Care Quality Commission: Morecambe Bay Hospitals

Debate between Earl Howe and Baroness Northover

Thursday 20th June 2013 Lords Chamber

[Baroness Northover]

I remind noble Lords that brief questions are allowed. As the Companion states, this is not the occasion for an immediate debate. I note that many noble Lords want to speak, so the briefer the better, please.

[Earl Howe]

My Lords, I recall the noble Lord, Lord Patel of Bradford, making those points very powerfully some years ago when we debated the Bill that created the CQC. He makes an extremely important point. I think that we can take it from the statements of David Prior yesterday that the decision taken in 2009 to take a generalist approach to inspection was a mistake. The CQC’s inspectors are in one sense specialist inspectors who are trained and supported to carry out their role, which they do to the best of their ability. However, requiring inspectors to have oversight of a wide range of service types from slimming clinics to acute hospitals, and indeed mental health establishments, has spread expertise too thinly.

We are clear that we must now work with the CQC to create a much more specialist approach to inspection, including on mental health. I think that the three new chief inspectors we are appointing will help to do that. It is not the whole answer, because they need to be supported by clinical expertise and by the people who are experts by virtue of their experience in care services. However, I will take away the noble Lord’s idea of a chief inspector of mental health. I must be honest with him that we have not discussed this, but I am sure that we now should.

Mid Staffordshire Foundation Trust Inquiry

Debate between Earl Howe and Baroness Northover

Tuesday 26th March 2013 Lords Chamber

[Baroness Emerton]

My Lords, I would like to mention nurse education. The suggestion of having some front-line experience before entering university is, philosophically and practically, very good if it can be worked, but it raises all sorts of questions. I spoke to a healthcare support worker a few weeks ago who said that all the students who come on to her ward tell her, “I wish we had had this experience that you are getting before going into training”, so there is evidence that many of them would like to have that kind of experience. However, this raises the question of their supervision during that time. Will there be adequate numbers of trained staff to supervise the continuing support workers as well as those who are pre-nursing apprentices, or whatever?

The logistics of this are going to be important to work on. We need to know whether the Government will look at minimum staffing levels. Where there are enough registered nurses and the minimum is stated, there should be means whereby registered nurses will be available whenever demands on patient care escalate, such as during a time of winter problems, rather than abusing and misusing the support workers. There is a tremendous amount of work to be done on that.

There is also the role of the Nursing and Midwifery Council, which has responsibility for regulating the pre-nursing standards. I hope the Government will ensure that the council takes an active part in this pre-nursing experience, because that will be important. I urge Ministers to have this minimum staffing looked at, if that is possible. I am extremely disappointed that the Government are not prepared to take on the regulation of these support workers because I fear that we may find ourselves having similar problems as in the past, unless we have some regulatory system.

[Baroness Northover]

My Lords, I remind noble Lords that brief questions only are called for after Statements, and that the briefer they are, the more colleagues will be able to get in.

[Earl Howe]

I reassure the noble Baroness that all the concerns that she rightly raised are very much in our sights, not least the need for proper supervision of nurse trainees and the practical aspects of having the right level of support on the ward. This is why we believe that this idea should be piloted first, so that lessons can be learnt. Yes, we will involve the NMC, and indeed the Royal College of Nursing, in these plans. As regards ratios, having the right staffing in terms of numbers and skills is clearly vital for good care, but minimum staffing numbers and ratios, if laid down in a rigid way, risk leading to a lack of flexibility or organisations seeking to achieve staffing levels only at the minimum level. Neither of those is good for patients. However, I do not dismiss the general concept. It is ultimately up to local organisations to have the freedom to decide the skill mix of their workforce, based on the health needs of those on the wards.

Social Care Funding

Debate between Earl Howe and Baroness Northover

Monday 11th February 2013 Lords Chamber

[Baroness Northover]

My Lords, I interrupt briefly to say that if noble Lords make brief contributions more of their colleagues will be able to get in this critical debate.

