those terms are defined. The definitions of “lay” and “volunteer” are designed to be as inclusive as possible. Essentially, they aim to cover those who wish to give up their time for something they feel passionately about to influence change and service improvement. In practice, very often lay people and volunteers are the same group of people, but we thought it important not to frame a definition in a way that would exclude other people who might not define themselves in precisely those terms. The definition should, and does, apply as much to those who have paid jobs but who wish to do their bit for the community in their spare time as to those who do not work or who are retired.

NHS Commissioning Board: Mandate

Debate between Earl Howe and Baroness Cumberlege

Tuesday 13th November 2012 Lords Chamber

[Earl Howe]

My Lords, I pay tribute to the noble Lord’s role in the NHS IT programme. He is right: we have a great deal to be thankful for in much of the IT that was rolled out under the previous Administration. It failed at a local level rather than a national level—it perhaps failed for honourable reasons—but that is history now and we need to move forward and find other ways of delivering the benefits which his Government identified and we are determined should be delivered at provider and commissioning levels. That is why there is emphasis in the mandate, in chapter 2.6, around technology because it is important that we have inter-operative systems at every level.

The noble Lord asked about the costing of the mandate and, in particular, the quality, innovation, productivity and prevention programme—or the Nicholson challenge as it is sometimes known. We refer to that on at least two occasions in the mandate, at chapter 6.4 and chapter 8.1. The NHS Commissioning Board has confirmed that it will continue to implement the Nicholson challenge and we will work with it to ensure that that happens.

As regards service configuration, the noble Lord will note that in chapter 3.4 we draw attention to that issue and, in particular, to the four tests that need to be met before service configuration can be considered acceptable. Those four tests must be determined locally and there must be a clinical buy-in to any reconfiguration of services. That is one of the most important features of the framework surrounding that area. We may well see fewer centres for a number of conditions but, if we do, it will not be through a top-down edict but because doctors and other health professionals think that it is the right thing to do for patients.

[Baroness Cumberlege]

My Lords—

--- Later in debate ---

[Baroness Cumberlege]

My Lords, I, too, congratulate the Government on the mandate. When we were debating the Bill, I requested that the mandate should be short, precise and well-focused, and it is all of those things. I particularly welcome the focus on the importance given to improving standards in maternity services. The mother’s experience and the start of life are very important and have a huge impact on the long-term well-being of children.

I wish to link the outcomes framework with the mandate. On the outcomes framework, at page 11 under “Trauma” we are told that this is an area for further improvement. It states:

“As part of the development of the placeholder ...‘improving recovery from injuries and trauma’ the indicator has now been defined as ‘Proportion of people who recover from major trauma’”.

That links very much with what my noble friend was saying earlier about expertise. The point I want to make on the mandate is that we are told that the objectives in the mandate can be realised only through local empowerment. The board’s role in the new system will require it to consider how best to balance different ways of enabling local and national delivery. These may include the duties and capabilities for engaging and mobilising patients, professionals and communities in the shaping of local services.

My concern is on A&E and the emergency services. With the NHS Commissioning Board having now appointed Tim Kelsey to look at communications, how can we get public leadership to understand that expertise in certain areas is very important for survival? The footballer Fabrice Muamba collapsed on the football field and passed several A&E departments to get to the one that saved his life because the expertise was there. Is there a requirement in the mandate that there should be a mobilising and further education of the community so that it understands what expertise is needed in order to save lives?

[Earl Howe]

My noble friend makes a series of extremely important points and I agree with everything she said about maternity services. Emergency services will be commissioned at a local level by clinical commissioning groups but that cannot be the end of the story. She rightly implied that paramedics and trauma care doctors require skills in sometimes very sophisticated techniques of maintaining life at the scene of an accident, for example, and hospital procedures. These skills must be maintained and improved. The short answer to her question is quite consciously missing from this mandate. This is the need for Health Education England to work very closely with the board because the Centre for Workforce Intelligence and Health Education England will have to ensure that we have not only the right numbers in the NHS workforce but those with the right skills and the right level of skills. As she rightly said, we also need to educate the public that the health service does not consist of a series of buildings; it consists of a network of services. We will have advanced considerably if the public can understand rather better than they generally do that the continuation and improvement of services matter, rather than bricks and mortar.

