Care Act 2014 and Children and Families Act 2014 (Consequential Amendments) Order 2015

Debate between Earl Howe and Baroness Wheeler

Thursday 19th March 2015 Grand Committee

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

My Lords, this order, while detailed, has a simple overarching purpose: to make amendments to primary legislation in relation to England consequent to new laws already passed by Parliament, primarily the Care Act 2014, but also to a small extent the Children and Families Act 2014, as I shall explain.

Part 1 of the Care Act 2014 is a crucial step in delivering the commitments in the Government’s White Paper Caring for Our Future: Reforming Care and Support. It takes forward the recommendations of the Law Commission to consolidate 60 years of fragmented law into a single statute, refocusing the law around the person, not the service.

The order before us today is part of the final step in this process, disapplying current legislation for England which is to be replaced by the Care Act, and changing references to that legislation in other Acts to reflect the Care Act. For example, many of the core entitlements to social care services included in the National Assistance Act 1948 are disapplied for England by this order because they are to be replaced by the overarching duty and power to meet care and support needs included in Sections 18 and 19 of the Care Act 2014.

The Department of Health and the Department for Education have worked together to ensure that carer provisions have been extended in key areas. Part 1 of the Care Act introduces improved rights for adult carers caring for adults, including to assessment and support. Sections 96 and 97 of the Children and Families Act 2014 amend the Children Act 1989 to introduce significant new rights for young carers and parent carers respectively. These new provisions will work alongside those in the Care Act 2014 for assessing adults to enable services to co-ordinate their approaches to assessment and support for young carers and the people they care for.

This consequential order therefore makes some amendments which are in consequence of the new provisions introduced by the Children and Families Act 2014. Because the previous legislation relating to carers is being replaced by a combination of provisions in these two Acts, it makes sense to deal with the necessary consequential amendments in a single order.

The order also includes some savings provisions which are necessary for the purposes of transition from the old system to the new one. Essentially the amendments in the Schedule to the primary order “turn off” the old law in England but, in respect of those currently in receipt of services, the order enables services to continue under the old law until those people move over to the new system. These savings provisions will work with separate transitional provisions, to be made by another instrument, and will ensure a smooth transition for those currently in receipt of services under the present law.

Lastly, I briefly outline how this order fits into the broader context of statutory instruments under the Care Act. Subject to parliamentary approval of this order, we will, as I have mentioned, be making a further transitional order that will complete the temporary legislative framework for local authorities and partners to move from old legislation to the Care Act. Also subject to approval of this order, we will make a commencement order to formally commence the relevant provisions in the Care Act from 1 April 2015.

We have also laid before Parliament the Care Act 2014 (Consequential Amendments) (Secondary Legislation) Order, which makes similar amendments to secondary legislation as the order before us makes to primary legislation. This is subject to the negative procedure.

I hope that this standard exercise of ensuring legislative coherence will not prove controversial, so I commend this statutory instrument to the Committee.

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his comprehensive introduction to the order. As we have heard, it is part of the final steps of implementing the Care Act and related aspects of the Children and Families Act in respect of transition for disabled children into adulthood and on parent and young carers. Contrary to previous form on such Care Act SIs, I do not intend to raise many issues. The SI is very much a technical instrument, potentially complex and involved. However, read in connection with the 2014 statutory guidance to local authorities on implementation and transition to ensure that current services can continue under the old law until the new legal framework applies, it becomes clearer and more intelligible, even to non-lawyers such as myself.

The key imperative, which we strongly support, is for local authorities to be able to manage the transition for existing people receiving care and support services and carers before 1 April 2015 in a practical, case-by-case way. Assessments, care plans and funding arrangements and services agreed under the previous legislation continue unless circumstances have changed, and in accordance with the established review procedures to ensure that arrangements comply with the new Acts.

The Minister knows that we share local authorities’ continuing concerns over capacity and resource issues to ensure effective implementation, and I would be grateful if he could update the House on the latest stock-take survey of local authorities’ readiness and their continuing areas of concern. I understand that the joint LGA/Department of Health/ADASS programme office will continue to monitor and evaluate implementation, as well as co-ordinating the consultation on phase 2 of the Care Act implementation on the care costs cap. I hope that regular updates and information on implementation can be provided over the critical April/May period, and I would be grateful for the Minister’s reassurance on that—even if only up until 7 May.

As the Minister said, the separate transitional order setting out the detail of the circumstances in which the new order is to apply is to follow shortly, so this is especially important. The Department of Health has undertaken to circulate the draft next week via its local authority and other networks before it is formally issued, to confirm the approach for both phase 1 and phase 2 of the Care Act implementation so that it can address some of the recent detailed queries and concerns from local authorities. That is to be welcomed, as I am sure that we all agree that the local authorities need all the help and support that they can get on what is a huge and complex implementation programme.

The department has also undertaken to share the draft with us, and I am grateful for that. However, publishing the final transitional order so close to the date on which the Care Act comes into force will cause considerable difficulties to local authorities. The Minister will know that the order cannot be published until after this SI has been passed in the other place, which will take place next Wednesday. Even if it is published immediately after Commons agreement, that is exactly a week before the changes begin to be implemented and there will be no real opportunity for parliamentary comeback on such a detailed and important implementation document. I recognise that much of the order content will have already been discussed with and communicated to local authorities, but receiving the final authorisation so late in the day presents even greater implementation challenges than already faced. What steps are the Government taking to mitigate that very difficult position?

Two other key issues arise from the statutory instrument. The first is that it formally sets out the position in respect of Wales concerning the Social Services and Well-being (Wales) Act 2014 in relation to adult social care law and to children. The enforcement date of that is currently intended to be 1 April 2016, but that is rightly up to Welsh Ministers. The SI provisions underline that any provisions disapplied in England to make way for the Care Act and the Children and Families Act continue to apply in Wales until such time as Wales brings in the Welsh Act. The Explanatory Note has reassured us that full consultation has taken place with the devolved Administrations in both Wales and Scotland. It also underlines that the order does not contain any provision which changes the current law as it applies to Scotland or Wales, and we welcome those assurances.

The second issue in the SI is in the detail of the Schedule setting out the consequential amendments to existing legislation on the provision of care and support to carers in England resulting from the implementation of the Care Act and the Children and Families Act. That has obviously been a major exercise in cross-government departmental working, and we fully recognise the scale and extent of the task that the department has had to undertake. It is to be congratulated on this work. It is also timely to remind ourselves of the pioneering work described in the Law Commission’s 2008 report, which set out the agenda for the reform of social care law. We have always strongly supported the need to update, consolidate and modernise social care legislation and the key principles of the Care Act, and have been committed to working closely with Members from across the House to ensure improvements and amendments to the Act.

Can the Minister update the Committee on the issue arising from the recent report from the Joint Committee on Statutory Instruments in respect of the drafting of paragraph 95 of the Schedule? The committee has said that the amendments to the Personal Care at Home Act 2010 made by this paragraph are not comprehensive and that consequential amendments are needed. This is an important issue and the department has undertaken to remedy this omission, so will the Minister ensure that the amendments are communicated to all interested parties and organisations as soon as possible?

[Earl Howe]

I am grateful to the noble Baroness. She asked about the local authority stock take. The results of the recent stock take in relation to implementation of the Care Act for January and February reported a positive picture overall regarding local authority preparedness. Specifically, the stock take’s headline findings reported that 99% of councils say that they are very or fairly confident that they will be able to deliver the Care Act reforms from April 2015, compared to 97% of councils in stock take 2 and 90% in stock take 1. Of the four authorities which reported low confidence in stock take 2, three are now fairly confident and one is very confident; one authority has gone from fairly to not very confident.

Seventy-five per cent of councils say that they are on track in 2015-16 in their preparations for the Care Act, the remainder being slightly behind. Confidence has increased on six out of 10 proxy measures from stock take 2 to stock take 3. The exceptions are self-funders, carers’ assessment costs and information, advice and advocacy.

We have already invested more than £5 million in developing a suite of support materials, learning modules and other tools to help councils implement the Act. This is in addition to £23 million of investment in regional and local support that we have provided this year.

The noble Baroness referred to the transition order and regretted the fact that, in her view, it had been published rather late in the day. We set out the approach to transition in the statutory guidance published last October. The joint implementation programme of the Department of Health, the Local Government Association and ADASS has supported transition conversations with local authorities since that time. We do not think that anything in the transition order will have come as a surprise to local authorities.

The noble Baroness referred to the JCSI report, which pointed out that a particular consequential amendment had been omitted from the order. We accept that paragraph 95 of the Schedule to the 2015 order should have amended Section 1(2) to (5) of the Personal Care at Home Act 2010. Failure to do so was an oversight. Those subsections make some prospective amendments to Section 15 of the Community Care (Delayed Discharges etc.) Act 2003. The issue here, however, is that the 2010 Act is not yet in force and there are currently no plans to commence it. The department will ensure that if the provisions of the 2010 Act are commenced, the necessary consequential amendments to Section 1(2) to (5) will be made in the same order using the consequential amendment powers in the Care Act 2014. In summary, while we regret the missed amendment, the omission has no practical effect, and we will have ample opportunity to correct it if the relevant legislation is ever commenced.

Gender-based Violence: Screening

Debate between Earl Howe and Baroness Wheeler

Monday 9th March 2015 Lords Chamber

[Earl Howe]

My Lords, the provision in the Serious Crime Act on controlling behaviour is one of the ways in which we have addressed that. The noble Baroness is absolutely right: abuse can take many forms. It can be physical, sexual, emotional or psychological. Thirty per cent of this abuse starts in pregnancy, and existing abuse may get worse during pregnancy or after giving birth. In the context of health and care services, the challenge is to alert staff to all those possibilities in a way that avoids them stereotyping the person sitting in front of them.

[Baroness Wheeler (Lab)]

My Lords, more than 26,000 women in the UK received HIV care in 2013. What are the Government doing to assess the relationship between women with HIV and domestic violence, so that effective counselling, advice and support can be given to the women at greatest risk?

[Earl Howe]

My Lords, NHS England is working with the Department of Health to identify the right pathways, access to and availability of psychotherapeutic support for victims of sexual abuse and, in that context, the risk factors at play for women who have HIV. It is vital that the support services that we have and the alerts in the system are sensitive to the issue which the noble Baroness raises.

Care and Support (Business Failure) Regulations 2014

Debate between Earl Howe and Baroness Wheeler

Tuesday 3rd February 2015 Grand Committee

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

My Lords, I come before the Committee today to introduce the draft affirmative regulations under Part 1 of the Care Act 2014. The regulations before us relate to some of the most important elements of the Care Act, which consolidated 60 years of fragmented legislation into a single modern statute built around the needs and outcomes of a person.

Following Royal Assent for the Care Act in May 2014, the Government published final statutory guidance and laid those regulations subject to the negative procedure before Parliament in October and November, as well as laying these regulations in draft. In keeping with the collaborative approach that we have sought to maintain through the development of these reforms, over the summer the Government conducted an extensive public consultation on the guidance and regulations, including draft versions of the regulations that we will consider today.

The consultation engaged the full spectrum of stakeholders including: people receiving care and support and their carers; social workers and other front-line practitioners; local authority commissioners; social care providers; national representative groups; and NHS bodies. In total, the consultation drew more than 4,000 responses from many different sources. Responses were carefully analysed and, where appropriate, changes were made to regulations.

I will briefly introduce each of the four statutory instruments. I turn first to the Care and Support (Business Failure) Regulations 2014 and the Care and Support (Market Oversight Criteria) Regulations 2014. I will address these together as they form the two pillars of our broader strategy to protect people from provider failure. There is a diverse provider market in adult social care where entry and exit is a regular occurrence. Local authorities are currently able to intervene to meet needs in relatively rare cases where services are closed at short notice and individuals are put at risk—and historically they have done so effectively.

The Care Act places specific duties on local authorities in Wales and England, and their broad equivalents in Northern Ireland, to temporarily step in and meet needs where a provider is no longer able to carry on because of business failure. The business failure regulations set out the meaning of “business failure” generally by reference to different types of insolvency, for example administration and winding up. This approach ensures that people receiving services are protected in the event that their provider enters insolvency, without diluting the core responsibility of providers to deliver care services under normal circumstances.

The social care market includes large care providers, operating across much of England, whose financial failure, were it to happen, would cause local authorities considerable difficulty in carrying out their business failure duties without early warning. One such recent example was in 2011 when Southern Cross, then the largest provider of residential services in England, was threatened with insolvency. Local authorities had no prior warning of its financial position. While few people eventually had to change care home, the Government recognised that the degree of worry for people receiving care and their families was unacceptable.

The Care Act accordingly places new duties on the Care Quality Commission to assess the financial sustainability of certain registered care providers. The CQC will do this by collecting and analysing financial information. The CQC may respond to significant risks identified to the financial sustainability of a provider by requiring it to develop a plan to mitigate any risks identified, or ordering an independent review of the business. Should the CQC be satisfied that a provider is likely to fail, it will provide relevant local authorities with an early warning and the information that they need to prepare adequately to protect the continuity of care for individuals. Where the CQC is not satisfied that the provider is taking all the necessary steps to return to financial health, or it feels that it has not been given the necessary information to assess financial sustainability, it is able to take a range of regulatory actions, up to and including the deregistration of the provider in question.

The Care and Support (Market Oversight Criteria) Regulations set the entry criteria for the CQC’s financial oversight regime. Any provider meeting those criteria will be subject to the CQC’s regulatory activities that I have described. They have been designed to capture those providers that—because they are particularly large, geographically concentrated or operate in a large number of local authority areas—would be “difficult to replace” were they to fail financially. It is important to note that inclusion in the regime is a comment not on the likelihood of failure but rather on the risks that would be posed should the provider get into difficulties.

The Care and Support (Children’s Carers) Regulations 2014 relate to the power in the Act for local authorities to support carers of children in a similar way to that in which they support carers of adults, setting out how the rest of Part 1 of the Act applies in this situation. It is important to note that this power applies only in the limited circumstances where carers of children have received a transition assessment in preparation for beginning to receive support under the adult statute, but the transition has not yet actually taken place.

The broad principle at work will be that adult carers of children are supported under children’s legislation, while adults caring for adults will be supported under the Care Act. This instrument is merely an acknowledgement that some flexibility in this regard may be desirable around the time of transition. The instrument has been carefully drafted to ensure that it does not replicate the support for carers of children under other legislation, so ensuring that there remains a clear division of responsibility. These regulations allow for flexible and personalised approaches to support, without forcing local authorities into unnecessary changes to different, broader policies for carers of children and of adults, which exist for good reasons.

Lastly, the Care and Support (Eligibility Criteria) Regulations 2014 set out the national eligibility criteria for adult care and support and carer support. All local authorities will at a minimum have to meet this threshold and cannot tighten their criteria beyond it, although they will have a power to meet needs that were not considered eligible. The national eligibility threshold has been set at a level where the person’s care and support needs, and their inability to achieve certain outcomes as a result, have or are likely to have a “significant impact on their well-being”. This is intended to have a similar effect to the eligibility level that the vast majority of local authorities operate at present. Together with funding announced in the 2013 spending round, this will allow local authorities to maintain the level of access to care and support when the new system is introduced in April 2015.

Given the critical importance of the eligibility criteria, the Government have been especially careful to ensure that they have taken account of the full views of all relevant stakeholders. The Department of Health carried out an extensive engagement to gather views on an initial version of the regulations from June to December 2013, and engaged the Personal Social Services Research Unit at the London School of Economics to evaluate the draft regulations against current practice. These findings informed the second version of the eligibility regulations that were consulted upon in summer 2014.

Alongside the consultation, the department asked PSSRU to evaluate the second draft of the regulations, working with 27 local authorities to compare the draft regulations with recent cases. We made a number of changes to refine the criteria on the basis of feedback and independent research. We have also worked closely with stakeholders to test the approach. I am confident that the final version before us fulfils the Government’s commitment to replicate the current access to care and support in setting the national criteria.

These regulations are required to meet fully some of the central aims of the Care Act: protecting people from the reality of provider failure and the extreme worry caused by its spectre; providing flexible and appropriate support for carers; and ensuring more consistency in people’s rights to care and support. I commend these statutory instruments to the Committee.

[Baroness Wheeler (Lab)]

I thank the Minister for his comprehensive introduction to these four important affirmative regulations. As he knows, I also have a take note Motion tabled for next week on the negative regulations on implementing the Care Act. Inevitably, there will be overlaps between today’s debate and next week’s but I hope that we can clear off some of the major issues today. The four SIs cover a number of important issues so, while we were happy to have them taken together to expedite the business of the Committee, I hope that the Committee will bear with me since there are a number of areas to cover in relation to implementation of the Care Act and the individual SIs. I also thank the Minister for the very helpful briefing meetings that he has had with Opposition Front Bench health team members on the regulations. He will know that both the Opposition’s health and local government teams are keeping a close watch on how the Care Act is being implemented, so we were grateful for the time that he took on this.

We believe strongly that this first phase of implementation has to be viewed across both the local government and health departments, and considered in the context of the huge funding pressures on local authorities, with a 40% cut in their funding since this Government took office. The Minister, of course, disputes this figure and others from independent bodies on the scale of local government cuts cross the piece and their devastating knock-on impact on social care. Whether the figures are from the King’s Fund, the Nuffield Trust or Age UK, they all put the scale of cuts to social care budgets in terms of billions of pounds.

Recent figures from the Association of Directors of Adult Social Services, with which the Department of Health has worked closely on the Care Act’s implementation, point to this year being the third year of continuing cash reductions and the fifth of real-terms reductions in spending on social care. It points out that, since 2010, social care spending has fallen by 12% while the number of those looking for support has increased by 14%. Social services departments have been forced to make savings of 26% in their budgets—the equivalent of £3.53 billion over the last four years. Compared to 2009-10, almost 300,000 fewer people over the age of 65 are receiving state-funded care.

On many previous occasions, the Minister has set out the additional funding being made available for Care Act implementation—and, despite the challenges, the recent DH stock-take shows encouraging overall progress in local authorities’ readiness for the phase 1 implementation from April 2015. Like the department, we commend the role of the joint LGA/ADASS/Department of Health programme management office. We fully recognise the scale and extent of the work that has gone into consultation exercises with stakeholders, the drafting of the regulations and guidance and the joint working on implementation with local authorities.

However, the same stock-take also makes clear councils’ continuing concerns about the adequacy of funding in the face of modelling which shows increasing support needs for local authorities around IT, workforce, information advice, carers and market shaping. Workforce capacity is a particular concern. The LGA view is that these aspects of implementation of the 2015-16 reforms may be underfunded by as much as £50 million.

Before moving on to the regulations, perhaps I may refer quickly to the Government’s plans to close down the Independent Living Fund in June 2015. We seek reassurances from the Minister that the funds transferred to local authorities from that fund will continue to be used to provide vital support for the disabled people who currently depend on it to be able to live independently in the community and have the same rights, choices and chances as any other citizen. My understanding is that it will be for individual authorities to make decisions on how the resources from the fund will be applied. Will the Government issue guidance to help protect the thousands of disabled people currently receiving ILF support who are affected by this decision? How will they ensure that the money is not just diverted into helping to fund the Care Act implementation or into general funding support for social care services?

The care and support regulations on the market oversight criteria, the interlinking negative regulation on market oversight information—covered by my take note Motion next week—and the business failure regulations are about trying to prevent the sort of problems witnessed in 2011 with the collapse of Southern Cross Healthcare, as set out by the Minister, by empowering the Care Quality Commission to monitor and obtain financial information from providers to check their financial stability and spot the early warning signs of potential difficulties and failure. The aim is to protect vulnerable people and their families if there is provider failure, to ensure that local councils have both early warning and support to be able to maintain vital continuity of support and to ensure that no one depending on the service will suffer.

Medical Innovation Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Friday 24th October 2014 Lords Chamber

[Baroness Wheeler]

My Lords, we have had a very authoritative and detailed contribution on the issues raised by Amendment 29 from the noble Lord, Lord Saatchi. Opinion among noble Lords and indeed the stakeholder medical and patients’ organisations is still divided on: first, whether a change to the law is required or whether the existing law and professional ethics arrangements will allow responsible innovation; and secondly, whether the potential two options/processes—or three as my noble friend now makes it clear will be available if the Bill becomes law—will improve and speed up the administering of innovative treatments or will cause considerable confusion among doctors about which system they should use, lead to more bureaucracy and deter them from embarking on the course?

As we said earlier, we welcome the attempts of the noble Lord, Lord Saatchi, to ensure that with this amendment the Bill does not affect the common-law Bolam test. On the overall Bill he has led a powerful campaign and is reported to have won the support of patients responding to the consultation and the publicity from Cancer Research UK, Marie Curie Cancer Care and other patient organisations. I was pleased that the noble Baroness, Lady Masham, raised a number of questions from Marie Curie about palliative care and the use of drugs arising from issues in the Bill, and I was grateful for the Minister’s very helpful response.