[Earl Howe]

My Lords, I am grateful to my noble friend for her remarks. She is of course quite right; many of us have heard for years the concerns of members of the public, friends and family about what might be the catastrophic burden of care costs in old age. If there is one thing that everyone should welcome, it is that aspect of this announcement. With regard to a rebate, no, that is not in our sights at the moment. If someone were to die in the circumstances posited by my noble friend, the arrangement would have to remain as set out to that person at the outset. We would not expect to move the goalposts after that person had died.

NHS Commissioning Board: Mandate

Debate between Earl Howe and Baroness Northover

Tuesday 13th November 2012 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Lord for the welcome he was able to give to aspects of the mandate, not least in the area of mental health where, as he will have noted, the original version of the mandate has been considerably strengthened in a number of places to emphasise the parity of mental health with physical health in a number of ways. I am glad he thinks that that is a positive step and I agree that it is a necessary one if we are to achieve the higher standards in the care of those with mental health problems which we all want to see.

The noble Lord also welcomed the focus on outcomes and the fact that the mandate has been restructured around the five domains of the outcomes framework. We thought it was logical and sensible to hold the board to account for objectives which related directly to indicators within the outcomes framework. That has been warmly welcomed by the board itself.

The noble Lord asked a number of specific questions. First, on personal budgets in mental health, I can tell him that, subject to the results of the current trials in personal health budgets which we expect to announce very soon, we expect that mental health will be one of the areas where patients will be able to exercise direct control over the services they receive. As the noble Lord well knows, patient empowerment in the area of mental health is, in itself, therapeutic. If we can encourage that, we should.

The noble Lord also mentioned mental health in the workplace and I completely agree with what he said about that. I recently mentioned, in your Lordships’ House, the network which Dame Carol Black and I chair in the department looking at health in the workplace and the pledges that have been devised and which businesses can sign up to. One of those pledges indeed relates to mental health. We hope that we can recruit willing enthusiasts from among the business community to sign up to as many of those pledges as they can.

The noble Lord referred to public health, and I agree with him that it is not a matter simply for the department; all government departments need to engage in it. I should say to him that the creation of Public Health England will provide an immediate opportunity for that body to work with other government departments, but also much more widely to ensure that we genuinely have a joined-up approach to public health objectives. He will know that the public health outcomes framework, which has been drawn up to align itself as far as possible with the NHS outcomes framework, will be a powerful driver for improvement across the field of public health.

The noble Lord characterised the mandate as an uncosted wish list. I can tell him that it has been costed, and the NHS Commissioning Board itself was fully consulted before the mandate was drawn up, because it would clearly not be in anyone’s interests to task the board with delivering the unachievable. The board is aware that it will receive real-terms increases in the budget for the NHS—increases the NHS has received during every year of this Parliament. He referred to cuts. I want to emphasise to him that while we are aware that there are significant constraints at a local level, particularly at provider level, the overall budget to the NHS is not being cut; it is increasing, year by year.

The redundancy payments that unfortunately have been necessary of course represent ongoing annual savings from now on. It is always painful to make people redundant, but we deemed that it was absolutely necessary if we were to retain a sustainable health service. Every pound that we save will go straight back into front-line care.

The noble Lord mentioned the performance of the previous Government, and I am the first to pay tribute to the improvement in the health service that took place under that Administration—not least in waiting times. It is why we have explicitly said in the mandate that waiting times continue to matter. They matter to patients, they are clinically a valid measure of patient experience, and we have no intention of abandoning that metric.

The noble Lord also spoke about enforced competition. I should correct him on that because, as he will know from our debates on the Health and Social Care Bill, we believe that competition can sometimes be a tool for commissioners. We do not believe that it should be shoved down anybody’s throat. Competition, as Sir David Nicholson pointed out the other day, should be regarded as a rifle shot, rather than a carpet-bombing exercise. It should be used only where it is in the interests of patients, which is why the first duty of Monitor, the economic regulator of the health service, is to serve the interests of patients.