Health: Obesity

Debate between Earl Howe and Baroness Cumberlege

Monday 12th November 2012 Lords Chamber

[Baroness Cumberlege]

My Lords, I beg to ask the Question standing in my name on the Order Paper. In so doing, I declare my interests as set out in the House of Lords register. Perhaps I ought to add another: I love my food.

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

My Lords, the Quality and Outcomes Framework already includes obesity. The process for reviewing clinical and public health indicators in that framework is overseen by the National Institute for Health and Clinical Excellence, which recommends changes annually for consideration as part of the GP contract discussions. NICE will continue to lead on this process but from April 2013 priorities for public health indicators will be set by Public Health England in consultation with the devolved Administrations.

[Baroness Cumberlege]

My Lords, I thank my noble friend for that full Answer. Does he agree that one of the successes in primary care has been the introduction of the Quality and Outcomes Framework, which incentivises GPs? Unfortunately, one of the incentives is to keep a register of obese patients—nothing else, just a register. In fact, that incentivises them to keep people fat. Does my noble friend also agree that obesity, which is forecast to cost the nation, or the NHS, £45 billion, needs prompt action? Will he assure me that under the new reforms that he just mentioned, Public Health England will prioritise the development of these indicators in the Quality and Outcomes Framework?

[Earl Howe]

My Lords, as my noble friend knows, the Secretary of State will set the strategic objectives and policy priorities of Public Health England. It will have operational autonomy and operate transparently. Rates of obesity remain high across England and continue to have clear links to health inequalities. GPs can play a key role in making every contact count by raising the issue of obesity and providing advice or referral to appropriate services, so I do not necessarily accept the criticism that my noble friend levelled at the current QOF indicators. GPs have every reason to act when they see obesity in front of them. I cannot pre-empt exactly what Public Health England will wish to prioritise in the development of the QOF, but I fully expect that it will want to work with NICE to review the evidence base for building on the current QOF obesity indicator.

NHS: Women Doctors

Debate between Earl Howe and Baroness Cumberlege

Tuesday 6th November 2012 Lords Chamber

[Baroness Cumberlege]

My Lords, I declare an interest, and my interests are in the register. Does my noble friend agree that some of the brightest women in the land choose a medical career and are well equipped to take on positions of leadership? Does he also agree that they are under-represented on the boards of the new clinical commissioning groups? Can he suggest to the national Commissioning Board that it examines this issue before authorising the individual boards?

[Earl Howe]

My noble friend makes a very important point. There is good evidence that women doctors make safer decisions, are often better at communication than men and understand better the needs of women, and we need them to inspire the next generation of women doctors. Therefore, to fish for clinical leaders from half the talent pool is not a sensible thing to do. As for CCGs, my noble friend makes a very important point. The NHS Leadership Academy has established development opportunities, including action learning sets for female CCG leaders. But we recognise that more work is needed at a system level to aid progress in this area.

Older People: Health and Social Care

Debate between Earl Howe and Baroness Cumberlege

Monday 18th June 2012 Lords Chamber

[Earl Howe]

My Lords, the NHS outcomes framework contains two domains that are highly relevant to this area. The NHS Commissioning Board will be in prime position to monitor those areas of the domains that relate to the patient experience. However, I have no doubt that the CQC will continue to do its work in maintaining essential standards of quality and safety. The Nursing and Care Quality Forum is an independent group and it is therefore for the forum itself to consider how to take forward the issues raised in the recommendation, but I understand that its chair, Sally Brearley, was already planning to consider care homes as part of the next phase of the forum’s work. She has already approached a number of individuals to strengthen the forum’s membership and add further expertise in that area.

[Baroness Cumberlege]

My Lords, one of the most important levers for change in the Health and Social Care Act is the mandate that has been agreed between the Secretary of State and the NHS Commissioning Board. Does my noble friend consider that one could include some of the principles that are established in this very good report within that mandate?

[Earl Howe]

My Lords, decisions about the content of the mandate will be made on the basis of a full public consultation, which will take place in the summer. More details on that score will follow in due course so there is a limit to what I can say at the moment. However, as I indicated during the passage of the Health and Social Care Act, the mandate is likely to include expectations for improving healthcare outcomes for patients, based on the NHS outcomes framework. That framework reflects the Government’s ambition for an NHS that provides high quality, safe and effective care, treating patients with compassion, dignity and respect.