The General Medical Council has now given its support to the amended Bill and the Medical Defence Union has said that the amendments cover the main objections to the previous Bill. However, we have to acknowledge that some key stakeholders maintain that the Bill is not necessary because the existing law already ensures protection for doctors to innovate, and the current law and ethical guidance from the General Medical Council are clear. The Royal College of Surgeons still has strong reservations about the Bill, particularly about it applying to surgery, as we have heard. The Medical Protection Society still believes that it confuses rather than clarifies the law. The Association of Personal Injury Lawyers says that the amendments make a confusing Bill even vaguer. The BMA still strongly questions the necessity and desirability of clarifying or changing the law. Action Against Medical Accidents, one of the leading patient organisations, still says that the Bill is fraught with unintended and dangerous consequences and will create a more bureaucratic system. Sir Robert Francis QC, while considering that the amendments have produced an improvement in safeguards over what was originally proposed, has said that serious problems remain. In particular, he is concerned, as my noble friend Lord Turnberg pointed out earlier, that the Bolam amendment, while restoring a level of safeguard, also has the disadvantage of restating Bolam in different language, leading to a real risk of confusion. His question is: why not just stick to Bolam? I would be grateful for the noble Lord’s comments on that.

Will the noble Lord, Lord Saatchi, and the Minister tell the Committee whether they consider that the amended Bill now meets Dr Dan Poulter’s key test that I referred to earlier; namely, of not placing an undue bureaucratic burden on the NHS or not exposing doctors to a risk of additional liabilities?

I welcome the response of the noble Lord, Lord Saatchi, on the question of convening a round table, which I think will be a very helpful way of going forward. Obviously, it will never be possible to satisfy everybody’s concerns but, if the Bill is to be further supported, what steps will be taken by the Government to engage with stakeholder concerns?

[Earl Howe]

My Lords, the Government support these two amendments, which ensure that the Bolam test will remain unaffected by the Bill. In practice, this will mean that it is for the innovating doctor to decide whether to take the steps set out under the Bill or to rely on the existing Bolam test. In other words, there would be no requirement for doctors to follow the Bill when innovating.

The amendments clarify that, separate to the existing Bolam test which is applied by the courts, the Bill provides doctors with an alternative option for showing that they are acting or have acted responsibly. Furthermore, subsection (2)(b) of the proposed new clause provides that doctors are not negligent, and thus will not be judged adversely if their actions are later challenged, merely because they have not followed the Bill.

My noble friend Lord Kirkwood asked how the proposed new clause affects how a regulator approaches a complaint or fitness-to-practise procedures. This Bill addresses clinical negligence law and how the courts will assess these cases, not how the regulators will process fitness-to-practise cases.

The noble Baroness, Lady Wheeler, asked whether the Bill was necessary. The Department of Health’s consultation on the Bill revealed that some doctors find the threat of litigation to be a block to innovation, although this view was not universally held. The Bill is aimed at reassuring those doctors who feel unable to innovate due to concerns about litigation. There will also be many doctors who are not afraid to innovate and for whom litigation is not a material concern. Those doctors can continue to act as they have done previously and rely on the existing law of clinical negligence, or, as I have explained, they may choose to take advantage of the Bill instead.

I hope that noble Lords will accept these two amendments, which give flexibility and choice to doctors who want to innovate.

Children: Obesity

Debate between Earl Howe and Baroness Wheeler

Monday 20th October 2014 Lords Chamber

[Earl Howe]

My Lords, our current emphasis is on overall calorie reduction, of which sugar forms an important part. The scope for reformulation to reduce sugar levels varies widely depending on the food that one considers and a reduction of sugar levels does not always mean that the overall calorie content is reduced. The issue is not black and white. An example of that is when sugar is replaced by starch or other ingredients. Nevertheless, we are discussing with the food manufacturing industry ways in which it can reformulate its food and the Scientific Advisory Committee on Nutrition is finalising its review on carbohydrates, looking at sugar as a particular component of that.

[Baroness Wheeler (Lab)]

My Lords, given the difficulty of ensuring effective cross-department co-ordination on childhood obesity, what is the Government’s response to a call by the Royal College of General Practitioners to set up a COBRA-style task force? Would that not be a key way of ensuring a joined-up approach that extended beyond the Department of Health?

[Earl Howe]

My Lords, as I mentioned earlier, we have set up the Obesity Review Group, which contains a multiplicity of experts to co-ordinate the efforts being conducted not only in government but also in local government and on the part of business and the wider private sector. While I buy into the central point made by the noble Baroness that this needs an overarching scrutiny, we believe that we have that already.

NHS: District Nurses

Debate between Earl Howe and Baroness Wheeler

Thursday 10th July 2014 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they are taking to ensure that the National Health Service has sufficient district nurses.

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

My Lords, the Department of Health is working with Health Education England, NHS England and the Queen’s Nursing Institute to raise the profile of district and community nursing and to attract more nurses to choose this as a career path. That work includes a workforce project led by the Community Nursing Strategy Programme to ensure an adequate supply of highly skilled district nurses to support patients in community settings, provide quality care and improve patient outcomes.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Does he not agree that the failure to address the chronic shortage of district nurses makes the RCN’s call to action even more urgent? The college has found that district nurses are so stretched that they can spend only 37% of their time actually dealing with patients in the community, which is deeply worrying. How does this help people with long-term conditions who depend on specialist nursing care to stay out of hospital? When is a comprehensive strategy that addresses the urgent action which needs to be taken on this matter going to be published?

[Earl Howe]

My Lords, we recognise the need for urgent action, and that it is required across the piece. We need to train more district nurses, and therefore training places have gone up both last year and this year. We also need to equip district nurses with technology. To that end, the nursing technology fund will address the issue that the noble Baroness referred to initially, which is the time that nurses have to spend with their patients. Technology can make time management much more efficient, and it is also good for the patient, who feels more in touch. NHS England and Health Education England have set up a workforce project which, as I said in my initial Answer, is designed to address not only workforce numbers but also the attractiveness of district nursing to trainees.

Health: Multiple Sclerosis

Debate between Earl Howe and Baroness Wheeler

Monday 30th June 2014 Lords Chamber

[Earl Howe]

My noble friend will know that NICE looks at the clinical effectiveness of a drug alongside its cost effectiveness. The cost-effectiveness equation will naturally include consideration of unpleasant side-effects. The advice that it issues will reflect the evidence that it has from clinicians on that matter. It will then be for clinicians to decide whether the risk-benefit ratio is appropriate for particular patients.

[Baroness Wheeler (Lab)]

My Lords, when considering the Care Act we were very concerned to ensure that care and support plans for social care users included contingency planning for people who have fluctuating conditions such as MS and rheumatoid arthritis, where support needs can vary from week to week and day to day. What mechanisms are being put in place to ensure the provision of the flexible and comprehensive care plans that are needed?

Health: Rheumatoid Arthritis

Debate between Earl Howe and Baroness Wheeler

Monday 16th June 2014 Lords Chamber

[Earl Howe]

I am grateful to my noble friend. Expenditure on musculoskeletal disease research by the National Institute for Health Research has increased from £15.5 million in 2009-10 to £23.1 million in 2012-13. The NIHR is investing over £21 million over five years in three biomedical research units in musculoskeletal disease. They are all carrying out vital research on rheumatoid arthritis. The NIHR is currently investing £2 million in a programme of research on treatment intensities and targets in rheumatoid arthritis therapy.

[Baroness Wheeler (Lab)]

My Lords, can the Minister tell the House what impact the very worrying reported shortage in take-up of family doctor training places is likely to have on the ability of GPs to support patients with potential rheumatoid arthritis symptoms? A recent survey by Pulse found that only 7% of the funding for medical schools goes into teaching general practice. Does this not augur badly for the future of primary care?

[Earl Howe]

My Lords, we of course recognise the very hard work that GPs do. Despite a decrease in headcount, there has in fact been a 1.2% increase in full-time GPs since 2012 and the number of practice nurses and practice staff has also grown. However, we also recognise that the workforce needs to grow to meet rising demand. That is why our mandate to Health Education England requires it to ensure that 50% of trainee doctors enter GP training programmes by 2016. Generally, we will work with NHS England to consider how to improve recruitment, retention and return to practice in primary and community care.

NHS: Clinical Commissioning Groups

Debate between Earl Howe and Baroness Wheeler

Monday 9th June 2014 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government how they will ensure Clinical Commissioning Groups’ strategies and implementation plans support carers and take account of their needs and aspirations.

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

My Lords, NHS England assures clinical commissioning groups’ plans to support and challenge them to meet the needs of their populations. This includes considering supporting carers, who are a hugely valuable asset for local communities. NHS England has published a commitment to a carers action plan. It will review the delivery of these commitments through feedback from carers and carers’ organisations and through progress towards the relevant outcomes indicators and mandate objectives.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. At the start of national Carers Week, it is right for the whole House to pay tribute to our 1.5 million carers and the vital support that they provide in caring for their partners, friends or a family member. What is the Minister’s response to a recent Carers UK survey, which found that while GPs have implemented systems to identify those undertaking carers’ responsibilities, few are actually doing anything differently to accommodate them—for example, giving regular health checks or changing appointment systems to support getting somebody to the surgery who is in a wheelchair or caring for somebody with dementia? Does the Minister agree that the appointment of carers leads under CCG implementation plans is a key step in bringing about the major push that is needed to get GPs to up their game? How will the Government ensure that that happens?

[Earl Howe]

My Lords, I fully endorse the comments of the noble Baroness about the importance of carers. They play a crucial role as partners in care for the well-being of those they look after. I saw that report and of course it is important that GPs are aware of their role in supporting carers. We set out our vision for this in a document we published, Transforming Primary Care. That recognises the importance of involving and supporting carers. It sets out an expectation for GPs to identify carers as a matter of course. As I said in my original Answer, CCG plans will be assured by NHS England, including the important element of carers’ support and recognition.

Care: Older People

Debate between Earl Howe and Baroness Wheeler

Wednesday 7th May 2014 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what response they intend to make to the findings of the Age UK report Care in Crisis on the impact of cuts to care for older people.

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

My Lords, social care is a priority for this Government, which is why we have allocated an extra £1.1 billion to councils this year to protect services. We are building on this by creating a £3.8 billion fund next year to join up NHS and social care services. Both health and social care need to work differently to respond to the needs of our ageing population, focusing on keeping people well and living independently for as long as possible.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Age UK’s report found that social care cuts between 2010 and 2013 have resulted in 168,000 older people no longer receiving help with essential tasks such as eating, washing and getting dressed. The Nuffield Trust recently put the figure over four years at 250,000 people who have lost state funding support. In the light of today’s developments, can the Minister please comment on what is now happening to the Better Care Fund and when does he expect to update the House fully on why the launch of the fund has been delayed? The Minister knows that the fund basically uses resources already committed to shoring up the existing reduced level of services and that there is no new money in it. We now learn that the Cabinet Office says that the fund lacks financial credibility, in particular as to how on earth local hospitals are to save money to move care into the community in the current climate of substantial cuts. How does the Minister think progress can be made on the transfer to community care amidst the chaos and confusion into which this policy has now fallen?

[Earl Howe]

My Lords, I can assure the noble Baroness that there is no chaos and confusion. As regards reduced numbers, which was where the noble Baroness started, the transformation in the service model that we are promoting focuses above all on prevention and is designed to enable people to live independently for longer, as I said earlier, so as to reduce the number of people who are dependent on formal care. Councils have told us that lower social care user numbers are partly due to the success of their core prevention work, but also due to increased use of re-ablement services for people who leave hospital to help them get back on their feet. As regards the Better Care Fund, there has been no delay there. We wanted to set aside enough time to make sure that all areas of the country have developed comprehensive plans for joined-up care. The better care plans start from April next year, as the noble Baroness is aware, and we have asked for early versions to be completed a year in advance so that we can review them, check their level of ambition and test how they will be delivered. That is what is happening now and we are broadly on track with the programme.

Health: Liver Disease

Debate between Earl Howe and Baroness Wheeler

Tuesday 6th May 2014 Lords Chamber

[Baroness Wheeler]

My Lords, I, too, pay tribute to Elena Baltacha, who was a truly remarkable and very brave woman. One in five people in the UK is at serious risk of liver damage, but a recent government response shows that the Secretary of State has not met any external organisations to discuss liver disease since May 2010, and current Ministers have not met representatives of people living with liver disease since September 2012. Can the Minister commit urgently to remedying this situation, particularly as it is in such stark contrast to the 130-plus meetings the Government have had with the drinks industry?

[Earl Howe]

My Lords, liver disease is very much in the sights of my honourable friend the Minister for Public Health, as is evidenced by the document we published last week, Living Well for Longer, in which there is a whole section on alcohol and liver disease, and by what NHS England and Public Health England are doing to tackle them.

Mental Health: Young People

Debate between Earl Howe and Baroness Wheeler

Monday 7th April 2014 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, a recent survey found that more than half of young carers reported having a mental health problem, including feelings of stress, anxiety and depression, eating and sleeping problems and risk of self-harm. What are the Government doing to support these dedicated young people? What guidance will be given in the Children and Families Act and the Care Bill on how local authorities should work with mental health services to ensure that young carers get the support they so clearly need and deserve?

[Earl Howe]

The noble Baroness is absolutely right and the pressures and strains on young carers have been well recorded. It is fair to say that compared with a few years ago, not least thanks to the efforts of the previous Government but also the work that we have continued, GPs and others working with families are much more alert now to the needs of young carers and can signpost them to appropriate support. The CYP IAPT programme is designed no less for young carers than it is for others.

NHS: Midwives

Debate between Earl Howe and Baroness Wheeler

Monday 17th March 2014 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, does the Minister accept that the Public Accounts Committee report on maternity services was pretty damning, not just in terms of midwife shortages but on the lack of overall government accountability and strategy for maternity services, the increasing clinical negligence bill and substantial regional and demographic inequalities and variations in maternity care? What are the Government doing about this and when can we expect a coherent plan in response to these issues?

[Earl Howe]

The noble Baroness is right: the PAC raised a number of very important issues, many of which we agree need close attention. I have already mentioned the work that we are doing to improve recruitment and to reduce variation in the quality of services around the country. This requires more than just government; it requires all the arm’s-length bodies with an interest to pull together and, of course, local commissioners to do their bit as well.

NHS: Essential Services

Debate between Earl Howe and Baroness Wheeler

Tuesday 14th January 2014 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government, in the light of the Dr Foster Hospital Guide 2013, how NHS England is monitoring access to essential services and how it intends to address variations in access to and provision of services at clinical commissioning group level.

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

My Lords, to help reduce variations in access to health services, Professor Sir Bruce Keogh, the medical director of NHS England, is working with the medical royal colleges and others to ensure that the NHS is clear about the evidence base for common types of surgical interventions. For example, it will produce guidance for commissioners to help ensure that consistent eligibility criteria are used to access surgical services and so minimise the scope for variation at a local level.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Dr Foster’s report shows that the number of knee and hip replacements and cataract removals has fallen to its lowest level in four years, meaning that more than 12 million people now live in areas where the number of these operations has substantially declined. This is despite our elderly population continuing to rise over the same period and these common surgical procedures being vital to ensuring that older people can regain their mobility, keep active and stay living in the community. Does the Minister agree that these are essential treatments? What pressures will be placed on NHS England to ensure that CCGs actually provide them and also that they fulfil their legal obligation to issue guidance to local communities, revealing what their policies are on providing medicines, surgeries and therapeutic interventions?

[Earl Howe]

My Lords, I should first tell the noble Baroness that we cannot reconcile our own figures with those of Dr Foster. We believe that there has in fact been a significant increase in the number of cataract and knee and hip replacement operations since 2009-10 and not a drop. Regardless of that, I suggest to her that the absolute numbers of operations taking place do not tell us anything about possible rationing or the absence of it. That question can be answered only with the benefit of fuller data. The key to consistent access to these treatments is a common understanding among commissioners of the evidence base in each case. That is exactly what Sir Bruce Keogh is working towards and will provide guidance on in due course.

World Innovation Summit for Health

Debate between Earl Howe and Baroness Wheeler

Monday 16th December 2013 Lords Chamber

[Earl Howe]

My Lords, in broad terms, dementia falls outside the scope of mental health but it is, of course, closely allied. Many of the principles that apply to good mental health care apply equally to dementia. We are, again, doing our best, in responding to the Prime Minister’s challenge on dementia, to ensure that those who contract this dreadful condition are looked after with dignity and respect in the appropriate setting.

[Baroness Wheeler (Lab)]

My Lords, the WISH report, to which the Government are signed up, recommends key improvements to community care for mental health by 2020. Yet the recent FoI survey of 51 NHS mental health trusts by BBC News and Community Care magazine shows overall budgets shrinking by over 2%, including those for community mental health support teams, despite referrals to them rising by 13%. How is this consistent with pledging to achieve the WISH goal by 2020? What leadership and direction will the Government give to preventing this very disturbing situation from getting worse?

[Earl Howe]

My Lords, we need to hold the NHS to account by reference to the outcomes that it achieves. I do not belittle the need to spend sufficient sums of money. The National Survey of Investment in Adult Mental Health Services has indicated that reported spend on mental health services has continued to hold reasonably steady over time. I reiterate that mental health and well-being is a priority for the Government, as I hope the noble Baroness knows. We have clear indicators in the NHS outcomes framework, which will ensure that NHS England will need to focus on this area very closely.

NHS: Walk-in Centres

Debate between Earl Howe and Baroness Wheeler

Tuesday 10th December 2013 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what plans they have in respect of the closures of NHS walk-in centres over the past three years, in the light of the preliminary report made by Monitor.

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

My Lords, since 2007, the local NHS has been responsible for NHS walk-in centres. It is for local commissioners to decide on the availability of these services. It is also for local commissioners to determine how walk-in centres fit into plans locally, rather than being governed by a top-down imposition of services. They make such decisions by involving patients and by using their clinical expertise to determine the pattern of local services and where walk-in centres fit in with this.

--- Later in debate ---

[Baroness Wheeler (Lab)]

I thank the Minister for his response. However, 76 NHS walk-in centres have been closed over the past three years and the Monitor report makes clear that this is often without proper consultation locally on alternative provision, leading to increased pressure on A&E and urgent care services. In Monitor’s survey, one in five patients using the centres said that they would have visited the nearest A&E department had the centre not been there. Monitor also finds in a number of cases that the closure decision has been made by CCGs, with member GP practices themselves having a financial interest in whether or not the service continues. What action will the Government take to ensure that, if future closures of walk-in centres are considered, the public will be properly consulted and patients will have access to an equivalent level of service?

[Earl Howe]

My Lords, when any service change is proposed, we expect that the four tests which the Government laid down early on in their term of office should be followed. One of those is a patient and public consultation or involvement in the decision. Another is clinical buy-in. I can give the noble Baroness the assurance that this is what local area teams of NHS England would expect to see in any proposals involving the closure of a walk-in centre.

NHS: Clinical Commissioning Groups’ Funding of Treatment

Debate between Earl Howe and Baroness Wheeler

Tuesday 12th November 2013 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government how many types of treatment Clinical Commissioning Groups have decided not to offer to patients since April 2013.

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

My Lords, clinical commissioning groups are now responsible for commissioning services and treatments for their local populations, with NHS England providing oversight and support. NHS England has advised that it does not routinely collect data on the number and type of treatments that CCGs have decided not to offer to patients. We have been clear: restricting access to services on the basis of cost alone is wrong and compromises patient care. Commissioning decisions should be made using clinical evidence and best practice guidance.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Is he not concerned about the recent British Medical Journal survey, which showed that since CCGs took over, one in seven have introduced new treatment restrictions, including treatment for hip and knee replacements, cataracts, and caesarean births for non-medical reasons? What steps are the Government taking to ensure regional and national monitoring and consistency of treatment policies across the NHS? Moreover, the Royal College of Surgeons is concerned that so few CCGs are meeting their legal obligation to publish guidance on how they will provide medicines, surgery and therapeutic interventions. This was meant to provide transparency in rationing decisions. What will the Government do about it?

[Earl Howe]

My Lords, the availability of some healthcare services is determined nationally; for example, under NICE technology recommendations. Some services are commissioned directly by NHS England, but in most cases decision-making on whether to fund a service or treatment is left to the local CCG or local authority. That is to enable CCGs and local authorities to commission services that best fit the needs of their local population. For such decision-making it is very important that the process is rational, transparent and fair. The right contained in the NHS constitution ensures that that happens. If a CCG decides that a treatment will not normally be funded, it needs to be able to consider whether to fund that treatment for an individual patient on an exceptional basis.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Tuesday 29th October 2013 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, from what my noble friend Lord Patel has said, it is clear that the issue of safeguarding inquiries is not at all sorted. He has highlighted a substantial gap in the Bill that could have a very serious impact on some of the most vulnerable people in our communities and prisons. He rightly seeks equivalence of care and protection for adults detained in prison and those residing in approved premises such as bail hostels—care and protection that all other vulnerable adults have when it comes to safeguarding inquiries by local authorities. We take on board his deep concerns about prisons and what appears to be a lack of co-ordinated and clear responsibilities in respect of safeguarding inquiries. I ask the Minister to look further into the matter, as my noble friend suggested.

My noble friend raises some key issues on whose responsibility it is to carry out a safeguarding inquiry for adults living in the community in approved premises. Given all the uncertainty about future service delivery as a result of the Government’s major reorganisation and break-up of the probation service, if that responsibility is currently with the local probation trust, this amendment, which calls on the Secretary of State to report to Parliament within one year of this clause of the Bill coming into force, becomes even more necessary. To require the new community rehabilitation companies or their successor bodies to account for how they have discharged their responsibilities for safeguarding adults residing in approved premises is an acceptable way forward.