The noble Lord referred to partnership working, and I was absolutely in agreement with him that there needs to be partnership, not only at a local level between GPs, social care, secondary care providers, but at the level of the arm’s-length bodies. Chapter 7.3 of the mandate covers the latter aspect comprehensively. However, in Chapter 2, we also place great stress on integration of services, which was the subject of a number of debates in your Lordships’ House during the passage of the Bill. Primary care is covered in Chapter 9.2, which is one of the main areas that the board will be commissioning.

The noble Lord asked me about networks, which we debated a few days ago. They can take various forms. The strategic clinical networks, about which he asked me in his Oral Question the other day, embrace, as he knows, four major clinical areas where we believe that considerable change is required if we are to see services improved to the extent that they should be. However, that does not preclude other networks forming at a local level—for example, at provider level—to ensure that services are joined up. I am sure that we shall encourage those networks, wherever they are appropriate, but we are not mandating them.

The noble Lord asked me about measurable progress. Today, we are publishing an updated version of the NHS outcomes framework, which includes an appendix that sets out the detailed definitions for the majority of indicators. We will have robust metrics which we shall be able to use to measure health outcomes. Over the past few months, the Health and Social Care Information Centre has been publishing many of the data as they have become available. Publishing data for the indicators will, in itself, show whether outcomes are improving. In order to interpret progress, we will work with the NHS Commissioning Board and experts to develop a methodology for measuring progress. There is time enough to do that and I will happily keep the noble Lord informed as that work rolls forward.

[Baroness Northover]

My Lords, perhaps I may remind noble Lords that contributions and questions should be brief so that as many noble Lords as possible can participate. I also remind noble Lords that contributions will come from around the House so Members other than those in the Labour Party need to speak now. Maybe we could hear from the Cross Benches.

Care and Support

Debate between Earl Howe and Baroness Northover

Wednesday 11th July 2012 Lords Chamber

[Earl Howe]

My Lords, I thank the noble Baroness for her comments and questions. While she levelled a number of criticisms at the Government, I was glad to hear her positive comments—although I would characterise her speech as a glass half empty speech rather than the opposite. Nevertheless, I am grateful to her for recognising that this package of proposals represents progress. In many areas it is progress that her party and mine fully sign up to. However, she said at the start of her remarks that there was a lack of vision and strategy in these proposals. I was sorry about that because I do not share her view. The White Paper and the draft care and support Bill undoubtedly form the most comprehensive overhaul of care and support since 1948. They respond directly to the concerns that people have raised with us time and again.

I hope that when the noble Baroness reads the White Paper she will agree that the whole flavour is about creating a system that keeps people independent and well. There are many major commitments in the White Paper, including more support and equality for carers, housing investment, better information and personal budgets. Those things all combine to set out a new vision that tailors care around people’s well-being, rather than expecting people to conform to a system, which is what we have at the moment.

The noble Baroness criticised the Government for delay. I gently point out that more than 13 years ago there was a royal commission chaired by the noble Lord, Lord Sutherland. The previous Administration had 13 years to respond to it but did not do so. Nevertheless, progress was made in certain areas. We have gladly picked up on some of the areas of progress that the previous Administration put in place, not least in the area of carers. However, it is not true that since the present Government came to office we have seen no action. One of the first decisions that we made was to protect care and support in the spending review through an additional £7.2 billion over four years. That was an explicit recognition of the strains that local authorities were expected to come under. I announced through the Statement today further funding in recognition of those strains at local level.

It is true that some of the changes will take longer than others, but progress will be made within 12 months. It will include introducing quality profiles for every provider so that people have comparative information on the quality of different organisations, investing £200 million over the next five years to develop specialised housing, publishing a code of conduct and minimum training standards for care workers, and launching a new national information website at nhs.uk. I hope that the noble Baroness will welcome those innovations.

On the deferred payment scheme, there is a lot of discussion to be had. Our proposals are that deferred payments will be available in all local authorities. Currently they are available in some but not all. As the noble Baroness knows, the social care means test requires people to use their housing wealth when they go into residential care. We are announcing that we will allow people to pay later, giving them more time to sell their home at their convenience or even for it to be sold after their death. We are not confirming now exactly who will be eligible or the rate of interest that will be attached, but we have said we will consult on these issues with the care sector.