Health: Local Healthwatch Organisations

Debate between Earl Howe and Baroness Cumberlege

Monday 11th June 2012 Lords Chamber

[Earl Howe]

One of the potential functions of local Healthwatch is to act as a support in terms of advocacy for local people and to signpost patients and the public to appropriate services. It is too early to say which local authorities will commission what services from local Healthwatch in an area, but the resources available to local Healthwatch have to be borne in mind in that context.

[Baroness Cumberlege]

My Lords, does my noble friend agree that in the light of the comparative studies that have been made between different health systems in developing countries, it is very disappointing that the National Health Service comes last out of seven when it comes to patient and public involvement? It does well on other factors but not on this one. Does my noble friend agree that although taxpayers’ money must always be very well spent, really strong patient and public involvement will ensure that healthcare is improved?

[Earl Howe]

My Lords, I firmly believe that, and that is why the NHS outcomes framework specifically includes a domain relating to patient experience. As we go forward, I think patients will come to realise that their voice really counts. It is about a culture change—I do not wish to wriggle out of that. This is not going to happen overnight, but it is very important that commissioners and providers in the health service are fully engaged with patients, and vice versa, to ensure that the patient’s voice—and indeed the patient’s needs—are right at the centre of commissioning and provision.

Health and Social Care Bill

Debate between Earl Howe and Baroness Cumberlege

Monday 19th March 2012 Lords Chamber

[Earl Howe]

My Lords, although I understand the noble Lord’s question, I do not think that I can answer it at the moment, and I am sorry to disappoint him. My advice is that we do not think that partnerships will be necessary in all or every case for Public Health England. Whether the NIHR can insist on trumping the operational independence of Public Health England is not a question that I can answer very readily. The main point is that research would not have to be jointly conducted. The Secretary of State has the power to carry it out on his own. That means that, if there were a tussle between two priorities, the Secretary of State could insist that a certain programme should be prioritised. I think that that is probably as far as I can go in answering the noble Lord at the moment.

My noble friend Lady Jolly asked me some general questions about lines of accountability. I hope that she will have gathered from my remarks today that Public Health England will be accountable directly to the Secretary of State in the first instance. Directors of public health will be joint appointments between local authorities and the Secretary of State, although they will be local authority employees and directly accountable to the authority chief executive. It goes without saying that close joint working between PHE and local authorities will be crucial.

My noble friend’s amendment and the powerful way that she has argued for its objectives are a tribute to her and to the noble Lords who have supported her. I believe that I have responded positively to each point that the amendment seeks to establish and that that response can be made comprehensively without amending the Bill. That remains our strong preference. I hope very much that my noble friend is sufficiently reassured by the commitments that I have made today to withdraw her amendment.

[Baroness Cumberlege]

My Lords, I have no intention of testing the opinion of the House this evening. We have negotiated long and hard with my noble friends Lady Northover and Lord Howe. It has been a very interesting experience. Those noble Lords who have supported me by putting their names to my amendments have tutored me well in the art of negotiation. It has occurred to me that clearly you can negotiate only if both parties are willing to participate, and in this instance that has been the case. The Secretary of State, my noble friend and noble Lords have been more than willing to meet us and to debate and discuss matters with us, putting forward some very strong assurances about the future of Public Health England.

I know that my noble friend Lady Jolly wanted the amendment to be made to the Bill and for those words to be included in the Bill so that the constituency in the country—all the public health people involved—would see what we are trying to achieve. I knew some time ago that that would not be possible, and we have had a very full debate today, albeit at Third Reading, because we are very anxious to get all those assurances articulated and recorded in Hansard.

We will be keeping a very close eye on the development of Public Health England and I shall be framing the assurances that I have been given today. I shall have them on my wall and, when there are new Secretaries of State, I shall present them with this framed undertaking so that we can absolutely ensure that Public Health England goes from strength to strength and, as my noble friend said, is a world leader and, I hope, a world beater. We have a very good reputation in the world on public health. It is something that we must retain and improve upon, ensuring that we have a healthier nation for the future. I beg leave to withdraw the amendment.

Health and Social Care Bill

Debate between Earl Howe and Baroness Cumberlege

Wednesday 29th February 2012 Lords Chamber

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

My Lords, the Secretary of State has a duty to keep under review the effectiveness of the exercise of health service functions by certain national bodies. These bodies are listed at new Clause 247C, inserted by Clause 51 of the Bill.

As it is currently drafted, the Bill requires the Secretary of State to keep the effectiveness of the Care Quality Commission under review in so far as it is exercising functions in relation to the health service. However, it does not make explicit reference to the HealthWatch England committee. Yet, while HealthWatch England will be established as a committee of the Care Quality Commission, it will have its own statutory functions that it must exercise outside of the CQC’s other functions.