I look forward to hearing from the Government about how they intend to deal with the matter in the light of the serious concerns expressed by my noble friend today and in previous discussions on the Bill, and in light of the huge confusion that will result from the proposed changes to the probation service. I very much hope that the Minister will be able to support my noble friend’s endeavours to fill what is potentially a serious gap in the Bill, and to ensure future adequate protection of these vulnerable adults.

[Earl Howe]

My Lords, I will begin by making absolutely clear that we agree that all prisons and approved premises should have arrangements for safeguarding the adults in their care. They should have a comprehensive policy that is understood by all staff and which ensures that vulnerable adults are identified and given appropriate support. I hope that we also agree that we cannot relieve prisons and probation providers of their duty of care by imposing a duty on a local authority to make safeguarding inquiries into suspected abuse or neglect in a prison or approved premises.

We need clear guidance for prisons, probation providers and local authorities to ensure that the procedures within prisons and approved premises are informed by best practice and local expertise. My officials will work with the Ministry of Justice and the National Offender Management Service, together with the Association of Directors of Adult Social Services and other stakeholders, such as the Prison Reform Trust, to develop instructions and guidance for prisons, probation providers and their local authorities. Those instructions and guidance will be in place by the time the Bill is implemented and will give improved clarity about the Prison Service and probation providers’ roles and responsibilities in safeguarding adults in their care, including the need to have a whole-institution approach to safeguarding, and cover their relationship with the local safeguarding adults board.

The Ministry of Justice encourages prison and probation staff to be involved with local safeguarding adults boards. The guidance on how safeguarding should be carried out in conjunction with local authority partners can draw attention to the duty in Clause 6 that local authorities and their partners must co-operate in the exercise of their respective functions relating to adults with needs for care and support. The guidance will be consistent with the broader advice and guidance on safeguarding adults in the community to ensure that good practice on safeguarding policies and inquiries is routinely shared.

In addition, the guidance will set out clearly the need for locally agreed relationships with local safeguarding boards, including clear local protocols around the circumstances for involvement of local SABs. The guidance will also make clear how prison and probation staff can benefit from the expertise of social services and local authority safeguarding teams.

For approved premises, the probation provider has a clear responsibility in relation to safeguarding but there is nothing to prevent it seeking advice from either the safeguarding adults board or the local authority safeguarding team. This already happens in many areas. Since a local authority’s duties in relation to safeguarding would not extend to safeguarding adults who are at risk of abuse or neglect by reason of their detention or their offence, a joint approach would be much more effective where there is a particularly difficult safeguarding challenge in an approved premises.

Her Majesty’s Inspectorates of Prisons and Probation and the Prisons and Probation Ombudsman will take account of the guidance and local agreements and make recommendations for improved practice, if relevant, when inspecting services and investigating complaints within the prison and probation services.

I wish to be clear in answering the noble Lord, Lord Patel of Bradford, who said that the document No Secrets said that local authorities have responsibility for safeguarding in approved premises. Local authorities do not have a statutory duty at the moment. It is the duty to conduct inquiries that will not apply—not that local authorities cannot conduct an inquiry if invited to by the probation trust or provider. Guidance and probation instructions will provide further detail on how local authorities and probation trusts, as they currently are, can work together at a local level. The guidance will go to all probation providers who run approved premises. Probation services will be contracted out in due course, so these will be approved premises provided by the probation service and by voluntary or private providers. The guidance will make it clear that the provider running the accommodation has a duty of care and a safeguarding responsibility.

I hope that, with those assurances and clarifications, the noble Lord will feel able to withdraw his amendment.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Monday 21st October 2013 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, we very much welcome this important group of amendments. If one reads back over the debates on the Bill in Committee, there can be little doubt that the provisions for HEE and LETBs have been considerably strengthened and improved by your Lordships’ detailed scrutiny and deliberations. These amendments consolidate that work.

We have also been encouraged by the progress that HEE has been making under the leadership of Sir Keith Pearson. The website demonstrates this, and the HEE leadership team has been highly visible at conferences and forums, setting out its proposed strategic priorities and consulting on the way forward. In particular, HEE seems to have taken up the key message that, in educating and training staff for NHS and public health, it must have a strategic understanding of the workforce requirements across the boundaries of health and social care and of the need for staff to work in an integrated way. This has been a major concern. I was pleased, for example, to hear the HEE medical director, Wendy Reid, emphasise this at a recent Westminster Health Forum workforce conference that I chaired.

These amendments strengthen the role of LETBs by emphasising that HEE duties under Clause 89 to ensure that quality improvement in education and training, promotion of research—as the Minister has stated—and the NHS Constitution all apply to LETBs. This is an important provision and reflects concerns expressed in Committee that LETBs must pay attention to the maintenance of standards and quality in education and training, as well as ensuring that sufficient numbers of staff are trained locally. This was a point made by my noble friend Lord Turnberg and which the Minister addressed earlier.

Amendments explicitly providing HEE with authority to delegate its functions to its committees, sub-committees, members or other persons are important in allowing HEE the flexibility that it needs to deliver its priorities and functions, and we strongly support them.

On HEE board and LETB representation, we join other noble Lords in expressing our relief at the government amendments, which ensure that people with clinical expertise are appointed to both bodies. This was a serious omission and its inclusion now greatly strengthens the Bill, as does the Government’s commitment that regulations will place a specific requirement on HEE and LETBs to include a nurse and a doctor. It is particularly important, as my noble friend Lord Hunt underlined in Committee, for the people in the driving seat on education and training requirements, standards and future needs at local level to be those who provide the services. HEE and LETBs must understand the pressures that the service is under in relation to staffing and to ensuring that education and training is flexible and responsive to the rapidly changing face and needs of health and social care. The implementation of the Francis recommendations for a lay patient representative on the HEE board and LETBs is also a key change to the Bill, which we strongly welcome and which will only enhance the work and effectiveness of those bodies.

Finally, as supportive of HEE as we are, it is hard to see in HEE work to date a clear strategy for developing the vital cadre of NHS managers that is needed to lead the NHS in the coming months and decades. There was a strong concern about this in Committee and the need for close working with HEE and the NHS Leadership Academy was acknowledged by the Minister. The Joint Committee wanted to see a statutory commitment for HEE to work in partnership with the academy, to ensure that managers in training work alongside their clinical colleagues and to increase the number of managers in the future who have clinical experience. Does the Minister not agree that this needs to be an explicit, upfront priority for HEE, which translates through to the work of LETBs? How will the Government ensure that this vital issue is addressed?

[Earl Howe]

My Lords, I turn first to the amendment in the name of the noble Lord, Lord Aberdare. He has, of course, raised a very important matter. I think that it would be too ambitious for me to offer him complete comfort on this issue at the Dispatch Box, but I hope that I can give him some. It is essential that patients have their conditions diagnosed promptly and effectively. Both Health Education England and the other responsible bodies, such as the professional regulators and royal colleges that are involved in setting the standards and content of education and training, must work together to ensure that the latest best practice is followed to deliver the best possible outcomes for patients. That is fundamental.

Going further, I reassure the noble Lord that in delivering its education and training functions, Health Education England will be very focused on doing so in a manner that supports the efficient delivery of NHS and public health services and the achievement of the best possible outcomes for patients. Health Education England has a clear duty in Clause 89 to exercise its education and training functions with a view to securing continuous improvement in the quality of health services. Those are not idle words; they are significant.

It is also important to remember that the NHS Constitution includes pledges on access to NHS services, including the right to access services within maximum waiting times. The Government are clear that bodies in the new health system must support the NHS constitution, which is why in Clause 89 there is a clear duty for Health Education England to promote the NHS constitution.

Finally, the list in Clause 91 of matters that Health Education England must have regard to includes the Government’s mandate to NHS England. I reassure the noble Lord in that context that the mandate already contains an explicit objective for NHS England to make progress in supporting the earlier diagnosis of illness as part of preventing people from dying prematurely. I acknowledge that this is a very important matter. I hope that for the reasons I have set out the noble Lord will feel somewhat comforted and reassured, at least enough not to press his amendment. I have no doubt that this is a debate that we will continue to have at reasonably regular intervals.

The noble Baroness, Lady Wheeler, asked what role Health Education England will play in developing NHS managers and whether it should be a priority for it. Health Education England is working closely with the Leadership Academy to support the development of the next generation of managers and clinical leaders. The Government included this as an objective in Health Education England’s mandate.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Wednesday 16th October 2013 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, we are very sympathetic to what the noble Baronesses, Lady Barker and Lady Tyler, and my noble friend Lady Bakewell want to achieve through the amendment in promoting the well-being, dignity, rights and welfare of older people. My noble friend Lady Bakewell, in particular, has campaigned long and hard for an older person’s commissioner and, as the Voice of Older People under the Labour Government, speaks first-hand about the job that needs to be done in government to join up policies on health, social care, housing, transport, welfare, work and pensions to address the economic and social challenges presented by an ageing society.

The importance of a cross-government overview and strategy on older people is why Labour has a shadow Cabinet Minister for Care and Older People. Liz Kendall has a vital role in ensuring joined-up policies across the range of services that must be changed and adapted to meet older people’s growing and changing needs. The importance of developing a coherent strategy and vision for our old age was recently underlined by the excellent report of the Select Committee on Public Services and Demographic Change, referred to by the noble Baronesses, Lady Barker and Lady Tyler. The noble Baroness, Lady Barker, is entirely right to say that in Ready for Ageing? the committee described the UK and its society as being “woefully underprepared”. It pointed out that the implications of an ageing society had not been assessed holistically and that it had been left to government departments,

“who have looked, in varying degrees, at the implications for their own policies and costs”.

The committee called on the Government to look at ageing from the point of view of the public and to consider how,

“policies may need to change to equip people better to address longer lives”.

When we consider that important report tomorrow, the role of an older person’s commissioner in helping to face the future and meet the challenges so graphically set out by the committee and today will be a key part of that debate

A considerable amount of work and thought has gone into the drafting of Amendment 139, but the main emphasis seems to be on rights and redress, rather than the all encompassing and unique role envisaged by my noble friend Lady Bakewell in her Second Reading speech and earlier today. That would give the commissioner effective access to planning across different government departments.

We would prefer that broad approach, and, of course, we also need to learn from the experience of the older person’s commissioners in Wales and Northern Ireland. We understand that the advocacy role has worked particularly well in Wales in promoting the rights and interests of older people and challenging discrimination.

Inevitably, costs are an important consideration. The older person’s commissioner’s salary, operational support and accountability costs would be significant. I would be interested to learn from the noble Earl whether the Government have undertaken any costing and impact work on that, as promised to my noble friend when she first raised this issue, as she said, under the Health and Social Care Bill.

[Earl Howe]

My Lords, I am grateful for the opportunity to discuss this extremely well crafted amendment, which proposes the establishment of an older persons’ commissioner. Our ambition is to make this country one of the best places to grow old in and I begin by saying that I have some sympathy with the intention behind the amendment; to ensure that older people receive the high-quality care they need and also to support them to use the complaints system effectively when things go wrong. However, disappointingly for the noble Baronesses, I cannot subscribe to the solution that is proposed in the amendment. The main reason for this is that the provisions contained in the amendment are, by and large, covered by work already being undertaken elsewhere. The interests of service users are already protected through a number of routes.

I begin by citing the role of the CQC. The Care Quality Commission’s role is to ensure providers of regulated activities in England provide people with safe, effective, compassionate and high-quality care. The new chief inspectors for hospitals, adult social care and general practice will champion the views of patients and service users and judge the quality of care. Then, separate from the CQC, the new chief social worker will ensure that social work practice is directly inputting into policy development and we now have Healthwatch, whose function it is to represent service users’ views. If noble Lords look at what we are doing in the Bill, new statutory obligations are being introduced, such as the duties to establish safeguarding adults boards and to undertake safeguarding inquiries and/or reviews. We also have the government amendment to require independent advocacy in certain cases.

Looking beyond the Bill, the vulnerable older people’s plan is working towards having an accountable clinician to ensure proactive care planning for older people and those with the most complex needs. Furthermore, we want older people to have a major voice in issues that affect them. The Minister for Care and Support and the Pensions Minister take part in the UK Advisory Forum on Ageing. This group gives Ministers the opportunity to engage with and hear directly from older people on the key issues affecting them. I suggest that all these steps, taken together, go a considerable way towards addressing the concerns at which the amendment is aimed, but I need to be clear that, to minimise the impact on the public purse, we would not envisage setting up a new public authority alongside those functions.

My noble friend Lady Barker asked why we should not have an older persons’ commissioner since there is a children’s commissioner? If an older persons’ commissioner were established, the supporting structure would potentially be very large and would cost significantly more than the children’s commissioner. This is not only because of the comparatively larger number of older people who receive services compared to children, but also because the amendment confers a wider range of functions on the older persons’ commissioner than the children’s commissioner.

Michelle Mitchell, former director-general of Age UK said last year:

“For us it’s not just about having a commissioner; it’s about ensuring that older people’s issues are central to the mainstream – not only the government agenda, but business and the public sector as a whole”.

I support that view. What matters, surely, is what is actually happening and whether the system is pulling together to make it happen. We want to ensure, quite simply, that issues affecting older people are at the heart of government business. I am happy to explore ways to further enhance the voice of older people, although without creating additional costly bureaucracies. On that basis, I hope that the noble Baronesses will feel somewhat comforted that there is a lot going on to protect the interests of older people and that my noble friend will therefore feel able to withdraw the amendment.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Wednesday 16th October 2013 Lords Chamber

[Baroness Wheeler]

My Lords, we fully support my noble friend in his valiant efforts once again to try to get this important issue on mental health aftercare sorted out. We recognise the Government’s concession in removing “the” from subsection (5)(a), but my noble friend is right that there still remains the very real risk that leaving the rest of the subsection in place could lead to local authorities arguing that,

“a need arising from or related to a mental disorder”,

was the requirement only to provide psychiatric, medical and follow-up services.

The statutory definition of aftercare services in the Bill is confusing because it separates out the needs arising from the person’s mental disorder from the need to reduce the risk of deterioration in the person’s condition and the risk of readmission to hospital. My noble friend’s amendment would instead define aftercare services as those services that reduce the risk of deterioration in the person’s mental condition and the likelihood of the person requiring readmission to hospital.

It is right that the definition of aftercare services focuses on reducing the likelihood of hospital readmission and does not lead to confusion or legal disputes about a local authority’s role in this or what services should be provided under Section 117 of the Mental Health Act. It is also right that aftercare continues to be viewed as a comprehensive range of generic services across healthcare, social care and other services such as suitable accommodation and community support.

Amendment 128A is a compromise offered by my noble friend that I hope the Government will take up because, as he said, he would prefer to delete Clause 5 entirely, so that the current position in relation to Section 117 remains unchanged. Mind, the mental health and disability committee of the Law Society and the Mental Health Lawyers Association all consider that the best way to avoid confusion over the definition of aftercare is to remove Clause 71(5)(a) altogether.

I hope that the Minister will have some good news for my noble friend and for other Lords who, too, are very frustrated that the mental health aftercare issue has not been laid to rest in the way we thought it had under our discussions as far back as on the Health and Social Care Bill.

[Earl Howe]

My Lords, I first would like to echo the comments made by my noble friend Lady Northover during Committee, when she paid tribute to the excellent work of the noble Lord, Lord Patel of Bradford, in the mental health field.

I think we can all agree that setting out a definition of mental health aftercare in legislation is important. A clear legal definition will mean that the scope of aftercare will no longer be entirely open to interpretation by the courts, whose views have varied over time. The question is what that definition should be. As updated by government Amendments 129, 130 and 131, our proposed definition contains a carefully framed duty that reflects the Government's policy on the appropriate scope of the duty to provide free aftercare services for a very small group of patients who have been detained for treatment under certain sections of the Mental Health Act. It has carefully drawn limits because the Government do not consider that it would be appropriate for the Mental Health Act to impose a duty on local authorities to commission services that are based on needs which neither arise from, nor are related to, a mental disorder.

Therefore we believe that the amendment tabled by the noble Lord, Lord Patel of Bradford, goes too far and would create an inequity between this group of people and others with equivalent needs for care and support who are not eligible for free aftercare, either because they have been detained under other provisions of the Act or not detained at all. They will be means tested and will have to meet eligibility criteria for the social care part of their aftercare package, so may not receive any social care from the local authority. In addition, with an ageing population, local authorities will have to be able to differentiate “mental health aftercare” in order to know when the “aftercare” finishes and ongoing support for other reasons begins.

The noble Lord suggested that the case of Mwanza was not a stable basis for primary legislation. He said that it is, after all, only one case. There is a bit of a misunderstanding around this. The Mwanza case merely triggered a debate; the issue is whether the definition is a good idea and, if so, how it can most helpfully be drafted. The Government’s definition of mental health aftercare services builds on the definition recommended by the Law Commission. The Government accepted the recommendation of the Law Commission as a sensible starting point, but we have gone further. We propose a wider definition than that suggested by the Law Commission, including that Section 117 services may relate to as well as just arise from the person’s mental disorder, and that the aftercare should prevent deterioration as well as readmission to hospital.

Because our definition is more precise, I feel that it will be more helpful than the noble Lord’s in ensuring that clinical commissioning groups, local health boards and both English and Welsh local authorities more easily agree on the aftercare services to be provided, so that these services can be put in place promptly.

I reassure the House that the definition we are now considering is the result of extensive consultation. In consequence, we have added a positive objective to prevent deterioration as well as preventing readmission to hospital, and have further changed the clause to remove the definite article when referring to “the mental disorder”, for which the noble Lord made the case in Committee. This is intended to remove any doubt about our intention that the scope of aftercare covers more than just one form of mental disorder, and is not necessarily limited to the specific disorder or disorders for which a person was previously detained under the Act and which gave rise to the right to aftercare.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Monday 14th October 2013 Lords Chamber

[Baroness Wheeler]

My Lords, in addressing these amendments I once again emphasise that we very much welcome the placing of safeguarding on a statutory footing in the Bill, and the establishing of statutory safeguarding adults boards. This builds on the legislation, regulations and advice on principles and frameworks for safeguarding for both adults and children that we established up to 2009, which are now being taken forward in the Bill.

The noble Baroness, Lady Greengross, and other noble Lords, again made a comprehensive case for granting the power of access by a third party to private premises if they suspect that a vulnerable adult is being abused. The noble Lord, Lord Rix, spoke of “mate” relationships among people with learning difficulties. It was a powerful example of what we need to address.

We know that there is both strong support and strong opposition among local authorities, NHS trusts, the health and social care professions, and patients and user organisations on this sensitive and complex issue. However, we have to remember that the Government's consultation had a relatively low response, particularly in terms of local council and NHS trust participation. On top of that, many of the consultation responses appeared not to have fully understood the limited nature of the change that was being proposed: namely, that the new power would apply only to situations where it is the third party who is denying access, not the individual.

The noble Baroness’s amendment sets out tough limitations and restrictions that would apply to such a power. Local authorities would have to apply to the courts and demonstrate reasonable cause for suspecting that someone was in danger of abuse. The power of access would be to enable the local authority to access the person and speak to them alone to assess the situation. It is clear that it is intended as a last-resort power to address third-party denial of access to a vulnerable adult, for use after all other efforts and mechanisms have failed.

Getting the balance right between proactively intervening in the lives of individuals in this way and limiting the extent to which this interferes with their rights to freedom and family life is the challenge that we face. Certainly there is widespread acceptance that the existing powers to intervene under government legislation are not being fully utilised and are not addressing the issues, and that the training of specialist staff needs urgently to address this. Will the Minister explain to the House how the Government intend to deal with this?

As we said in Committee, on balance we support the case for inclusion in the Bill of the power of access by a social worker or the police where there is a danger of third-party abuse. Our work on safeguarding when we were in government, especially in relation to children, makes us sympathetic to the approach in the amendment of the noble Baroness, Lady Greengross. We recognise that safety should be paramount in this instance. However, we recognise the strong concerns of Mind on this issue, and of the Royal College of General Practitioners, which would prefer to use other powers, such as working with the sector to co-produce best-practice guidelines. Will the Minister explain how the Government propose that denial of access by a third party to a potentially vulnerable adult will be addressed if the issue is not dealt with in the Bill?

I support the intention of Amendment 79A, tabled by the noble Lord, Lord Rix, to include in the Bill a definition of abuse that reflects other types of abuse besides the financial abuse currently included in the Bill. The noble Lord has the very real concern that this would encourage hard-pressed local authorities to narrow their focus to financial abuse alone. The Confidential Inquiry into Premature Deaths of People with Learning Disabilities published its findings in March 2013. It looked at the deaths of 233 adults and 14 children with a learning disability in the south-west and found that 20% of the people concerned had experienced safeguarding concerns. While some of these may have been due to financial abuse, it is more likely that they concerned other forms of abuse: in particular, neglect. The study showed that 37% of deaths would have been potentially avoidable if good-quality healthcare had been provided. Neglect is undoubtedly one of the reasons, and thus the definition in the Bill should be broadened. I ask the Minister to look again at this and come back with a more balanced clause reflecting other types of neglect and abuse. It is important, for example, that hospital safeguarding leads should be clear that the definition is broad, and should take appropriate action.

The noble Lord’s Amendment 81A would also be a welcome alteration to the Bill. It is a small but important matter, because sending SAB annual reports to the Secretary of State will ensure that safeguarding is given the high level of oversight needed, particularly over areas that might be failing.