As regards the cross-party talks, I should like to put it on the record that we fully intend to continue to engage with Her Majesty’s Opposition and with the sector on options for implementing the Dilnot model as well as with Mr Dilnot himself. At this stage, we are open-minded as to what form that engagement should take. As has been the case to date, discussions on funding reform will be led by the Department of Health on behalf of wider government. We wish to continue what I believe has been a very constructive series of discussions, with the Opposition in particular. The disagreements and criticisms that blew up over the weekend were regrettable and we wish to draw a line under that. I hope the noble Baroness will appreciate from the correspondence that has flowed between our two lead spokesmen that that is indeed the intent.

The noble Baroness is not correct as regards the NHS underspend. It was not lost to the NHS. The overall year-end surplus of £1.6 billion for PCTs and SHAs last year will be carried forward and made available in 2012-13. That represents a 3% increase in funding available to the NHS relative to last year. As I mentioned earlier, we are allocating further funding on top of the £7.2 billion that we previously announced in support of local authorities.

There are many questions to answer in this package. I do not hide from that, but it is right that we take time to work through this, including engaging with all stakeholders to ensure that any reform is sustainable and fair.

[Baroness Northover]

My Lords, before we get into the session where all Peers can contribute, I remind noble Lords that the Companion states that ministerial Statements are made for the information of the House and that, although brief comments and questions are allowed, Statements should not be made the occasion for immediate debate. Perhaps I may emphasise brevity and therefore the courtesy of allowing as many noble Lords as possible to contribute.

Health and Social Care Bill

Debate between Earl Howe and Baroness Northover

Monday 13th February 2012 Lords Chamber

[Baroness Kingsmill]

Can the Minister explain the distinction and why we cannot have both? It seems that culture change is best reinforced by legislative change, and the contractual point that the Minister made is a good idea.

[Baroness Northover]

For clarification, can I point out that only the mover of an amendment or the noble Lord in charge of a Bill should speak after the Minister on Report, other than for short questions of elucidation to the Minister or where the Minister speaks early to assist the House in debate? As this makes very clear, it is possible for a noble Lord to ask a short question about what the Minister has just said, but he or she should not introduce other speeches.

[Earl Howe]

The question of the noble Baroness relates back to something that I said some time ago. The answer is that we believe that culture change stands the best chance of happening when you bring home to those with direct responsibility for patient care that it is in the contract of the organisation that it must be candid. There are different views about this. I do not disagree with the noble Baroness that, in some cases, regulation is the right way to go. I will say a little more about that in a moment, as I wind up.

I was just talking about primary care in sympathetic terms. We need to remember that other requirements for openness still apply to all NHS services. All primary medical service contractors must have regard to the NHS constitution, professional codes of conduct, any guidance issued by PCTs or the Secretary of State and so on in relation to openness. Once they are registered with the CQC, a failure to be open with patients contravenes clear expectations set out in CQC guidance. The CQC can then take action. Therefore, primary care contractors currently have no excuse to avoid telling their patients about things going wrong with their healthcare. However, I acknowledge the concern of the noble Baroness, Lady Finlay, and others that primary care contractors will not be covered by the current proposals for a duty of candour in the NHS standard contract. Any contractual amendment in relation to primary care contractors is a more complex process, requiring amendments to secondary legislation, among other things. Specifically because of this, we asked for views on this in our recent consultation, which closed at the end of last month. I can confirm to the House today that we are giving further thought to the issue of primary care and the duty of candour in light of the consultation responses we have received. They are complex issues. I hope noble Lords will understand that I cannot prejudge the careful analysis that is already under way in deciding how we go forward in this area. However, it is something that we are actively considering.

Public Health

Debate between Earl Howe and Baroness Northover

Tuesday 30th November 2010 Lords Chamber

[Baroness Northover]

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

[Earl Howe]

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

NHS: White Paper

Debate between Earl Howe and Baroness Northover

Monday 12th July 2010 Lords Chamber

[Earl Howe]

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

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

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

[Baroness Northover]

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

[Baroness Morgan of Drefelin]

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

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