This is, therefore, a helpful and welcome amendment from my noble friends Lady Cumberlege and Lady Jolly. It helpfully clarifies the distinction, in terms of the Secretary of State’s accountability, between the exercise of functions by HealthWatch England and that of the CQC.

The amendment would add HealthWatch England to the list of bodies the Secretary of State must keep under review in respect of how effectively it exercises its functions in relation to the health service in England. Importantly, it would emphasise that HealthWatch England itself is responsible for exercising the statutory functions of HealthWatch England.

I have reflected on this and I will be supporting this amendment. I hope that other noble Lords will join me in doing so.

[Baroness Cumberlege]

My Lords, I think we are on a roll. I am very excited that we have had another amendment accepted. I very much thank my noble friend.

I appreciate some of the other points that have been made in this debate, but I think we will be debating them next week and perhaps we could hold our fire until then. Indeed, we have debated them previously and noble Lords will know that I am in favour of the present proposal in the Bill that HealthWatch England should be a committee of the CQC, and that is why I have chosen those particular words.

I am very grateful to my noble friend. I think this is the first time ever this has happened to me and I feel very pleased about it. Thank you.

Health and Social Care Bill

Debate between Earl Howe and Baroness Cumberlege

Tuesday 22nd November 2011 Lords Chamber

[Baroness Cumberlege]

Those words are so warm to my heart, I cannot tell the noble Lord how much. One of the things that really concerns me is delay. I am worried that if we get this outside group it will delay matters, because some of this is very urgent at the moment. What is the relationship between this and the independent review panel—I am not sure what it is called—which deals with hospitals at the moment?

[Earl Howe]

It is the Independent Reconfiguration Panel.

[Baroness Cumberlege]

I am indebted to my noble friend for that. Does the Independent Reconfiguration Panel play a part in this? Is it something different? Do we have to go through that as well, in which case it will take even longer?

[Lord Warner]

Something equivalent to the Independent Reconfiguration Panel was used earlier in the system. It was put in to bat with the local area by Monitor when it saw trouble coming down the railway track in the form of failure. I envisage that a standing group of people would be approved to work in this area, which Monitor would be able to assemble very quickly. My amendment proposes that a timescale is set for this panel to work with local people and to come back with a solution to the problem, but I think that more people than are currently approved for the reconfiguration panel will be needed because of the points made by my noble friend. In many parts of the country we are likely to have to intervene quite quickly because we have spent a lot of time over the past 10 or 20 years putting off decisions about some of these places. A lot of these places will come to Ministers, the national Commissioning Board and Monitor over the next few years, so we will need quite a few different panels.

Health: Osteoporosis

Debate between Earl Howe and Baroness Cumberlege

Tuesday 19th October 2010 Lords Chamber

[Baroness Cumberlege]

To ask Her Majesty’s Government what steps they are taking to reduce the number of fractures which result from osteoporosis.

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

My Lords, the steps we are taking in this area include guidance via a commissioning toolkit to support organisations on effective falls and fracture prevention and management, NICE’s published guidance on osteoporosis, falls and fractures—NICE is also working on clinical guidelines for hip fractures for publication in spring 2011—and a best-practice tariff which offers financial incentives to hospitals meeting quality standards for hip fracture patients, including a fracture prevention assessment.

[Baroness Cumberlege]

My Lords, I thank my noble friend for his comprehensive reply and welcome the progress that has been made. We must bear in mind that last year alone, some 65,000 people were admitted to hospitals for hip fractures, which represents an increase of 17 per cent on the previous decade and is one of the highest figures in Europe. Will my noble friend ensure that the outcomes framework currently under review, which concentrates mostly on hip fractures, also includes indicators to reduce all fragility fractures? That would ensure that the NHS puts a comprehensive fracture preventive service in place.

[Earl Howe]

My Lords, my noble friend is right to say that the outcomes framework will be central to assessing the performance of the NHS and driving up quality generally. The framework is still in development, and my department is currently looking at the responses to the recent consultation and carrying out the necessary analysis to ensure that it is as balanced and robust as possible. Having said that, the consultation document contained a number of proposed indicators that relate to falls and fragility fractures which are candidates for inclusion in the framework, although the department cannot take any final decisions until we have digested all the consultation responses.