We also support the amendments to Schedule 2 contained in Amendment 81 from the Government, and Amendments 80 and 82 from the noble Baroness, Lady Greengross. The SABs would benefit from professional social worker representation, as would safeguarding adult review teams from having a qualified social worker supervising the review.

The two final amendments of the noble Baroness, Lady Greengross—Amendments 78 and 79—raise the important issue of establishing a new duty of care on a local authority or its relevant partner to report to the authority if they suspect that there is a failure of care, and to set out the terms of conviction for any person guilty of neglecting or ill treating an adult at risk of abuse. We share some of the concerns of the LGA, for example, on these amendments: namely, that there would need to be clarification of exactly what the care quality, professional practice and safeguarding concerns would be under the new duty, and how the duty would relate to other partners involved in service delivery. We also share concerns that while the criminal conviction provision may present the way forward in cases of neglect, it might unintentionally create a lower order of offence and tariff for older and disabled victims of crime.

Finally, I underline the vital need, when so much care now is contracted out and provided by the independent, private and voluntary sectors, to ensure that safeguarding is built into procurement and contract management in health and social care. Will the Minister tell the House how the Government intend to ensure that this will happen?

[Earl Howe]

My Lords, for the first time the Government will, through this Bill, place adult safeguarding in primary legislation. Local authorities, the NHS and police will have statutory duties to work together to help prevent and respond to abuse and neglect. This sends a clear message that safeguarding is not the sole responsibility of one agency but requires the very best of partnership working and information sharing. Amendment 77, which would introduce a power of access to a person for a confidential interview, runs counter to that message. Having said that, I am well aware of the strength of feeling in relation to this matter, both inside your Lordships’ House and elsewhere. Whether there ought to be a power of access or entry is a sensitive question. That is precisely why the Government launched a three-month consultation in 2012 to gauge the opinions of professionals and the public. The consultation revealed no clear consensus. Of 212 respondents, 50% backed a new power, with 40% opposed. However, among individuals, 77% disapproved. The majority of respondents in favour of a new power of access were health and care professionals, yet it was very noticeable that their responses revealed the painstaking weighing of potential benefits against unforeseen consequences.

The mental health charity Mind said:

“A power of entry risks being seen as a quick solution, in place of greater focus on community engagement, co-operation and a preventative approach that can be truly empowering to the people involved”.

This was a theme found in many responses. I stumble over the consequences of what the noble Baroness seeks to do. Here I respectfully but fundamentally disagree with my noble friend Lady Barker who said that there was no real comparison with the situation in mental health. A power such as this might well ensure access but the central issue will remain—how will the professionals then work with the situation to achieve the best outcomes? Trust will have been compromised and, short of a power of removal, which we certainly would not want to see, the options for action seem pretty limited.

Our consultation revealed no compelling evidence for further legislation. Even those respondents in favour pointed to how rarely a new power might be applied and identified potential unforeseen consequences. Proposed new Subsection 4(c) of the amendment states that an access order should be granted only if doing so,

“will not result in the person being at greater risk of abuse or neglect”.

I have to ask how a court could ever reliably make such a judgment in these circumstances.

The other key point which I would like to believe may sway the House is the following. There exists no legislative vacuum preventing care or other professionals accessing those in urgent need of assistance. Under the Police and Criminal Evidence Act 1984, the police have the power to enter premises if harm has occurred or, indeed, is likely to occur. The Domestic Violence, Crime and Victims Act 2004, the Fraud Act 2006 and, for those lacking capacity to make decisions, the Mental Capacity Act 2005, provide a wealth of powers for use at the front line, and the inherent jurisdiction of the courts to intervene provides a secure safety net. Therefore, it is not the lack of legislation; rather, as safeguarding lead directors at ADASS have put it, it is a question of a “lack of legal literacy” within the social care and other professions. What is needed is greater knowledge of existing legislative options. If they have that, professionals will be fully equipped to support people to be safe. The core role of an adult social worker is to support people. Further legislation for a new power of access risks undermining this approach, sending the message that legal intervention takes primacy over negotiations and consensus. I stress that legal intervention, on those rare occasions when it is needed, is already possible under the law. For those reasons, I cannot accept this amendment.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Tuesday 16th July 2013 Lords Chamber

[Baroness Wheeler]

My Lords, this has been a valuable debate and important issues designed to probe and improve aspects of these crunch stages in the care and support journey have been raised. The amendments relate to the duty of the local authority in respect of the care and support plan for the adult, the support plan for the carer, the personal or independent budget resulting from the assessment of the adult’s and carer’s needs, and care accounts and direct payments. This is a large grouping and we have nine amendments. I will speak to them as they relate to other amendments in the group as briefly as I can.

Amendment 92ZZG seeks to specify in the Bill that the adult or carer needs in the care and support plan or support plan include both social care, to be met by the local authority, and health needs, to be met by NHS bodies in the area. This requirement would reinforce the need for local authorities and primary, secondary and community health services to work closely together for the benefit of the adult and the carer. It would also provide a clear, joined-up picture of the adult and/or carer’s interlinking care and support and health needs and how they are to be met. Amendments 92ZZP and 92ZZQ also provide for this important joining-up mechanism to apply to the care and support plan and support plan reviews by underlining that in the review process, local authorities must have regard to any changes in the health needs of the adult or carer, including any health provision that they are entitled to receive.

Amendment 92ZZK, in the name of the noble Baroness, Lady Browning, extends the intent of our amendment by specifying that in a young person’s care and support plan, both health and education, in addition to care and support, should be included, integrating with any existing plan in these areas. The importance of this amendment to young people with autism—or indeed to their carers, as the amendment is not specific—has been underlined by the noble Baroness.

The noble Baroness, Lady Greengross, has tabled a number of amendments. In the time available I will refer to four of them. Amendments 92ZZCA and 92ZZR address the need for the Bill to be explicit and thorough in relation to the assessment and eligibility entitlements where the adult lacks mental capacity to arrange for the provision of care and support. The amendments are designed to ensure that the local authority provides free care and support in the circumstances where the person authorised to represent the adult under the Mental Capacity Act 2005 asks for the care and support on the adult’s behalf.

Amendment 92ZZR addresses concerns raised by the Alzheimer’s Society and other groups that Clause 28(7) does not offer adequate protection to people who lack capacity and puts people with deteriorating conditions such as dementia at risk of falling through the gaps. Government Amendment 92ZZQC is designed to address this and the Minister’s recognition that the clause is open to misinterpretation is welcome. These are complex issues but we all recognise the importance of ensuring that the Bill is watertight in respect of adults lacking capacity to arrange care and support, and of having clarity in respect of the local authority’s duty to carry out a needs assessment and to continue to maintain their care account. Can the Minister reassure the House that the Government’s amendment addresses the concerns raised by noble Lords in this debate?

The noble Baroness also raises a key issue in her Amendments 92ZZRA and 92ZZRB, which go to the heart of the choice agenda to ensure that the current right for individuals to choose a preferred care home, and the ability of their representatives to choose a home on their behalf when, for example, the individual has dementia, is upheld in the Bill. Currently the Bill does not make this mandatory on local authorities and it is important that it does. I ask the Minister how the Government’s policy on patient choice can be met when the Bill does not reinforce the current right for people to choose their preferred care home.

Our Amendments 92ZZRAA and 92ZZRAB probe this issue further and are intended to explore the Government’s appetite for including the right to express a preference for the nature and location of accommodation. We support the intention of the Government, the Law Commission and the Labour Party that the Care Bill should increase the choice and control of adults using social care and their carers. I am, however, intrigued to determine whether the Minister thinks that this right in Clause 30 might be made more meaningful if it were extended to include the nature and location of this accommodation. It is important to seek to give adults needing care and support both choice and voice, including them in decisions about them. I look forward to the Minister’s response.

I support the intention of my noble friend Lord Dubs in his Amendment 92ZZH to ensure that care and support plans or support plans specify contingency planning for an emergency, ensuring that plans reflect the flexibility needed for fluctuating conditions, such as MS and other conditions referred to by my noble friend, where there can be severe changes and rises and falls in care needs. Having discussions and planning in advance for this, so that the care is there when it is needed, would be a significant step forward.

It is also important to look at contingency plans in case the carer suddenly becomes ill or is unable to provide care. The self-direct assessment model includes discussion on contingency and risk, but the extent to which clear provision is covered in the care and support plan is patchy. Indeed, it is not always easy to be specific about what would happen because often the reality is that instant emergency care cover is hard to organise when relatives live a considerable distance away or the cared-for person is not able to summon emergency help themselves.

My noble friend also underlines the importance of including a review date in the plan. It would be valuable to require social services departments and providers to be clearer about not just the review date for the plan but what the monitoring and review process is, and what kind of client feedback, or complaints process, there will be, as well as client/carer involvement in assessing quality of care and standards of service. I suspect that very few care plans currently address these issues. Our Amendments 92ZZMA and 92ZZQB probe how a reasonable request for a review of a care and support plan is to be interpreted and, most importantly, to be interpreted fairly across the country. We support a national care service and a national entitlement to care.

We also in our Amendment 92ZZEC draw attention to the important issue of the need for the completion of the care and support plan and support plan to be conducted within a reasonable timeframe. The assessment is a worrying and often traumatic time for the cared for and carer, so knowing what the timeframe is from interview to completion, and then for the personal budget decision, is pretty important. Getting an early assessment and getting the clock ticking towards the cap will also be crucial, so there must be targets and timeframes for the local authority to adhere to and meet. Assessments under the self-directed support process in my local experience as a carer involved four meetings with social services, including with the domiciliary care agency provider and with the daycare provider, and a lot of supported work to be undertaken by the adult or the carer on the client’s behalf. Is the Minister confident that local authorities will really have the capacity and resources to cope with the demands of the new system, including the estimated quarter of a million additional assessments for self-funders that will need to be carried out?

Finally, our Amendment 92ZZSB seeks to implement the recommendation of the Joint Committee on lifting the Department of Health’s current ban on direct payments being used to pay for local authority services if the individual chooses to achieve the agreed outcomes. Our amendment would bring this into effect by underlining in the Bill that there should be no restriction in terms of type of provider placed on the services which can be purchased by direct payments. I hope that the Minister agrees, and I look forward to his response.

[Earl Howe]

My Lords, I thank all those who have contributed to the debate on an issue which is crucial to the Government’s vision for a personalised care and support system—the care planning process.

In relation to Amendment 92ZZCA, I hope I can reassure the noble Baroness, Lady Greengross, that it is already the case in the Bill—the Explanatory Notes make this clear—that where the adult lacks capacity to make a request, it may be made by someone else on their behalf. This is the effect of the Mental Capacity Act 2005. It is not necessary to set this out in legislation each time. We will also make this clear in guidance. Condition 3 in Clause 18(4) imposes a duty on the local authority to meet needs in cases where the adult lacks capacity and has no one to arrange care on their behalf. This is an additional safety net, enacting a provision previously set out in guidance.

On Amendment 92ZZEC from the noble Baroness, Lady Wheeler, it is vital that local authorities retain the ability to be proportionate to the needs to be met. For some people the care planning process may be relatively simple and therefore can occur relatively quickly, but that may not be the case for people with multiple complex needs. As we discussed earlier, there may be a need for experts to be engaged in some cases, and this should not be overlooked in order to meet a centralised target. Introducing a defined timescale may also have the unintended consequence of some plans being rushed in order to meet the deadline, or even introduce gaming into the completion of care plans. I hope that the Committee will agree that this does not fit very well with our vision of a personalised care and support system.

We will work with stakeholders to set out best practice for conducting care and support plans in guidance. This will include indicative but not definitive timescales for care plans. Amendments 92ZZG, 92ZZP and 92ZZQ in the name of the noble Baroness, Lady Wheeler, raise the issue of specifying health needs in the care plan. The Bill creates a clear legal framework to enable such integration to happen in practice. However, it is not for the local authority to specify in the care plan which needs the NHS should meet. Clause 25 requires local authorities to involve the adult and carer, and take all reasonable steps to agree the plan with them, which would include whether to refer to any health needs.

In relation to Amendment 92ZZGA in the name of the noble Baroness, Lady Emerton, we believe that everyone should receive a personal budget as part of their care plan to ensure individuals are made aware of the cost of their care and the contributions both they and the local authority need to make. Giving local authorities discretion on whether to provide a personal budget would undermine our aim of giving people more choice and control over their care and support. Removing this duty will also affect the ability of the local authority and adult to track progress towards the care cap. I realise—at least I hope I realise—that the amendment was a probing one.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Tuesday 16th July 2013 Lords Chamber

[Baroness Wheeler]

My Lords, I do not have a great deal further to add on this issue, given that we fully supported this approach in the earlier debate on our amendment. The noble Lord, Lord Low, and my noble friend Lord Touhig have made their case powerfully for the need for specialist expertise in assessing people with complex care and support needs—for example, deafblind people, people with autism and those with profound and multiple learning difficulties.

As the noble Lord, Lord Low, pointed out, the draft Bill originally provided for the regulations to specify the circumstances in which a person with expertise in a specialised matter must carry out the assessment on behalf of the authority. However, this was altered in the published Bill, with the only requirement being consultation with a specialist. Noble Lords are right to consider this to be a retrograde step and I look forward to the explanation from the Minister on this and an undertaking to reinstate in Clauses 12 and 27 the current approach, as the amendments propose.

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

My Lords, I thank the noble Lords, Lord Low and Lord Touhig, for bringing forward these amendments. I say straight away that I fully support the intention of Amendment 88M, which is to ensure that local authorities engage a suitable expert when carrying out complex assessments. The assessment will remain an integral part of the process of determining a person’s care and support needs and whether these meet the national eligibility criteria. To ensure that this is done correctly, it is essential that the person carrying out the assessment has the right knowledge, skills and competence. We heard from users of care and support during the engagement on the draft Bill about the importance of the assessor having knowledge of the condition that the person may have, whether they are, for example, a frail older person, a person with mental health problems or a person with autism.

Care managers and social workers are trained to carry out assessments. Their skills and experience will allow them to assess people with various conditions such as physical disability. There are, however, certain complex conditions where these skills are not sufficient to allow assessments to be carried out effectively. I am particularly thinking about a person who is deafblind—the example, given by the noble Lord, Lord Low. In those circumstances, most care managers would find it very difficult, if not impossible, to communicate with the person. It takes someone with expertise to carry out an assessment properly and identify the person’s needs and the outcomes they wish to achieve.

I agree with the noble Lords that, in such circumstances, the local authority must engage a person with the relevant expertise to carry out the assessment. That continues to be our policy. I also accept that if the adult’s condition is so complex at the assessment stage as to require the services of an expert in the field to provide advice, then it makes perfect sense for this to be repeated when the plan is to be reviewed. I should like to reassure the Committee that the Bill already has provisions in place to allow this joined-up approach to occur if an adult’s circumstances have changed in a way that affects the care plan. Clause 27(4) states that the local authority must, to the extent it considers appropriate, carry out a fresh needs assessment. In doing so, it would have to follow the requirements of regulations to consult a person with expertise. I hope I have reassured noble Lords of our agreement to the principles that they raise. In the light of what they have said in support of the amendment, I will look again at Clause 12 to ensure that we are giving ourselves the relevant powers to achieve our aims. I hope that the noble Lord, Lord Low, will find that undertaking welcome.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Tuesday 9th July 2013 Lords Chamber

[Baroness Wheeler]

My Lords, the Joint Committee on the Bill acknowledged that it had been widely welcomed, but asserted that this did not mean that it could not be improved—there are gaps and risks and unintended consequences. The failure of the Bill adequately to underline the importance of housing not just to well-being but to integrated care, to prevention and to being included in the provision of advice and information on quality of care and assessment is what these amendments seek to address. The interplay between housing and well-being—the standard of someone’s living circumstances and their health condition, the appropriateness of their house or flat and the likelihood of their being able to remain in it and care for themselves—is long established. However, as noble Lords have shown, it is overlooked in key clauses of the Bill.

Our Amendment 87ZC takes forward the vision of specialist houses fully integrated into the health and social care system which was so comprehensively set out by stakeholders from across the housing sector in their evidence to the Select Committee. The quality of that evidence was commented on by the noble Baroness, Lady Jolly. There are numerous examples of inspiring best practice where housing is an integral part of care and support and service delivery. The Bill needs to provide the momentum for good practice to become embedded across all local authorities and health providers.

The evidence to the Select Committee from organisations across the housing sector cites inspiring examples of where housing, health and social care provision and support join up to provide integrated person-centred care. However, alongside this, there is huge frustration that progress across the country has been so slow and patchy. This is especially so when what stakeholders refer to as low-level interventions, which really make a difference, are often the services earliest to be cut back and dispensed with. The Anchor Trust, for example, described the determination to keep its service-level manager on site at one of its sheltered housing schemes because it made all the difference. The noble Lord, Lord Martin, made this point, too. Anchor said that, in its view, once the manager left, the next steps for elderly and frail people were usually into residential care. This was one of the many examples given of the consequences of not having housing-related support regarded as a key social determinant of health. I look forward to the Minister’s explanation as to why the Government have not ensured that this is fully reflected in the Bill.

Earlier, we heard the case from the noble Lord, Lord Best, and my noble friend Lady Wilkins for Amendment 81, supported forcefully by the noble Lord, Lord Rix, on the importance of including the promotion of housing provision in the duties of local authorities under Clause 3 to provide integrated services, and of ensuring that there are similar duties placed on the health service. Our amendment to Clause 6 complements this by reinforcing integrated joined-up working with registered housing providers, including housing associations and registered social landlords, and recognising these as key, relevant partners under the Bill.

The need to recognise housing as a preventive service cannot be overestimated or overemphasised. Schemes such as Midland Heart’s reablement service for the elderly or frail combine social care and housing association support to enable people to be discharged from hospital back to their homes quickly and help independence to be regained. They delay or prevent the need for more intensive care, reduce the likelihood of repeated hospital stays and can prevent avoidable accidents. Commissioners need to be encouraged to consider specialist housing, home-from-hospital services, housekeeping-related support and adaptations when designing preventive services. Housing is a crucial preventive service and Amendment 80 is important for ensuring that this is recognised in the Bill.

Amendment 88 is also important for ensuring that needs assessments include an assessment of housing options, as is Amendment 86, which underlines the importance of ensuring that local authorities provide information and advice for adults and carers on available housing options and the choice of providers available in the authority’s area. While in Amendment 87 we fully recognise the need for more specialist housing to be built to meet the needs of care and support, we would be cautious at the present time of putting this extra burden on local government when it does not have the resources or the means to deliver. It is the responsibility of national government to provide the £10 billion extra investment in infrastructure that the International Monetary Fund has called for to get the economy moving and make shovel-ready projects such as housing happen.

I am grateful to the National Housing Federation for its excellent briefing, and I refer to an example of integrated care and support it gives that was provided by one of its members, the housing association Look Ahead, for a psychiatric patient. It shows what can be achieved. Following a six-month stay in hospital, it had initially been intended that he should move to a residential care placement, but instead he was referred to Look Ahead’s rehabilitation service. The support that he received helped him with basic life skills, diet management and managing his condition. After 18 months, he had successfully moved to his own flat, had been able to reduce his psychiatric medication and had started a nursing diploma. This service, taking him from hospital to independence in his own flat in 18 months, was provided by successful joint working between the housing association, the local authority and the NHS trust, with an estimated saving of nearly £250,000 across the three services.

We heard, too, at our latest stakeholder group meeting yesterday about a successful jointly procured and delivered reablement centre in Liverpool that is funded by the local authority and the clinical commissioning group in respect of hospital discharge. The scheme provides two to three weeks of intensive occupational therapy and other key services, which doubled from 40% to 80% the percentage of patients who did not require a continuing care package after this initial support. However, we understand that in some parts of the country CCGs are expressing reluctance to enter into joint funding schemes with local authorities in case the health funding element is leaked into other council services, given their budget situations—literally, I suppose, into filling potholes or such like. Can the Minister tell us what steps are being taken to reassure CCGs about this potential barrier to providing integrated services?

As part of its oral evidence, Jake Eliot from the NHF said:

“Too often, the integration that occurs happens because service users, carers, providers and commissioners are working skilfully in spite of the system rather than because of it”.

This is something that the Bill can change effectively. I hope that the Minister takes these words to heart and accepts the amendment. It would ensure that the Bill recognises the importance of housing. It is important not just for well-being but for prevention, for the provision of advice and information in the assessment process and for ensuring that the overall quality of care is fully recognised.

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

My Lords, in tabling these amendments, the noble Lord, Lord Best, brings to the attention of the Committee the important role that housing plays in both care and support, and as a determinant of well-being. I have listened with care to the powerful contributions in support of them. Having done so, I begin with an observation that I hope is incontrovertible, which is that simply having a roof over your head will have a profound impact on your well-being. Having access to suitable housing for those with care and support needs plays a vital role in promoting not only their well-being, but their independence. The noble Lord, Lord Best, brought this point home very well. Properly taking into account the suitability of someone’s living accommodation could, for example, help to prevent a frail older person from falling and thus suffering the pain and trauma of broken bones and an unnecessary stay in hospital, the need for a greater level of care and support following discharge, and the costs of this to the public purse. It is vital that the system actively works to promote independence rather than waiting for people to reach a crisis point.

To reflect the importance of housing as a determinant of well-being, we have explicitly included the “suitability of living accommodation” in Clause 1(2), which sets out a list of things to which well-being relates and that the local authority is required to promote in performing its care and support functions. Furthermore,

“accommodation in a care home or in premises of some other type”,

is set out in the high-level list of examples of how to meet needs in Clause 8. Together, this means that the Bill ensures that housing is an integral part of care and support, where it is not general housing as excluded by Clause 23.

NHS: Association of Medical Research Charities Report

Debate between Earl Howe and Baroness Wheeler

Thursday 27th June 2013 Grand Committee

[Baroness Wheeler]

I, too, congratulate my noble friend Lord Turnberg on securing this debate, especially his timing following hot on the heels of our scrutiny of the Health Research Authority under the Care Bill. My noble friend is a much respected and tireless champion for research and innovation, leading to improved quality care for patients, and we in our party rely strongly on his expertise and support.

My noble friend and other noble Lords from across the House between them ensure that the importance of research and innovation to the NHS is kept to the fore, by this debate and, for example, in recent debates by the noble Lord, Lord Kakkar, on the impact of the EU healthcare in the UK and the concern over the UK losing its global allocation of clinical trials, and in the powerful debate earlier this year of the noble Lord, Lord Saatchi, on medical innovation, which reinforced the need to deal with the regulatory burden, to which noble Lords have referred, and to speed up the availability of innovative treatments.

Like other noble Lords, we welcome the progress on speeding up research approvals made by the HRA through the single portal of entry and single application procedure and bringing together the various research ethics committees. However, the point about the need for progress in getting the local R&D committees of NHS trusts singing from the same hymn sheet is well made and I look forward to the Minister updating us on the action that the Government are taking.

Like other noble Lords, I congratulate the AMRC on its excellent report and the accompanying survey of healthcare professionals’ views on the importance of research to the NHS and to staff working for it. Under the Care Bill, the need for Health Education England to ensure that research and innovation are incorporated into education and training for healthcare staff was a major theme, echoing the Joint Select Committee on the Bill on this issue. All NHS staff need to be able to make use of research throughout their careers and should be equipped with the tools to understand and support research and to assess and use evidence to inform their decisions when caring for patients or supporting clinical staff.

As noble Lords have pointed out, the association’s survey showed the challenges to be faced. The good news was that staff overwhelmingly recognised the value and importance of research, but the barriers to taking part in research, identified by the majority of staff surveyed, including doctors and nurses, was deeply worrying. It is clear that these barriers of lack of time, problems over funding and support and the difficulties of navigating regulation have to be overcome, particularly the need to develop stronger support among GPs to become personally involved in research. After all, they are such an important gateway to spreading the message to get patients interested and involved in research. As my noble friend put it, there is still much to do at the coal face. This is where the ARMC report is so valuable. It offers an authoritative but very practical vision of how the goal of having every clinician a researcher and every willing patient a research participant can be progressed and achieved, as well as how the leadership and support that the NHS staff need can be developed and built into a service-wide research culture.

The case studies in the report are particularly informative, providing examples of excellence and best practice in cancer, arthritis and other key research areas of patient consultation and involvement, and of building staff support and confidence about participating and using research findings so that they can show their patients the benefits of them taking part.

In the context of this debate it is important also to reflect on the progress being made on the UK life sciences and the innovation, health and wealth strategies, the central aim of which is for innovation to become the NHS’s core business. No one reading these reports and the recent one-year reviews can be in any doubt of the dramatic pace and scale of change in the medical and life sciences, such as the breakthrough in genomic medicine, which is changing fundamentally the way disease is diagnosed, prevented and treated, and the progress on regenerative medicine, which are all breathtaking to a lay person such as myself.

There are important developments on the service side, too, as part of the high impact innovation programme, such as in wheelchair design. Can the Minister update the House on progress on implementing the strategies? I could not find any details on the website about further review reports or of the Government’s response to the MHP Communications review of the strategies, which charted good progress but also some continuing problems, including implementation of NICE technology appraisals by NHS trusts and the poor level of awareness of the IHW strategy; only 30% had discussed the strategy at board level. How are these issues being addressed?

Finally, on the association’s vision, I would reinforce the need to keep our foot on the pedal to ensure that we continue to be a world leader in clinical research. We must ensure that CCGs in the absence of SHAs and PCTs continue the focus on research and do not allow it to diminish. The AMRC vision highlights the need for leadership and guidance to CCGs to promote research; to encourage NHS managers so that they understand the value of research and actively support it through their management decisions and processes; and to ensure that all parts of NHS support research, including primary care and all non-NHS providers. I look forward to the Minister’s response updating the House on the Government’s actions to ensure that real progress is made on all these fronts.

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

My Lords, I begin by thanking the noble Lord, Lord Turnberg, for having tabled this debate. He has spoken with both authority and passion about Our Vision for Research in the NHS, the report by the Association of Medical Research Charities. The Government welcome the report; it is a challenging and insightful contribution to the debate on optimising the research potential of the NHS.

It is now more than seven years since the National Institute for Health Research was established in April 2006. The NIHR has a wide-ranging role that is central to our debate today. It provides the framework through which the Department of Health can position, maintain and manage the research, research staff and research infrastructure of the NHS in England as a national research facility. Indeed, together, NIHR people, facilities and systems represent the most integrated clinical research system in the world—driving research from bench to bedside for the benefit of patients and supporting economic growth.

My noble friend Lady Sharp referred to the importance of clinical trials, and of course, that is centre stage for the NIHR. As a result of the NIHR, large numbers of patients have the opportunity to take part in research. In the past financial year, more than 630,000 participants were recruited to trials and studies hosted by the NIHR Clinical Research Network Portfolio, and more than 99% of NHS trusts were involved in the recruitment. During the whole of 2013-14, the NIHR is promoting the fact that, “It’s okay to ask” about clinical research. We want everybody to get involved—patients, medical professionals and the public to support the campaign.

In March 2013, the Government published the revised NHS constitution, which contains a pledge to inform patients of research studies in which they may be eligible to participate. The pledge aims to give people better access to the potential benefits of participating in research studies, including clinical trials. We have already improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I just say to the noble Lord, Lord Aberdare, who spoke very powerfully about pancreatic cancer and the need to enlist more patients into trials for that condition, that the launch of the gateway was promoted through leaflets and other printed materials, including postcards and posters, and the gateway is also being actively promoted by INVOLVE, which is the NIHR-funded patients and public involvement body. In the course of just one month, May of this year, there were 11,570 visitors to the gateway website. Although not all of them will be related to pancreatic cancer, I hope that that gives an indication of the powerful influence that we hope the gateway will have in alerting patients to relevant studies.

Crucial to all this activity is the need to both protect and promote the interests of patients and the public in health research. That is why we established the Health Research Authority in 2011, and provisions in the Care Bill will give it added stability and independence. To my noble friend Lady Sharp I would say that the HRA has a programme of work to enable the implementation of a unified approval process and to support the authority in promoting consistent and proportionate standards for compliance and inspection. The programme includes a feasibility study with a number of pilots to test the effect of rationalising and combining elements of NHS study-wide review with elements of the research ethics committee review into a single HRA assessment. The findings are expected to identify and show how to release the potential to improve both study set-up times and the quality and consistency of ethical review.

The noble Lord, Lord Kakkar, very helpfully acknowledged that enactment of the Health and Social Care Act is a milestone for research in the NHS. It recognises the need to promote research and the use of research evidence and created unprecedented powers and duties at all levels to meet that need. The Government’s mandate to the NHS Commissioning Board—now NHS England—sets an objective to ensure that the new commissioning system promotes and supports participation by NHS organisations and patients in research funded by both non-commercial and commercial organisations, most importantly to improve patient outcomes, but also to contribute to economic growth.

The noble Lord, Lord Kakkar, specifically asked how CCGs will be held to account. The mandate asks for demonstration of progress against the five domains and all the outcomes indicators in the NHS outcomes framework. The framework document emphasises that vital to the quality and delivery of these outcomes will be continued research and the use of research evidence in the design and delivery of services at a local level.

NHS England welcomes the vision for research set out by the AMRC and shares its aspirations to empower patients to take part in research; to engage clinicians and other NHS staff; and to implement research findings to lead to better outcomes for patients and the public. Although NHS England is a new organisation, the NHS—as I do not need to tell the noble Lord, Lord Turnberg—has a strong existing culture of research, although we want to strengthen that culture. There is a wide wealth of research activity already taking place and considerable expertise within organisations. However, NHS England recognises there is further work to do to ensure that all NHS commissioning staff embrace a research culture, which was the theme of my noble friend Lord Saatchi’s excellent contribution, that they have access to research evidence and use it to inform commissioning decisions. It has recently recruited a team to lead the research agenda and develop and implement its research strategy. It is anticipated that a draft strategy will be in place by autumn this year, when extensive consultation with key stakeholders and partners, including patients, will be undertaken.

The noble Lord, Lord Turnberg, and my noble friend Lady Sharp rightly referred to the vital role of clinical commissioning groups within the new system. Through their formal declaration of compliance, all these groups have confirmed that they understand and will comply with their statutory responsibilities regarding promoting research. They have also confirmed that they are committed to following the policy of ensuring the NHS meets the treatment costs for patients taking part in research funded by government and research charity partner organisations. Alongside NHS England, Health Education England has responsibility for promoting high quality education and training that is responsive to the changing needs of patients and local communities. It will work with stakeholders to influence training curricula as appropriate.

HEE will work to build a workforce that is research-literate, with the skills and confidence required to diffuse the latest ideas and innovations. HEE will establish mechanisms to ensure that ongoing engagement takes place with a wide range of partners. This will include building relationships with academic health science networks and academic health science centres to align education with research and innovation. The noble Lord, Lord Turnberg, referred to the role of LETBs, which are responsible for commissioning education and training and securing quality and value from education and training providers. Indeed, they will need to ensure that the education and training that they commission is in line with national objectives, which include building a flexible workforce that is receptive to research and innovation. HEE and the LETBs are working with the NIHR to ensure appropriate investment in education and training, to develop clinical academic careers and to increase the number of staff accessing academic careers programmes across all clinical and public health professions.

I say to the noble Lord, Lord Rea, that the NIHR supports a wide range of programmes for research training and career development. The purpose of these is, self-evidently, to create the next generation of researchers focused on people-based research. The programmes provide support for the academic training paths of all healthcare professionals and other key disciplines involved in health and social care research, including, importantly, general practice. The NIHR is actively building research in general practice—for example, through its School for Primary Care Research. Through its integrated academic training programme, the NIHR has already taken a lead in reversing the decline in clinical academic careers.

The noble Lord, Lord Turnberg, spoke about investing in research, and of course I very much identify with the need to do that. As part of the commitments announced by the Government yesterday to invest in Britain’s future, the department will provide £150 million of capital investment in 2015-16 to fund health research infrastructure in the areas of dementia, genomics and imaging.

As regards clinical excellence awards and the consultant contract, discussions are ongoing between the UK government health departments, NHS employers and the BMA about changes to the consultant contract. The aim is to agree a heads of terms next month and to move to detailed negotiations. I will write to the noble Lord with further details about that.

My noble friend Lord Selborne spoke very powerfully about data from the NHS. One million people have some form of contact with the NHS every 36 hours. That produces, as he rightly said, a staggering amount of data, which can be used to drive forward research into new treatments. The NHS is in a unique position in that sense. We can draw on linked datasets on a scale unprecedented elsewhere in the world. Provided that we ensure confidentiality and privacy for individual patients, the opportunities for research and innovation are vast. In April last year, we established the Clinical Practice Research Datalink, which enables access to anonymised patient records to support the development of novel treatments. I can reassure the noble Lord, Lord Turnberg, that the CPRD is working with the NIHR primary care research network to recruit more GP practices to contribute their data to the CPRD’s data assets.

The clock is moving against me, so noble Lords will have to forgive me if I do not cover all their questions today but I undertake to write to those noble Lords whose points I have not covered—and there are many. I hope that the noble Lord, Lord Turnberg, in particular, has gained a sense of the importance that the Government attach to promoting research in the NHS, and a sense that we need, and have, a whole-system approach to this agenda, which is so vital for the future health and prosperity of our nation.

National Health Service (Direct Payments) (Repeal of Pilot Schemes Limitation) Order 2013

Debate between Earl Howe and Baroness Wheeler

Thursday 20th June 2013 Lords Chamber

[Baroness Wheeler]

My Lords, I thank the Minister for his comprehensive explanation of the background and purpose of the order. We recognise that it is a technical amendment, but this is nevertheless a good opportunity to be updated by the Minister on the consultation on the extension of direct payments for healthcare and how the learning points from the pilots are to be translated into the revised regulations. Labour is fully supportive of extending personal health budgets, having pioneered them in social care through our personalisation and transformation of social care agenda, and set the ball rolling into 2009 on the PHB direct payments pilot.

It was also right to focus on exploring the use of PHBs and direct payments where people had the highest needs, such as those with long-term health and mental health conditions and who access the NHS most frequently. The pilot group covered CIPD, diabetes and long-term conditions, mental health and stroke and patients eligible for NHS continuing care. Labour was particularly concerned that PHBs do not stop at physical health but also include people with learning disabilities.

The national rollout target for PHBs to be extended to 56,000 people by April 2014 is challenging but is necessary to boost the take-up of PHBs across the country, as is the NHS mandate provision for every patient who will benefit to have the option of a PHB by 2015. Is the Minister confident that in the current circumstances, the resources will be available to support achieving these targets?

The pilot evaluation concluded that the majority of budget holders and their carers reported positive impacts of PHBs on patients—on health and well-being, care and other support arrangements for family members. As we know, PHBs have the potential to improve quality of life and satisfaction for both patients and carers, including psychological well-being. Helping patients design packages of care and support from clinicians, primary and secondary care and community health services also helps to provide joined-up integrated care, as the Minister pointed out, and in many instances has led to a reduction in the number of hospital visits. This is exactly where we need to be in terms of future service provision.

As a member—like many Members on all sides of both Houses—of the Westminster Health Forum, I recently chaired a specialist conference on PHBs which was attended by staff, providers and practitioners from across health and social care. The forum conferences are a valuable exchange between experts and staff on the ground including, in this case, those who are part of the multidisciplinary teams supporting and delivering PHBs. There was strong support for PHBs but it is clear, as the Minister said, that we are still very much in a learning process about their development. As usual, as you would expect, there were many questions and answers about some of the implementation, monitoring, accountability and evaluation issues.

I should like to finish by asking the Minister three questions on the issues that arose. First, there were widespread concerns at the conference that the evidence on the impact and effect of PHBs needed to be sharpened up in the future evaluation process. The pilot evaluation showed that there did not appear to be an impact on health status per se. Can the Minister explain whether there are plans in the rollout to assess possible measurements of health improvements, although of course we recognise that these can be hard to achieve in long-term health conditions?

Secondly, a number of GPs at the conference spoke about the challenge of getting wider GP buy-in to PHBs. Can the Minister update the House on discussions with the Royal College of GPs and the BMA on addressing this important issue? The college’s guidance on PHBs was especially commended by conference participants.

Finally, there was widespread concern about how PHBs will be taken forward by commissioners, health professionals and service users. Can the Minister update the House on advice planned or issued by the Department of Health in this respect?

[Earl Howe]

My Lords, this is most definitely one area of policy where all sides of the House are at one and I am grateful to the noble Baroness for her comments. She is right that the pioneering work on social care budgets was carried out during the previous Administration and gave us—and her own Government in 2009—sufficient confidence to institute these pilots for healthcare. I am pleased that she is as gratified as I am that the pilots have been a success, although as I emphasised earlier, we still need to feel our way in rolling them out.

The noble Baroness mentioned specifically people with learning disabilities and I agree with what she said. Although the number of people with learning disabilities involved in the pilot was small, it is clear from their stories that people with learning disabilities and their families benefited from the flexibility and control offered by personal health budgets. As the final report on Winterbourne View identified, personal health budgets have the potential to improve commissioning for people with complex needs and challenging behaviour. Many people in out of area placements, or who are at risk of such placements, are funded entirely through NHS continuing healthcare or have some NHS funding. These groups could be offered personal health budgets as the basis for a person-centred approach, meaning that they could have more control over where they live and the care they can access. It is that kind of intangible benefit—the noble Baroness asked about health benefits—that is very difficult to capture metrically, but it is nevertheless an important factor.

The noble Baroness asked me about resources and whether they will be available. As I mentioned earlier, personal health budgets are not about new money, they are about using existing money more effectively. Funding for budgets will need to be found from within normal NHS allocations and how that is done will be a decision for local CCGs. The personal health budget toolkit contains learning from the pilot programme on this and more information will become available during the early rollout phase as Going Further Faster sites consider sustainability issues. NHS England will be publishing guidance to help CCGs consider how to introduce direct payments for healthcare and personal health budgets on a local level in a sustainable way.

In answer to the noble Baroness’s question about health outcomes, it might be helpful to run through some of the findings from the pilots, which I think show that we can hold our heads up and say that they benefit people. First, we are clear that personal health budgets are cost-effective. They improve or maintain outcomes and reduce costs or are cost-neutral. These results are particularly true for people eligible for NHS continuing healthcare and people with mental health problems. When personal health budgets are implemented so that the person has choice over services and how they receive the budget, the cost-effectiveness increases. People can choose to meet their needs in different ways through lower-cost interventions, for example by training their personal assistants to carry out some health tasks, such as changing dressings. This means that people’s needs can still be met but in a different way, and perhaps in a way which is less stressful for them.

Personal health budgets also clearly resulted in an increase in the quality of life. The study found that effects were greater when people had budgets of more than £1,000, and this generally applies to people who have higher levels of health need, as I mentioned earlier. People benefited more from personal health budgets when there were fewer restrictions in place around what they could spend the money on and how they received the budget—that is, having a choice of a direct payment, a third-party budget or a notional budget. I hope that that is helpful to the noble Baroness in answer to her question.

In answer to the noble Baroness’s further question, I can tell her that the review will include a review of whether the budget is meeting the individual’s needs. That is clearly an important factor. We need to make sure not only that the money is adequate but that the plan itself and the money that goes with it are in step with each other. As regards the Royal College of General Practitioners and wider GP buy-in to personal health budgets, we have been very careful to engage with the royal college at all stages. We met them in conference last week to discuss their role going forward. It is important, as the noble Baroness stressed, that we engage GPs in this process, and I hope that we can continue that active co-operation with them.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Monday 10th June 2013 Lords Chamber

[Baroness Wheeler]

My Lords, I shall make a brief intervention in support of the desire of my noble friend Lord Rea to draw our attention to the importance of interprofessional education if we are to develop health and social care staff’s mutual respect, understanding and knowledge of each other’s professions that will bring about the collaboration, joint working and integration of care and support that we need. My noble friend describes this as staff knowing “how the other half lives”—in other words, staff knowing about each other’s services and how they operate, and being aware of boundaries, interdependence on achieving outcomes and competing agendas. He commends IPE because it provides an established model of collaboration and co-operation on the ground.

The amendment refers back to our earlier debate on integration and the need for multidisciplinary teamworking, and it will also be relevant to the debate that we will come to shortly on the importance of continuing professional development for healthcare workers. It adds promoting the use of joint IPE for clinical and social care staff as a matter that HEE must have regard to in relation to its responsibility for promoting the integration of healthcare and health-related provision.

My noble friend helpfully sent me a considerable amount of background information on his amendment in which, as a former HR professional, I was genuinely interested. It included extensive research by the Centre for the Advancement of Interprofessional Education, which my noble friend referred to, supporting the effectiveness of interprofessional education and training. My noble friend also referred to discussions between CAIPE and Health Education England to explore HEE’s role in taking IPE forward and embedding it in professional curricula. This is to be welcomed. Two-thirds of UK universities with two or more undergraduate programmes in health and social care include IPE, so these discussions will be helpful. These programmes cover a wide range of professions, including nursing, social work, physiotherapy, pharmacy, clinical psychology and radiography—all professions that are increasingly required to work flexibly across different care settings as part of multidisciplinary teams.

The Nuffield Trust evaluation of the first year of the inner north-west London integrated pilot that I referred to earlier underlined the importance of staff in multiprofessional teams having a high level of commitment to the pilot as a key factor in improving collaboration across different parts of the local health and care system. However, the evaluation also reminds us of the international evidence that integrated care takes years to develop and that a minimum of three to five years is needed to show impact in relation to patient experience and outcomes. Culture change, moving from silo to collaborative working among professionals, is a slow process, however committed we are to trying to make it work. I look forward to the Minister’s response to my noble friend’s amendment.

[Earl Howe]

My Lords, if I may say so, the noble Lord, Lord Rea, has explained his amendment in a very compelling way. Amendment 31 seeks to amend Clause 88(1)(h) so that Health Education England must have regard to the promotion of joint interprofessional education of clinical and social care staff where appropriate. As he is aware, much of the ground on these issues was covered in our earlier debates, when I hope I was able to reassure noble Lords that the Government take this issue very seriously. Clause 88 of the Bill, in listing the matters that Health Education England must have regard to in exercising its functions, is clear that Health Education England must support integration between health and care, and support staff so that they are able to work across different settings in health and social care.

In establishing Health Education England with a multiprofessional remit with responsibility for the development of all the professions, the Government have reinforced the importance of planning and developing staff in an interprofessional manner. As I mentioned, this approach is reinforced further in the Government’s mandate to Health Education England, which places a clear requirement on Health Education England, where appropriate, to develop multidisciplinary education and training programmes. I hope the noble Lord will agree that that is very much consonant with the principles that he was propounding in his contribution.

We entirely appreciate the importance of close working between the professions. I am sure that that is something Health Education England will consider carefully. I will write to the noble Lord if I can add any useful detail once I have had a chance to investigate further the issues that he raised and once I have discussed them with my officials.

However, I point out, as the noble Baroness, Lady Wheeler, did in our earlier debate, the importance of the recent commitment entered into by 12 of the national leaders of health and care, who signed up to a series of undertakings on how they will help local areas to integrate services. This was the document Integrated Care and Support: Our Shared Commitment—the first ever system-wide shared commitment. That document set out how local areas can use existing structures such as health and well-being boards to bring together local authorities, the NHS, social care providers, education, housing services, public health and others to make further steps towards integration. The ambition here is to make joined-up and co-ordinated health and care the norm. It works towards the first ever agreed definition of what people say good integrated care and support looks and feels like. That will be developed by national voices. There will be new pioneer areas around the country, to be announced in September of this year. One of the 12 partners of that shared commitment is Health Education England.

I hope that the noble Lord will be reassured by what I have said. I am entirely in tune with the spirit of his remarks. I will be happy to write to him if I have further and better particulars to impart, but for now I hope that he will feel able to withdraw his amendment.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Monday 10th June 2013 Lords Chamber

[Baroness Wheeler]

My Lords, we support the amendment. Our amendment on this issue relating to Health Education England’s national role in planning education and training for healthcare workers was considered last week. We were, in particular, keen to probe the role that LETBs will play in that important area.

The amendment would ensure that the annual reports of LETBs specify how they propose to support continuing professional development in that area. We strongly support that. The amendment specifies the medical professions, but it is applicable across the healthcare workforce. CPD is about ensuring that structured learning continues throughout one’s career, with clear objectives set and progress logged and regularly reviewed. CPD complements formal training and enables practitioners and other staff to acquire new knowledge and skills, as well as to maintain and improve their standards across all areas of their practice.

The HEE mandate has a small subsection on supporting the professional and personal development of the existing workforce, underlining the importance of HEE leadership and work with LETBs, but that aspect is far from being given the importance that it needs in the mandate—the point made by the noble Lord, Lord Ribeiro. There is of course emphasis elsewhere in the document on the workforce needing to be flexible and receptive to research and innovation, but CPD is wider than just keeping up to date and applies to values, behaviours and the ability to understand how one’s working role relates to the wider service, as we heard during our earlier debate on integration.

I could not see CPD addressed in any depth on the HEE website, although we join other noble Lords in welcoming the general, across-the-board progress that HEE has made in its new role so far. HEE recognises that providing leadership and ensuring greater transparency in the investment that employers make in their workforce and in supporting and championing multidisciplinary and professional CPD is a strategic priority. Does the Minister agree that HEE needs to step up and develop its CPD strategy as a major priority, and does he accept that the mandate needs better to reflect the importance of CPD?

The HEE website also mentions that it will be allocating a limited amount of central funding for LETBs to invest in CPD, particularly for staff employed at Agenda for Change bands 1 to 4 and equivalent staff employed as part of primary care teams in general practice, community pharmacy and other community-based employers.Does the Minister have any further information on how the Government expect HEE to take this forward with LETBs?

Last week I mentioned the recent member survey by the Royal College of Nursing on CPD, showing how varied the time allocated by NHS trusts is. It is worth going into the findings in a little more detail today. The survey found that in the past 12 months almost a third of respondents had received no CPD that was provided or paid for by their employer. By sector, just a third of respondents in the NHS received no training in the past 12 months, compared to just under a quarter of those working in the independent or voluntary sectors. Just over a third said that the amount of CPD provided had decreased in comparison to the previous year, while 45% said that it had stayed the same.

Interestingly, overall, members working in the NHS were more likely than those working in the independent and voluntary sectors to report that the amount of CPD undertaken had decreased. Obviously, CPD is a mix of both employer-supported and resourced training and personal development learning resourced by the individual, either in their own time or with their own money. However, the RCN survey shows a very worrying trend in the importance employers place on providing CPD. Can the Minister comment on this and on how the problem can be addressed in the future? Is he confident that HEE or LETBs will have the resources to address this problem?

Our earlier amendment was similar to the wording that the Government included in the original Bill but subsequently deleted. I am sure the Minister will explain his thinking behind this and, as the noble Lord, Lord Patel, fully expects, delight us all by announcing that he has decided to put the CPD wording back in.

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

My Lords, I make no apology for repeating my firm belief that the staff working in our NHS and public health system are the health service’s most precious resource. We must do all we can to ensure that staff have and continue to have the right values, training and skills to deliver the very highest quality of care for patients.

Clause 93 requires local education and training boards to publish an education and training plan for each financial year. The education and training plan must set out the local education and training board’s proposed investment in its current and future workforce for the following year. Note the word “current” in this context. In developing an education and training plan, the Bill makes clear that a local education and training board must consult with and have regard to the local priorities of, among others, the NHS and health providers and the commissioners that it represents.

The noble Lord, Lord Patel, asked what level of funding is attached to CPD in the NHS. The answer is that investment in CPD is really a decision to be taken locally. As I indicated, local providers and commissioners are best placed to decide what ongoing professional development their staff need. It will be their job to feed that in to the LETB as the local education and training plan is developed. I have already spoken in reply to an earlier group of amendments about the importance of continuing professional development, and the leadership role that Health Education England and local education and training boards can play in supporting this.

The noble Lord, Lord Patel, and the noble Baroness, Lady Wheeler, asked what happened to the reference to CPD in the draft Bill. The answer is that we widened the description in Clause 84(6) so that the Bill states that:

“HEE may, with the consent of the Secretary of State, carry out other activities relating to … education and training for health care workers”.

This still very much includes CPD. I emphasise that we consider this to be an important part of the way HEE may exercise this power. The NHS constitution sets out that staff can expect employers to invest in their development, and that all healthcare providers must take this issue seriously. Employers have a clear responsibility to provide their staff with the support and personal development they need, as well as access to appropriate training to enable them to fulfil their duties. However, Health Education England will play a crucial role in providing leadership in supporting employers in this area. The mandate sets out that Health Education England will work with LETBs and healthcare providers and commissioners to ensure that professional and personal development continues beyond the end of formal training to enable staff to deliver safe and high-quality health and public health services, for now and in the future.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Monday 10th June 2013 Lords Chamber

[Baroness Wheeler]

My Lords, I support my noble friend Lord Warner’s amendment. There will of course be further debate on integration in the wider context of the Bill, but the amendment is important because it underlines that Health Education England must have the strategic overview and understanding of the workforce requirements across the boundaries of health and social care if it is to undertake its role effectively.

Our stakeholder meetings have shown that there is considerable concern among stakeholders on that issue. They want the links between HEE and the social care sector to be more explicit. The noble Earl’s reassurances last week in that regard concerning Clause 88 were helpful, and I look forward to hearing from him further on how HEE is to work with integrated care delivery. I hope that he will concede that my noble friend’s cross-reference in his amendment to Clause 85 is necessary, because it links the HEE’s duty in Clause 88 to have regard to promoting integration to its key role of ensuring that there are sufficient skilled healthcare workers available.

The Health Education England mandate acknowledges that the future needs of the NHS, public health and care system will require a greater emphasis on community, primary and integrated health and social care. HEE is essential in that. Staff must be trained and developed in the skills that are transferable between different care settings and in working in cross-disciplinary teams in a range of different health and support settings. It must also work closely with the social care sector by developing common standards and portable qualifications across the NHS, public health and social care systems. The local LETB role, linking up with the health and well-being boards, is particularly important in that respect.

It is worth briefly mentioning two recent reports on integration, both of which, among other things, reinforce how much awareness and understanding of each other’s roles must take place for integrated services to happen and to be delivered. The shared commitment statement under the National Collaboration for Integrated Care and Support was drawn up by an impressive mix of national partner organisations, including government departments, the HEE itself, regulatory bodies, the Association of Directors of Adult Social Services, National Voices and other stakeholder groups. It pledges to help,

“local organisations work towards providing more person-centred, coordinated care for their communities”.

There is not time to go into detail, but National Voices’ A Narrative for Person-centred Coordinated (“Integrated”) Care, which sets out what integrated care and support looks like from an individual perspective, for both the cared-for and for carers, is a powerful vision for the future. It underlines how closely staff across primary, community, NHS and social care will have to work if this is to be achieved. The section of the narrative on communication describes professionals talking to each other, and patients always knowing who is co-ordinating their care, always being informed about what is going on, and having one point of contact. This in itself would be nirvana to most patients, service users and carers.

The recently published Nuffield Trust report, Evaluation of the first year of the Inner North West London Integrated Care Pilot, looks at developing new forms of care planning for people with diabetes and people over the age of 75. It underlines the importance of staff having a high level of commitment to the pilot and to the care planning process in particular. Initial results show that work on care planning and multidisciplinary groups resulted in improved collaboration across the different parts of the local health and social care system.

On public health, the HEE mandate itself states:

“The health of people in England will only improve in line with other comparable developed countries when the entire NHS, public health and social care workforce genuinely understands how their services together can improve the public’s health”.

Does the Minister accept that the HEE mandate supports the case for the Bill to include an explicit reference on the overall strategic context?

HEE’s role is to provide national leadership for workforce training, planning and development, ensuring that we have skilled, committed staff in the right place, in the right specialities and numbers. We need to meet these challenges of the future and of the changing face of healthcare provision. How to ensure an integrated approach to education and training across the NHS, public health and social care is a very strategic issue. I hope that the Minister will reassure the House on this by responding positively to the amendment.

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

My Lords, integration between health and social care is a strong theme of the Bill, and the Government take it very seriously. I very much agreed with a great deal of what the noble Lord, Lord Warner, and others said on that topic.

First, to deliver integrated care, it is important that local planning is aligned and is mutually reinforcing. That applies also to the planning of education and training. As Members of the Committee are well aware, the future needs of the NHS and the public health and social care system will require a greater emphasis on community, primary and integrated health and social care than in the past. An understanding is required of working in cross-disciplinary teams and working to break down barriers between primary and secondary care.

The mandate the Government published a couple of weeks ago gave Health Education England a clear remit to ensure that it trains and develops a workforce with skills that are transferable between these different care settings. The amendment of the noble Lord, Lord Warner, seeks to amend Clause 85 to require HEE to have,

“regard to the promotion of integration with care and support provision”,

when it performs its duty under that clause of ensuring that there are sufficient skilled healthcare workers for the purposes of the health service. As the noble Lord is well aware, Clause 88, which lists the matters that Health Education England must have regard to in exercising its functions in Clauses 85 and 87, already includes a requirement at subsection (1)(h) that Health Education England must support,

“integration of health provision with health-related provision and care and support provision”.

Subsection (1)(i) requires Health Education England to support staff to be able to work across different settings. These provisions were added to the Bill at the recommendation of the Joint Committee following pre-legislative scrutiny. Although Health Education England does not have a direct remit for the social care workforce, it will be expected to work closely with the social care sector at local and national level to ensure that workforce plans align with the training and development of the healthcare and public health workforce.

To support the development of this integrated approach, Health Education England needs to work with partners across health and care to develop common standards and portable qualifications. This must make it easier for staff to work and move between settings and should build on existing work, such as skills passports and national minimum training standards. Health Education England will work closely with the sector skills councils, Skills for Health and Skills for Care, nationally and through the local education and training boards, to ensure that workforce development is co-ordinated and integrated.

Health and Social Care

Debate between Earl Howe and Baroness Wheeler

Wednesday 5th June 2013 Lords Chamber

[Earl Howe]

Again, my noble friend asks an extremely good question. The year-on-year success of public health interventions to address non-communicable diseases, for example, will be measured through the public health outcomes framework. The department will incentivise some of the indicators in the public health outcomes framework through the health premium incentive scheme. Some of the indicators that will be selected may contribute to prevention of non-communicable diseases.

[Baroness Wheeler]

My Lords, on social care, the charity Mind has pointed out that many people with mental health problems are never properly assessed to see if they need social services, such as having somebody to help with admin or household tasks, or with washing, dressing or something meaningful to do during the day. Is the Minister confident that the outcomes framework is robust enough to measure this problem, and how does he think that local councils will be able to address this issue in the light of the £2.7 billion cuts that they will have had to their adult social care budgets by the end of this spending round?

[Earl Howe]

My Lords, the adult social care outcomes framework was put together with a great deal of help and support from local authorities, so we hope that there will be a great deal of buy-in to it. It has as its focus high-quality care and promoting people’s independence and well-being, and it enables councils to make comparisons, assess scope for improvement and measure progress against their own local priorities in adult social care. Therefore, the virtue of the outcomes frameworks is, above all, transparency and accountability, leading to improved quality of care as defined locally by councils.

Care Bill [HL]

Debate between Earl Howe and Baroness Wheeler

Tuesday 4th June 2013 Lords Chamber

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

My Lords, the health service is dependent on having the right numbers of staff, with the right skills and behaviours. Quite rightly, patients expect the people who deliver health services to be well supported and to have the right professional and clinical skills. To achieve this, we need a system that can attract people with the right values, give them the right career advice, support the development of excellent professional and clinical skills, emphasise the centrality of providing care with compassion, kindness and respect, and ensure a workforce that is responsive to changing needs and innovations in services. That, in a nutshell, is why we have established Health Education England and the local education and training boards.

Health Education England is already established as a special health authority and is already working to put in place requirements similar to those placed on it in this legislation. Establishing Health Education England as a non-departmental public body will ensure that it has the independence and impartiality that it requires to plan, commission and quality-assure education and training for the long term. As an NDPB, it will be accountable to the Secretary of State and Parliament for ensuring that there is an effective education and training system in place. The establishment of Health Education England has been welcomed, I am glad to say, by stakeholders across the health and education system. It has the support of the Health Select Committee and the Joint Committee that scrutinised the draft Bill. It is viewed as an important step forward in promoting the development of the healthcare workforce and driving up standards.

Amendments 8 and 10 seek to ensure that Health Education England gives equal consideration to physical and mental health in the delivery of its education and training functions. I have no quarrel with noble Lords bringing us back to that familiar theme, but primary legislation is not required for Health Education England to give equal consideration to the importance of physical and mental health.

To start with what I hope is an obvious point, in establishing Health Education England, the Government are making clear their commitment to the development of the entire health and public health workforce. One of the significant weaknesses of previous workforce planning and education commissioning arrangements has been the fragmented approach, with responsibilities scattered across different bodies and silo approaches taken to considering the development needs of different professions and services. Health Education England will be different. It will be responsible for the planning and development of the whole workforce, whether in primary care, secondary care, public health or mental health. Although it will retain a strong focus on the development of different professions, it will do so with a multiprofessional remit and perspective that promotes multidisciplinary education and training where appropriate.

I would like to take the Committee back to the Health and Social Care Act 2012, which places a clear duty on the Secretary of State to ensure an effective education and training system for,

“persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England”—

which is a very wide scope. That duty is very important. It reflects the importance of education and training in the NHS and public health system, and is a key duty underpinning the Secretary of State’s duty to ensure,

“a comprehensive health service designed to secure improvement … in … physical and mental health”.

The Bill delegates the Secretary of State’s education and training duty to Health Education England, giving it a clear and unambiguous remit for workforce planning, education, training and development across England. I hope that that conveys to the Committee the direct legal linkage between this Bill and the 2012 Act in respect of the parity of esteem issue.

Clause 88 requires Health Education England to have regard to the Government’s mandate to NHS England. It is appropriate that the education and training objectives are aligned to service commissioning objectives in this way. It is especially relevant in the context of this amendment because the NHS England mandate requires mental and physical health conditions to be treated “with equal priority” and to,

“close the health gap between people with mental health problems and the population as a whole”.

The Government’s mandate to the Health Education England Special Health Authority reflects this and requires Health Education England,

“to focus on the mental health workforce”.

I listened with care, as I always do, to the noble Lord, Lord Rix. I simply say to him that Health Education England can support better education, training and development for staff so that they can better support people with learning disabilities and difficulties. The core components of education and training for all staff should be to treat people with kindness and compassion and communicate well with all patients and carers. That, I hope, goes without saying, but it is particularly relevant to those with learning difficulties and disabilities. In saying that, of course I recognise that there are certain specialist skills that people in that field require.

Amendment 12 relates to continuing professional development. I absolutely recognise that the continuing professional development of healthcare workers is important. This is enshrined in the NHS constitution, which places a commitment on all employers that supply NHS-funded services to invest in this area and provide their staff with the support and personal development that they need, as well as access to appropriate training to enable them to fulfil their duties.

Health Education England will play a crucial role in providing leadership in this area. The mandate that the Government published only recently for the Health Education England special health authority sends out a clear message that the staff working in our NHS and public health system are the health service’s most precious resource. We must do all we can to ensure that staff have the right values, training and skills to deliver the very highest quality of care for patients. To support the development of the existing NHS and public health workforce, the mandate sets out that Health Education England will work with Local Education and Training Boards and healthcare providers to ensure professional and personal development continues beyond the end of formal training to enable staff to deliver safe and high quality health and public health services, now and in the future. This will include supporting those staff who may wish to return to training.

I hope that those remarks are helpful to the noble Baroness. To cover a number of questions that were put to me, the noble Baroness, Lady Wheeler, asked about the Royal College of Psychiatrists report. We very much welcome the report. The Minister for Health and Care Services will be attending the report’s launch on 19 June and will be setting out what the Government will do to respond to the challenge that the Royal College has articulated.

The noble Lord, Lord Warner, asked what Health Education England will do to address the issue of reliance on locums and agency staff, a very pertinent question. Health Education England can make a significant contribution in this area. Better workforce planning, linked to service and financial planning, is a key aim of the new system that should ensure less reliance on locum and agency staff.

The noble Baroness, Lady Wall, asked me what Health Education England was doing to support career development for healthcare assistants. The capability of care assistants, and public confidence in that group of workers, is of increasing importance. Health Education England will work with employers to improve the capability of the care assistant workforce, including those in the care sector, as well as the standards of training that they receive. Health Education England will develop a strategy and an implementation plan to achieve that, building on the Cavendish review, which will be published quite soon, and on work by Skills for Health and Skills for Care on minimum training standards. The strategy should cover job roles, recruitment, induction, training standards and transparency, as well as identifying opportunities for career progression. I hope that those comments are helpful to the noble Baroness.

[Baroness Wheeler]

I thank the Minister for his thorough response and for his reassurances on the Government’s intentions in respect of parity of esteem. The debate as to whether parity of esteem is inferred or assumed in legislation, or should be specifically included, will continue. We will be strongly supporting this issue as we move through the Bill, with the comments of the noble Lord, Lord Rix, on the need to ensure the inclusion of people with learning difficulties. I am disappointed that the Minister is resisting this issue of inclusion. It would underline the importance of parity of esteem as a guiding principle, ensure consistency with the Health and Social Care Act and reinforce the HEE mandate role in this respect.

Amendment 12 received strong support from my noble friend Lord Warner, the noble Lord, Lord Willis, and the noble Baroness, Lady Emerton. I welcome that. My noble friend was right to underline the particular importance of CPD in the light of the current challenges facing the service. I look forward to the fuller debate later on in the Bill on this. With that, I beg leave to withdraw.

Care Quality Commission

Debate between Earl Howe and Baroness Wheeler

Thursday 14th March 2013 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they propose to take in the light of the findings of the Care Quality Commission’s home care inspection review Not Just a Number.

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

My Lords, the Government were encouraged that almost three-quarters of the domiciliary care agencies inspected by the CQC for the review were found to be meeting essential standards.

As the regulator of health and adult social care, the CQC has a range of powers to ensure that services are safe and of good quality. The CQC has the Government’s full support to take firm action where it finds services are unacceptable or failing.

[Baroness Wheeler]

I thank the noble Earl for his response and welcome the CQC’s positive findings on the 75% of home care services it inspected. However, the 25% of failing providers are a cause for deep concern, particularly as regards the number of late or missed calls and their complete failure to have systems to document, assess or monitor the quality of care they are supposed to deliver. Where there is a live-in carer, late or missed calls can at least be managed in some way, even if the cared-for person cannot be got out of bed. However, if people are on their own, the consequences are deeply distressing and can be very serious. What information does the department have nationally across the sector about this very worrying issue? What action is being taken to address the problem? Should we not ensure that all providers are required to keep records of the numbers, reasons for and remedial actions taken for missed and late calls, including refunding charges to self-funders or to the local authority?

[Earl Howe]

My Lords, the noble Baroness is quite right: there is no room for complacency in this area. Care has to be right every time, not just three-quarters of the time. I noted from the CQC’s report that, although it recorded a number of common issues undermining the majority of good home care from a significant minority of providers, many of these were fairly minor. However, the noble Baroness has alighted on a very important failing among several of the agencies inspected. I do not have national information on late and missed calls but in the work that we are doing with local authorities, providers and, indeed, the CQC, all of whom share responsibility for driving improvement in services, this will inevitably be an area of focus for it.

NHS: South London Healthcare Trust

Debate between Earl Howe and Baroness Wheeler

Tuesday 8th January 2013 Lords Chamber

[Baroness Wheeler]

I thank the Minister for repeating the Answer to the Urgent Question. We commend the work of the trust special administrator and support a number of the recommendations developed from previous reviews. However, it is difficult to understand how the Government consider this report to constitute the full strategic review of the sustainability of services across south-east London that is required. The TSA has overstepped its remit under the Health Act 2009 by including service changes to Lewisham hospital; and the parallel work by King’s Health Partners on reconfiguration under three other south-east London trusts has yet to be completed.

Can the Minister explain why the rules on making changes to hospitals have been changed to allow back-door reconfigurations in this way without proper scrutiny and consultation? What public consultation will there be on the King’s Health Partners report? Can he reassure the people of Lewisham that they will have their full consultation rights to challenge the closure of their A&E services and the other major changes being proposed?

[Earl Howe]

My Lords, I am grateful to the noble Baroness and I understand the concerns that she has raised.

The first question she asked me was whether I considered the trust special administrator to have overstepped his remit. The clear advice that we have received is that no part of the NHS can exist in a vacuum. The independent trust special administrator is responsible for developing recommendations to deal with the severe failings at South London Healthcare Trust based on local discussions and consultation. I hope that the statement I read out gave the House a flavour of how extensive those consultations have been. His recommendations must secure high-quality care for local people in a financially sustainable way.

However, as I have mentioned, each NHS trust is part of a complex, wider health system, and it is quite clearly the view of the administrator in this case that it is not possible to find a solution without considering the possible impact on other hospitals in the areas. That conclusion is one that my right honourable friend will have to consider very carefully, but Ministers have received clear advice that it is within the powers of the administrator to make recommendations about necessary changes to other local providers if they are a necessary and consequential part of finding a long-term solution to securing high-quality services for patients at that trust. I emphasise that I do not in any way wish to pre-empt the decision that my right honourable friend has to take within 20 working days. However, he will have to consider advice on the clinical, legal and financial aspects of the administrator’s recommendations and I have no doubt that concerns raised by the noble Baroness will be central to his consideration.

Social Care: Apprenticeships

Debate between Earl Howe and Baroness Wheeler

Thursday 29th November 2012 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what progress they are making on establishing social care apprenticeships; and how voluntary registration of social care workers will assist apprentices and staff to provide the quality of care required in domiciliary and community settings.

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

My Lords, apprenticeships and voluntary registration for social care workers are part of the vision set out in the care and support White Paper and will contribute to improving quality of care. The latest figures report that more than 60,000 apprenticeships have started in 2011-12. A system of assured voluntary registers will help to support the delivery of quality care by enabling individuals to demonstrate that they meet set standards of education, training and competence.

[Baroness Wheeler]

I thank the Minister for his response and welcome the progress being made. As he knows, apprentices will join the current social care workforce of 1.6 million, more than two-thirds of whom now work in the voluntary, independent and private sectors or are employed directly by service users in their homes. Given the Government’s desire to have only a voluntary register for social care staff, can the Minister explain to the House how consistent quality and dignified care are to be delivered across this fragmented employer base?

NHS: Women Doctors

Debate between Earl Howe and Baroness Wheeler

Tuesday 6th November 2012 Lords Chamber

[Earl Howe]

Yes, indeed, my Lords. The noble Baroness, Lady Deech, raised that in her report as an action point. It can be done at a trust level or at a higher level in the health service. But it is certainly important to monitor—I understand that the term is “credentialing” —the skill sets of those doctors, who may move out of the health service and want to move back in again, so that jobs can be found for them more easily.

[Baroness Wheeler]

My Lords, I am sure the Minister will agree that recruiting women into the medical profession is just as vital as retaining them once they are trained and working. Given the high costs of university fees and the burden that these place on young people, particularly those from poorer backgrounds and those with family and caring responsibilities, how will the Government ensure that women are not put off applying to medical school?

[Earl Howe]

My Lords, there is no evidence that there is a problem with female recruitment into the health service. Indeed, the male-to-female gender balance over the past few years has decreased from 1.83:1 in 2001 to 1.25:1 in 2011. However, I recognise that we should not be complacent. Even with the increased participation of women in medicine, we appreciate that more can be done to improve the selection of senior doctors into senior positions.

Care Homes

Debate between Earl Howe and Baroness Wheeler

Wednesday 27th June 2012 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they will take in the light of the finding of the Care Quality Commission’s recent unannounced inspections of care homes and treatment centres for people with learning disabilities, that around half of those inspected were not meeting essential standards of care.

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

My Lords, the CQC’s findings show unacceptable levels of care. On Monday a Department of Health report set out 14 national actions to improve care and support for people with learning disabilities or autism and behaviours that challenge. All parts of the health and care system have a role to play in driving up standards, stopping abuse and transforming local services.

[Baroness Wheeler]

My Lords, in its inspection of care homes and assessment centres in the light of the serious abuse and appalling standards of care at Winterbourne View hospital for people with learning disabilities, the CQC found that of the 150 inspections it carried out, independent healthcare providers were twice as likely to fail to meet the required standards as NHS providers. How does the Minister account for that? Can he say specifically what steps he will be taking to ensure that clinical commissioning groups tackle the problems the commission found over lengths of stay in services, failure to review care plans so that residents can be moved on to community-based services, and the very worrying overuse of restraint of patients?

[Earl Howe]

My Lords, it is true that CQC inspectors found that for the kind of services they inspected, there was more non-compliance in services run by the private sector. But the information the CQC gathered for its report does not enable it to analyse the reasons for that. I would simply say that all providers of services, whether in the independent sector or the NHS, need to ensure that they comply with essential standards. The noble Baroness summarised a number of the areas where the CQC found failings and I endorse her view that there is a fundamental failing across the system, not just in providers but in terms of commissioning as well. The examples of poor care show up a fundamental need for commissioners to review commissioning plans and care plans, and make sure not just that the providers are capable of offering and providing care to the right standards but that they are actually doing so at the right level for the patients and service users they look after.

Older People: Health and Social Care

Debate between Earl Howe and Baroness Wheeler

Monday 18th June 2012 Lords Chamber

[Earl Howe]

I come back to the point that I made to the noble Baroness, Lady Finlay. Domain 4 of the NHS outcomes framework is about ensuring that people have a positive experience of care and reflects the importance of providing that positive experience, including treating patients with dignity and respect. Domain 5, which is about treating and caring for people in a safe environment and protecting them from avoidable harm, also relates to that area. These areas will be centre stage in the way that the NHS CCGs in particular are monitored by the board.

[Baroness Wheeler]

My Lords, the recommendations of the Delivering Dignity report focus on tackling the underlying causes of poor care in hospitals and residential care. As the Minister knows, there is widespread concern among key stakeholders, including voluntary organisations, care professionals and care providers, about the serious impact that the growing crisis in social care funding is having on providing good-quality care in residential homes. Does this not make it even more vital for the Government to stand by the Prime Minister’s pledge to deal with social care funding and with the recommendations of the Dilnot commission in this Parliament?

[Earl Howe]

The noble Baroness makes a very fair point. As I made clear last week, our aim has been and remains to legislate in this Parliament to create a fairer, more just and better funding system for social care.

Social Care: Legislation

Debate between Earl Howe and Baroness Wheeler

Monday 11th June 2012 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what is the timetable for the draft Bill to modernise adult care and support in England announced in the Queen’s Speech and to what extent the proposals in the Bill follow the recommendations of the Dilnot commission.

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

My Lords, the Government have committed to publishing a draft Bill for pre-legislative scrutiny this Session, and will outline plans for transforming care and support in the forthcoming White Paper. The Dilnot commission’s recommendations are hugely valuable. However, implementing them would have significant costs, which must be considered in light of the growing demand for social care, and of other priorities. We will set out the way forward in the progress report alongside the White Paper.

[Baroness Wheeler]

I thank the Minister for his response. However, with local authorities having to cut £1 billion from current social care budgets, does he not agree that there must be a package of reforms that will embrace current and long-term funding solutions, as well as the legal framework proposals expected in the White Paper and Bill? Will he reassure the House that the progress report accompanying the White Paper will contain a clear timetable for consultation on funding issues? Will he also reassure us that the Government intend to honour the Prime Minister’s pledge to deal with social care funding in this Parliament?

[Earl Howe]

My Lords, this is the first reform of social care law in more than 60 years. It is a unique opportunity to get the legal framework right. That is why we have deliberately taken time to engage fully with those who have experience and expertise in care and support. Many people in the sector have called explicitly for scrutiny on a draft Bill, so publishing a Bill in this way demonstrates our commitment to working in partnership. We remain absolutely committed to introducing legislation at the earliest opportunity in this Parliament to establish a sustainable legal framework for adult social care. The draft Bill will be the critical next step in delivering the reform agenda.

Care Homes

Debate between Earl Howe and Baroness Wheeler

Monday 28th May 2012 Lords Chamber

[Earl Howe]

The noble Lord made a very good point. As he will know, there are existing oversight and regulatory frameworks, with the CQC regulating the quality of care and support services and local authorities overseeing local providers. The point made by the noble Lord is a major part of why the Government are engaging with the sector, as I described just now to my noble friend. The main point to stress is that under the existing system no one will be left homeless should a provider fail. In an emergency, local authorities have a duty to provide accommodation to anyone, whether they are publicly funded or self-funded, who has an urgent need for it.

[Baroness Wheeler]

My Lords, this summer the Care Quality Commission is conducting thematic inspections of dignity and nutrition in 500 care homes with nursing provision. Does the Minister agree that these will be vital in providing evidence and guidance to ensure improved standards of care? Will he assure the House that these inspections will go ahead despite the commission’s increased responsibilities and workload resulting from implementation of the Health and Social Care Act and other government policy initiatives?

[Earl Howe]

My Lords, the noble Baroness is right; this is very important work. I am led to understand by the CQC that the programme is due to proceed as planned. We will place a great deal of reliance on its findings. In the light of recent distressing and unfortunate stories about the absence of dignity in certain care settings and the shortcomings in care quality, it will be important to learn lessons from the CQC’s programme.

NHS: General Practitioners

Debate between Earl Howe and Baroness Wheeler

Wednesday 23rd May 2012 Lords Chamber

[Lord Harrison]

My Lords—

[Baroness Wheeler]

My Lords, at the conference this week we heard the growing concern of GP leaders and delegates that grass-roots GPs were being excluded from involvement in clinical commissioning groups. How will the Minister address this, and will he ensure that CCG guidance includes best practice on how their involvement can be ensured?

[Earl Howe]

My Lords, each GP practice will have a GP or other health professional who will represent the practice in dealing with the CCG. Other GPs may be involved in the clinical design of local services, building in some cases on existing GP involvement in practice-based commissioning. Most day-to-day commissioning activities are likely to be undertaken by staff within CCGs, but part of the rationale for this is clinical engagement and involvement. I would be very concerned to hear of instances where GPs felt that they were being shut out of the process of development that is now under way. If the noble Baroness could draw my attention to any such instances, I would be grateful.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Tuesday 13th March 2012 Lords Chamber

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

My Lords, I shall speak also to the other 41 amendments in this group, some of which, I stress, are minor, technical or consequential.

Part 9 establishes the information centre in primary legislation, setting out its powers in relation to the collection, analysis, publication or dissemination of information. Several noble Lords, as well as the British Medical Association and the NHS Future Forum, have expressed a keen interest in the need to ensure an appropriate balance between the protection of patient information and the use and sharing of information to improve patient care. For example, I recall that the noble Baroness, Lady Wheeler, stressed the need to provide,

“safeguards that are strong enough to protect patients”.—[Official Report, 21/12/11; col. 1802.]

She is, of course, absolutely right. We are sensitive to these concerns.

Your Lordships have already approved amendments that raise the threshold required for the board and CCGs to disclose personal information. Government Amendments 268, 280 to 282, 284, 285 and 287 to 289, which are supported by the BMA, further strengthen the protections in the Bill in relation to confidential personal information. Government Amendment 268 would in effect restrict the bodies that are able to request the centre to collect confidential personal information to the principal bodies—that is Monitor, NICE and the CQC—or any other body prescribed in regulations. It also restricts the making of such requests to a person to whom information may be lawfully disclosed—for example, because they have obtained consent or have a power in statute to require such disclosure—or where the information may be lawfully disclosed to the centre.

Government Amendment 272 limits the circumstances in which the information centre may require provision to it of confidential personal information. Government Amendments 280, 281, 282, 284, 285, 287 and 288 clarify when dissemination by the information centre of information which identifies or enables the identity of an individual to be ascertained would be permitted, and when the information centre may be directed to disseminate or not to disseminate information. Government Amendment 289 would require the information centre to publish a code of practice for health or social care bodies or anyone providing publicly funded health or social care on how to deal with person-identifiable or other confidential information.

We believe these amendments strike the right balance between appropriately protecting an individual’s confidential personal information and ensuring that the wider benefits of safely and securely sharing information, which include improvements in the quality of services and treatments, can be realised. There are also a number of minor and technical amendments to improve the drafting of the clauses and to ensure that they can be effectively exercised in practice.

Government Amendments 291A to 291D and 297A to 297D are intended to provide a further degree of future-proofing to ensure that the exact requirements for the future development and delivery of informatics systems to support the health and care sector can be met. Last week, my right honourable friend the Secretary of State for Health highlighted our approach for delivering informatics systems in the future. We intend that the board and the Secretary of State will be supported in the management of informatics systems and services by a lean delivery organisation that will take over from NHS Connecting for Health from April 2013. We are currently looking at where these delivery functions will sit, with the information centre as an option to house some or all of this work. These amendments would enable provision to be made so that the centre could exercise the functions of the Secretary of State or the board in relation to delivering these systems. The amendments will also help to future-proof the legislation so that the provisions can support a more flexible, agile approach to delivering informatics systems in the future. I beg to move.

[Baroness Wheeler]

My Lords, I welcome and support the government amendments in this group. In Committee, I stressed our strong support for placing the Health and Social Care Information Centre on a firmer statutory footing and replacing the current special health authority. The centre, male-midwived by my noble friend Lord Warner, as he put it, was set up by the Labour Government and has enjoyed a large measure of success, particularly in developing the bedrock quality improvement initiatives in the NHS. I stressed then that if we are able to get the patient confidentiality issues right, the UK has a huge opportunity to lead the world in health research.

The government amendments go a long way towards meeting the concerns expressed by me and other noble Lords on safeguarding patient confidentiality and the need to place a greater emphasis on obtaining consent from the patient when this information is collected or published. The information centre now has to obtain consent before it publishes information that could identify a person.

The new clause in Amendment 268, in particular, which establishes what type of information is confidential and how the information centre must deal with information, is a major step forward, as is the new clause outlined in Amendment 289 requiring the information centre to develop a code of conduct on confidential information.

The noble Earl quoted me from Committee stressing the need for safeguards that are strong enough to protect patients. As that is the first time that I have ever been quoted by the Government, I think I can legitimately claim credit for the subsequent amendments. The extra safeguards to protect patients—for example, detailing when the Secretary of State can request information and who can request the information centre to collect information, and ensuring that consent must be obtained where the information is deemed confidential—are all vital to ensure public and patient confidence that information will be properly acquired, stored, used and published.

We also strongly support Amendment 268, limiting the range of bodies that can request that the information centre collect personal or confidential information to principal bodies, such as Monitor, CQC or NICE, which are able to make a mandatory request because they have obtained consent and have the power under statute.

On the code of conduct, I hope that the noble Earl will assure us that there will be widespread consultation on the development of a code. I should also be grateful if he could reassure the House that the code will provide further detail about the proposed mechanisms that the centre will need to obtain the consent of patients. It is obviously important that we get this issue right. What will be the process for obtaining consent where people are unable to provide it—for example, patients who are unable to make decisions for themselves under the Mental Capacity Act 2006?

Finally, the Government’s Statement in the House on 6 December on UK life sciences announced their intention to share much more patient information with the private and independent sectors in an anonymised form to aid medical research and development. I believe that there are to be discussions with the BMA and other appropriate organisations on that matter to ensure strict safeguards that will instil public confidence. We particularly want to be clear how the Government will judge to which companies they will make that information available and what criteria they will use in those circumstances. I should be grateful if the Minister could update the House on progress on that issue.

--- Later in debate ---

[Earl Howe]

My Lords, I am very grateful to the noble Baroness for her broad welcome for this group of amendments. She is absolutely right: they improve the provisions for patient confidentiality and, at the same time, the sharing of information where that is appropriate. I also welcome her endorsement of our approach to the information centre, which, as she rightly said, was set up under the previous Government and, we believe, has proved its worth in the mean while.

She asked a number of questions. On the first one, relating to consultation, yes, we will work with a range of groups in developing the code and will publish proposals in due course. On her other questions about the mechanisms for consent and obtaining consent from patients who are unable to give it because of mental incapacity, I hope that she will allow me to write a letter to save the time of the House but also because I want to get my answers absolutely correct, and I fear that I would leave important things out if I tried to answer her now.

[Baroness Wheeler]

My Lords, before the noble Earl sits down, what about the point relating to UK life sciences and the information given to the private and independent sectors?

[Earl Howe]

I apologise; I did not mention that. I will cover that point in my letter as well.

--- Later in debate ---

[Baroness Wheeler]

My Lords, these Benches strongly support the amendment tabled by the noble Baroness, Lady Greengross, and the noble Lords, Lord Low and Lord Rix, to which I have added my name. It is frustrating that we appear to have moved no further forward from Committee, when the noble Baroness, a plethora of respected organisations representing older people, mental health, disability and human rights organisations, as well as the Equality and Human Rights Commission, were saying that there was a real problem which needed to be addressed by primary legislation. There are powerful arguments for amending the Bill in line with the amendment. They have again been ably made by noble Lords and I do not need to go over them again.

I believe that my noble friend Lord Wills addressed key points raised by the noble and learned Lord, Lord Mackay, and other noble Lords—as far as I was able to follow as a non-lawyer—and indeed acknowledged that this was unfinished business on the part of the previous Government. We amended the Health and Social Care Act 2008 to address this issue in respect of residential care. What has changed dramatically since then is that well over two-thirds of home care services are now provided by the private and voluntary sectors and this Bill is likely to increase the proportion of contracted-out provision still further.

The Government’s view, expressed in Committee, that any further legislation would cause uncertainty in other areas outside health and social care is a strange one. In this light, the obvious counter-argument is that the 2008 Act has already opened the door and, in my view, that factor only strengthens the case for the loophole to be closed off. Analysis by key human rights lawyers, counsel for the Equality and Human Rights Commission, key charities and civil liberties organisations have all endorsed this approach and stressed that case law does not support the Government’s view. As we have heard only recently, the Joint Committee on Human Rights’ report on independent living again called for the current Bill to be amended to extend the public function definition to the provision of care at home. For me, that is the key point. All these organisations still argue strongly that there is a loophole that needs to be addressed.

Moreover, the Government’s argument, again in Committee, that the YL v Birmingham City Council judgment has not been challenged to demonstrate that home care services are not covered by the Act or existing legislation is also weak, in my view, and does not inspire confidence in what might happen in the future. My understanding is that the subject of the YL judgment was residential care and the scope of the 2008 Act is therefore limited to that.

I hope that the noble Earl will have good news for us that the Government have rethought this issue and recognise the very real problem and concern that exist for the future. I hope that he will accept this amendment. We all agree about the importance of taking a human rights approach to care provision, with dignity and respect for older people embedded. The current loophole in the provision of personal care in the home by third or voluntary sector providers is of deep concern to thousands of recipients of home care. We need to ensure that this key opportunity to achieve clarity in this matter in the current Bill is not missed.

[Earl Howe]

My Lords, we have heard many excellent speeches in this debate, not least from the noble Baroness, Lady Greengross. I know that the noble Baroness and all those supporting her are motivated by a determination to ensure that everyone who uses publicly funded health and social care services is protected from abuses of their human rights. I want to make it clear that I absolutely share that determination.

It is crucial that we ensure that vulnerable people are protected, no matter what age they are, no matter whether they have a disability, and no matter where they happen to live or where they happen to be at any given time. The requirement for people to have their human rights protected and respected is not negotiable. This is absolutely fundamental in a civilised and democratic society. The question we have before us today is how best to achieve that, and whether the proposed amendment would help or hinder us in doing so.

Amendment 292A is intended to provide certainty about the coverage of the Human Rights Act with respect to healthcare and home care providers. I understand the noble Baroness’s arguments for her amendment, and I completely agree about the importance of the Human Rights Act and the public sector equality duty. It may provide reassurance if I state clearly and unequivocally that the Government’s view is that all providers of publicly funded health and care services should indeed consider themselves bound by the Act and the duty. This is the position that we expect private and third sector providers to follow and the position that we would argue for if a case were to be brought; and we think there are good arguments with which a court would agree.

Of course, legislative provision is far from the only mechanism we have for ensuring protection for those using healthcare and domiciliary care services and for improving the quality of that care. In fact, we would argue that in order to ensure that users of those services are protected from the kinds of tragic abuses that the noble Baroness and others have spoken about so eloquently, we need to focus efforts on changing the culture and practice of services which provide poor care. We are working hard on several fronts to drive improvements in the way that people, including older people, experience health and social care services. We know that this is essential, and much of it predates the excellent EHRC report that resulted from the inquiry led by the noble Baroness, Lady Greengross.

To offer just a couple of examples of the work that we are doing to this end, we have made the Care Quality Commission responsible for assuring quality of care from April. The CQC will undertake a programme of inspections of 200 home care providers that will specifically look at supporting home care workers, the care and welfare of those receiving home care, and the involvement of people in planning and managing their own care. The new disclosure on barring service will replace the vetting and barring scheme in November this year and will make it easier for home care employers to check the suitability of their staff by providing a seamless service and introducing portable criminal record checks.

We know that legislation has a role, which is why we intend to put adult protection on a firm statutory basis for the first time ever by requiring local authorities to convene and manage local safeguarding adult boards, by legislating for their key roles and responsibilities, and by requiring them to be in touch with and accountable to local communities. We expect to see much better sharing of information and action that will help to drive up the safety and quality of services. The forthcoming White Paper on social care, which we intend to publish later this spring, will set out the broader strategic context not only on safeguarding adults but on improving quality in care services overall. The Government also intend to respond to the Law Commission report on adult social care law by creating a single statute for social care supported by statutory principles which place the well-being of individuals at the centre of the decisions made about people.

To return to the amendment itself, I am afraid that, despite the persuasive case put by the noble Baroness and others, I am not able to support it, and I hope that noble Lords will allow me to set out why. The problem is that while, on the face of it, this amendment simply provides helpful certainty about the coverage of the Human Rights Act with respect to health and homecare providers, in reality it has very serious and unhelpful implications for the wider interpretation of the Act. This may sound like a rather dry, legal argument, but it is an extremely important one with very practical consequences. By stating expressly that providers of healthcare and homecare services were covered by the Act, we would cast doubt on whether all the areas beyond health and social care were covered by it. However we framed it—whether we made it an avoidance of doubt provision or a deeming provision—we would weaken the applicability of the general test, suggesting that a narrow interpretation of the Act was appropriate and raising doubt about the Act’s applicability to all those bodies that had not been specified explicitly in the legislation.

We would also encounter the significant problem, referred to by my noble and learned friend Lord Mackay, of how to ensure that a specific provision of this type did not have the unintended consequence of making the situation less clear with respect to healthcare and homecare services. When noble Lords think of the wide range of services that fall under the banner of homecare services, I am sure they will appreciate the difficulty of drafting legislation that covers all relevant services and avoids any potential loopholes. My noble friend Lord Lester made a similar point. We can see how the proposed amendment, as drafted, makes the situation unclear. It is not clear how it applies to a person receiving care in the home of a family member—a point made by my noble and learned friend—or whether it applies to services provided under direct payment arrangements rather than being commissioned by a local authority or NHS body.

It is for those reasons that the Human Rights Act is quite deliberately designed to make broad provision that applies to all public bodies across the whole range of services. As my noble friend Lord Lester said, the Act is very carefully put together. Any amendment of the Act must be done by looking at it in the round, otherwise we risk destabilising its careful construction. That brings me to another point mentioned by my noble friend Lord Lester.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Wednesday 29th February 2012 Lords Chamber

[Baroness Wheeler]

My Lords, I would have liked to debate this amendment in the light of next week’s debate on the status, powers and functions of HealthWatch England under Clause 180, when we will fully air once again the serious and continuing concerns across the House about the proposed relationship between HealthWatch England and the CQC, and hear from the Minister how the Government intend to address these concerns as they flesh out their proposals for healthwatch, and as the CQC comes under closer scrutiny. However, we support this amendment requiring the Secretary of State to include HealthWatch England in the organisations specified in the Bill that he or she must keep under review. Obviously we do this in the context of the separate independence of HealthWatch and not as a committee of the CQC.

However, it is also important to make it clear that we do not think that the measure in itself, or combined with other government proposals, for example, on the HealthWatch board membership, will be anywhere near enough to provide the independence that HealthWatch England needs if it is to be the robust and trusted patients’ watchdog that is needed—and I emphasise trusted by the public.

The Minister must appreciate that the concerns across the House over the CQC’s relationship are not addressed by referring to the close synergies between the two organisations or to the powers and influence of the CQC rubbing off on HealthWatch. In this context it is difficult not to dwell on the recent developments in the commission and the Department of Health performance and capability review of the commission. I say this as a genuine supporter of the CQC and its work—for example, last year’s excellent special review of stroke services, and the one of residential care—but the department’s major findings that the CQC needs to be more strategic, that accountabilities within the CQC are unclear, as well as the strong concern over the blurring of boundaries between the CQC board and executive team, do not augur well for the future relationship between the CQC and HealthWatch.

Of course, we will come to these matters in detail when we have the full debate on HealthWatch and local healthwatch organisations. I hope that at that stage the Minister will address these ongoing concerns, particularly about the clash of cultures between HealthWatch and the CQC, about public faith and trust in HealthWatch if it is to be formally linked to the CQC, and the lack of confidence in the new arrangements on the part of the overwhelming number of LINks organisations and NALM. As the letter from NALM in the Guardian earlier this week underlined:

“Healthwatch will only be considered the true voice of the public, if it is seen to be independent of those it monitors”.

I look forward to next week’s debate.

[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.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Monday 27th February 2012 Lords Chamber

[Baroness Wheeler]

I am pleased to speak in support of the Government’s Amendments 56, 97 and 98, which take an important step along the route of making the Bill more explicit on the duties of the NHS Commissioning Board and clinical commissioning groups to promote patient involvement in decisions about an individual’s care and treatment. We particularly welcome the requirement for the board to publish guidance for CCGs on the patient involvement duty. We argued strongly for this in Committee. It will go some way to ensuring that CCGs are clear about what is required of them to meet the duty of involvement of each patient. We know that the evidence shows that many commissioners are currently unaware of the increasing evidence that involving individual patients in their care and treatment is proven to be more clinically effective, provides better patient experience and makes better use of healthcare resources. The guidance will enable strong signals to draw commissioners’ attention to the proven interventions that they require from their providers.

CCGs will need considerable help and support to bring about the changes we need, so clear and explicit guidance to them will be crucial. For individuals, participation must mean involvement in care planning and support for patients who manage their conditions. Sharing in the choice of treatment involves major cultural changes in the behaviour, approaches and attitudes of key professionals from across the specialisms. As we have stressed before, this means changing the way that patients and clinicians, in particular, relate to each other, and changing the way that the NHS relates to patients in terms of, for example, information provision, the organisation of clinics and the style of consultation that professionals have with patients.

Amendment 142 underlines the importance of the provision of information to patients and is supported by us. It includes the participation of the patient in monitoring systems that measure the impact of service delivery or the range of services available, and this is welcome. My noble friend Lord Harris has commented on Amendments 49A and 94A, and I endorse those comments.

In Committee, noble Lords strongly supported the call from patient organisations and other key stakeholders for a definition of patient and public involvement to be included in the Bill. The guidance to CCGs will need to address this issue. I hope that the Minister will also ensure that it focuses on ways in which patients will be genuinely engaged during the development of the commissioning plans rather than just consulted on plans after they have been drawn up. Guidance will help patients, carers and their representatives make informed decisions. This group of amendments form the basis for moving forward. We look forward to the Government also looking favourably on the subsequent amendments, which would also provide real impetus to the patient involvement agenda that we need.

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

My Lords, we have spent a good deal of time in debate on this Bill discussing the issue of patient involvement, and for good reason. Patients rightly expect to experience responsive health services where they are treated as individuals. It is central to the Government’s vision for the NHS for patients to become genuine partners in decisions about their health and treatment, with services designed around their needs. The Bill will lay the foundations to achieve that. So I understand completely the motivation behind my noble friend Lady Williams’s suggestions in Amendment 49A and 94A to place an additional duty on commissioning bodies when taking decisions to put the interests of patients above all other considerations, as far as resources allow. On the face of it, this sounds obvious, and I am deeply sympathetic to the principle. However, I think that I am going to have to seek to persuade my noble friend that it would be extremely hard to get this right.

--- Later in debate ---

[Baroness Wheeler]

My Lords, we strongly support the amendments in this group, which underline the importance of the NHS Commissioning Board and CCGs seeking advice from healthcare practitioners from across the patient care pathway, including local clinical specialists and allied health professionals, and going beyond professional input to seek advice from organisations with expertise in the experience of patients.

We hope that the Government will recognise the strong case put forward by the noble Baroness, Lady Finlay, and other speakers to these amendments for also recognising the expertise of patients’ organisations in the Bill and ensure that commissioners seek their advice as well as that of health professionals. By this we mean patients’ organisations not just being consulted but being genuinely involved in helping to co-design or co-produce services. Many patients’ organisations, such as the Stroke Association for example, are key providers of local services such as reablement or information, advice and support services to stroke survivors, carers and family members across the country. They have first-hand, direct experience of the issues that matter most to patients across the whole care pathway, hospital and community. Involvement of patient groups would also help the patient voice in the clinical senates and networks, which the noble Baroness, Lady Masham, also mentioned. To remind the Government, this approach was supported by the clinical workstream of the Future Forum, round one, but was overlooked in the Government's response. Now is a good opportunity to address this issue.

Amendment 65, tabled by the noble Lord, Lord Patel, and the noble Baroness, Lady Finlay, deals with information collected by the board on the safety of services provided by the health service being made available to healthcare providers, the Care Quality Commission and HealthWatch England, local authorities and professional organisations in healthcare. We fully support this, along with the caveat provided by Amendment 66 that the information should be freely available without charge. I hope that the Minister will accept the need to make progress on this important issue and reassure the House about the involvement of healthcare professionals and patient organisations in developing the commissioning plans.

[Earl Howe]

My Lords, this has been an interesting and worthwhile debate and I appreciate the concern that the noble Baroness, Lady Finlay, and other noble Lords have demonstrated throughout the Bill’s proceedings to ensure that the board and CCGs benefit from as wide a range of advice as possible. The Government have been clear that everyone with a role to play in securing the best possible services for local people should be able to do so. The NHS Future Forum recommended that we strengthen the legislative duties to help achieve this, which is why the duties on the board and CCGs to obtain appropriate advice were strengthened in another place to incorporate the wording used to define the comprehensive health service and to ensure that it was clear that such advice should come from persons who, taken together, have a broad range of professional expertise.

I mentioned clinical senates on the last group of amendments. Of course we envisage a role for clinical senates in the arrangements for how these duties are fulfilled, providing not just clinical but multidisciplinary advice from professionals from public health and social care alongside patient and public representation and other groups as appropriate. The noble Baroness, Lady Masham, asked me specifically about clinical senates. They will be established as strategic advisory bodies, with a clear focus on quality improvement and improving outcomes. They will bring together clinicians with strong clinical credibility, drawn from across the disciplines, as I have mentioned. They will include patients and members of the public as well. They will have a role, too, in advancing public understanding of health and healthcare.

Why do we need clinical senates? Commissioning is at its best when it is a collaboration of professionals, based on a shared drive for continuous quality improvement. Maximum participation will be key here. The Future Forum report showed:

“There was universal agreement that people would be”,

better served if their,

“care were designed around their needs and based on the input of the public, patients and carers, health and social care professionals”,

the voluntary sector, “and specialist societies”. The exact detail of who will be part of the clinical senates, the number that will exist and the roles that they may have are all to be determined through a process of discussion and engagement, but I hope that I have outlined, at least in broad terms, what they will be there to do.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Monday 27th February 2012 Lords Chamber

[Baroness Wheeler]

My Lords, we had a long debate on this very important issue of the duty of candour before the Recess, and I do not intend to take up very much of the House’s time on this amendment by responding to the issues that we covered then, or by repeating our views on why we are concerned that the Government’s current proposal for a contractual duty will not address the need for the huge cultural change in the NHS that has to take place in order to ensure openness and honesty when things go wrong in the care and treatment of patients.

Nevertheless, I hope that the Minister will accept the case for regulations on including the duty of candour in commissioning contracts. We on these Benches emphasise our commitment to trying to help to make the contractual duty work. I therefore place it on record that we welcome the Minister’s reassurance during the previous debate that he will come back to the House on the outcome and actions resulting from the current government consultation on the contractual duty. I also hope that he will be magnanimous in the victory that he had before the Recess in the vote rejecting statutory requirement by standing by his assurances on a future review of the effectiveness of the contractual duty, after an appropriate period, and whether its effectiveness is being held back by the lack of statutory provision. My third hope is that the NHS Commissioning Board will issue clear and strong guidance to assist CCGs in this matter, and I look forward to the Minister’s response.

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

My Lords, this has been another very good debate on the duty of candour. As we have discussed previously, the Government’s position is that the NHS contracts are the most appropriate mechanism through which to implement a further requirement for openness. Amendment 38A proposes that the contractual duty of candour should be given a specific reference in primary legislation. I hope that I can satisfy the House on this and that the undertakings I am about to give the noble Baroness from this Dispatch Box will reassure her sufficiently to enable her to withdraw the amendment.

I give an assurance to the House that the Government propose to use the provisions in Clause 19 relating to the standing rules to specify that the contractual duty of candour must be included in the NHS standard contract, developed by the NHS Commissioning Board. If that assurance is accepted, as I hope it will be, a specific reference is not required to ensure that a contractual duty of candour is imposed. The question, therefore, is whether, despite my assurance, it is necessary or appropriate to include a provision in Clause 19. I have given this proposal substantial thought, and I admit that it is one which on the surface has some appeal. I have spent a good deal of time discussing the matter with noble Lords as well as with Professor Sir Bruce Keogh, the NHS Medical Director.

Let me explain where my deliberations have taken me. At present there is a very wide range of issues that we incorporate into the standard contract. These include issues of paramount importance to the quality and safety of healthcare. For example, the contract is used as one of the mechanisms that we are using to drive improvements in prevention of venous thromboembolism, or VTE. It has been estimated that every year 25,000 people in England die from VTE that they have contracted in hospital. We also use the standard contract for driving improvements in cancer treatments and referrals in healthcare-associated infections in issues such as consent and many other areas.

As the Bill stands, it does not contain a list of the requirements which are to be included in the standard contracts, and for good reason. The Bill should not contain unnecessary detail. On top of that—and I think that this is perhaps a more important point—there should be sufficient flexibility for the Secretary of State and the board to consider and draft appropriate terms and conditions and adapt them to changing circumstances.

The question I pose to myself is this: if, through a reference to the duty of candour, we are to start down the road of specifying particular quality and safety contractual requirements in the Bill, then where do we stop? Just including the few issues that I have briefly mentioned, without any others, means that we will almost certainly land up with a cumbersome and unwieldy list. There are many other areas besides those which some might see as having a similarly valid claim to be mentioned. We should not use primary legislation to cherry-pick priorities to the detriment of other equally important areas.

We have further concerns about precisely what the amendment would require the Secretary of State to provide in the standing rules. We are still looking at what the appropriate contractual term should be in the light of the recent consultation that was mentioned. Imposing a duty in the Bill to adopt a specific formulation, as the amendment would have us do, constrains our ability to take proper account of the consultation and the engagement that we have had with stakeholders—it risks forcing us to implement an inappropriate requirement—and from easily improving it in the future, if the evidence supports that.

I was struck by the very powerful speech of my noble friend Lord Faulks during our last debate on this topic, and indeed by his words today, when he challenged the House to consider the difficulties involved in drafting a duty which adequately encapsulates these obligations. The noble Lord, Lord Winston, was very wise in what he said. For example, how would we specify the types of incidents to which any contractual requirement would apply? The contractual duty and provision in the regulations must be neither too wide nor too narrow in order to be effective and proportionate. We need the flexibility to consider this in more detail.

The noble Baroness’s amendment would have us require particular steps to be taken in particular defined circumstances and adopt a particular definition of the incidents to be covered by the duty of candour. I am extremely uncomfortable with that. Apart from anything else, we specifically asked this question in the public consultation, so we would be undermining that process if we were not properly to consider the responses we received. I really think, therefore, that it would be better to let that consultation guide us as to the precise way in which the duty should be framed. It is for those reasons that, after considerable thought, I can tell the noble Baroness that I do not think it would be wise for us to accept Amendment 38A.

The noble Lord, Lord Walton, asked about the duty placed on individual doctors within a trust. Doctors are expected to follow the code of practice laid down by the GMC, as he will know, and failure to do so may lead to action against a doctor by the regulator in the exercise of its statutory powers. I can confirm to the noble Lord that the code is not just words; it is backed up by real regulatory force. Indeed, I have the wording of the code in front of me:

“If a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects”.

There are similar provisions in the Nursing and Midwifery Council code as well.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Monday 13th February 2012 Lords Chamber

[Baroness Wheeler]

My Lords, on behalf of these Benches, I would like to support Amendment 17 in the name of the noble Baroness, Lady Masham, to which I have added my name. As we did in Committee, we have again had an excellent debate, which I believe has gone a long way towards addressing the concerns expressed by some noble Lords during Committee and during this debate about making the duty of candour statutory, as well as demonstrating why the Government’s approach of relying solely on a contractual duty will not work or lead to the sea change in culture in the NHS that is needed to ensure openness and honesty when things go wrong in the care and treatment of patients.

The case for the introduction of a statutory duty has been forcefully made by the proposers and supporters of the amendment, and I shall not go over the issues again in detail. The amendment from Committee has now been substantially redrafted to ensure that there is no duplication or clash with the professional regulation and that the duty of candour applies only to actual patient-safety incidents, as already defined in statute. Thus we would no longer face the problem of how to define whether or not an incident is serious or harmful or whether it could lead to potential harm in future, a consequence feared by some noble Lords and by the Minister in his response to the Committee debate. Instead, our amendment would amend the current Care Quality Commission (Registration) Regulations by drawing on the actual text used in those regulations, requiring patient safety incidents which cause harm to patients to be notified to the CQC. The effect would be to place a statutory duty on any organisation registering with the CQC to,

“take all reasonable steps to ensure”,

openness with patients when things go wrong and cause harm. The definitions of harm and the organisations to which the duty would apply are exactly the same as those currently used to require notification of incidents to the CQC.

The Government's main arguments against statutory duty of candour are threefold: first, that implementing the contractual duty would suffice, and bring the responsibility for requiring openness closer to patients and with clinician-led commissioners; secondly, that the current consultation exercise on the contractual duty has only just closed and the Government need to analyse the responses—not much of an argument when the Government ruled out introducing the statutory duty in that consultation; and, thirdly, that existing provisions including the professional codes of practice, National Patient Safety Agency policy guidance and the requirements of the NHS constitution, with the new contractual duty, will address the problem.

However, as noble Lords have said, existing provisions exhorting NHS organisations to openness and health professions to openness and disclosure are not changing the culture of denial, obfuscation and blame that is so deeply embedded in many parts of the NHS when things go wrong. The instances of serious failure in care and treatment that have led to the campaign by patients’ organisations are, as we have heard, deeply shocking and tragic. Expecting CCGs to have the strength and will to take on powerful providers that have failed to be open and to enforce remedial measures without the support of a statutory authority will not achieve the changes we need.

On the role of the CQC, noble Lords have more than answered the Government's reservations. It is an appropriate role for the regulator and the new duty of candour would not require detailed monitoring of individual incidents or communications with patients, but could be reinforced by the CQC by using its guidance already in existence and setting it alongside all the other essential standards of quality and safety which have statutory force. I hope the Minister will reconsider his position and accept in principle that the duty of candour should be statutory, and incorporated into the Bill.

We of course recognise that there would need to be considerable work and consultation undertaken with all stakeholders to introduce and implement the statutory duty of candour. The work around implementing the contractual duty could be put to good use in this effect, as it would complement the statutory duty. Moreover, putting the principle into the Bill and working out later how it is to be implemented has been a central feature of most of the Bill's provisions, so it can be applied in this case. Tuesday’s letter in the Daily Telegraph from all the leading patient organisations emphasised that the introduction of a statutory duty of candour,

“would be a historic step forward for patients’ safety and rights”.

On these Benches we endorse this, and I hope that the Minister will now reconsider his position and accept this amendment.

[Earl Howe]

My Lords, this has been an excellent debate and I would like first to pay tribute to the noble Baroness, Lady Masham, for her tireless advocacy of the need for openness and transparency in the NHS. She spoke very powerfully. What struck me from the debate is the consensus that there seems to be on all sides of the House on three key points. First, there is agreement on the importance of openness and candour in healthcare, and I think we would all accept that the NHS could only call itself a world-class health service if it embraced openness wholeheartedly. Secondly, there is agreement that at present there is significant room for improvement, the story of my noble friend Lady Hussein-Ece being a case in point. While areas of the NHS, such as Barnet and Chase Farm, are already providing exactly the transparency we wish to see, that is not by any means universal. Thirdly, there is agreement that something needs to change.

I, too, am in complete agreement with those points. I agree that we must do all that we can to encourage the development of a culture within the NHS that supports people to disclose where errors have occurred, so I am at one with the noble Baroness in her intention in tabling her amendment. The question before us is not whether we should do something but what we should do. We need to ensure that the route that we choose gives that good intention the best chance of succeeding. I note from today’s debate that opinion has not been all one way.

Health: Stroke Care

Debate between Earl Howe and Baroness Wheeler

Monday 13th February 2012 Lords Chamber

[Earl Howe]

My noble friend is right: individual health budgets have enormous potential in the case of stroke patients. I do not have any specific data on that in my brief, as it is still relatively early days for the personal health budgets. However, if I have further information to give her, I will gladly write.

[Baroness Wheeler]

My Lords, the CQC report highlighted huge problems for stroke patients in consistency of care and support after hospital discharge and for long-term stroke survivors in the community. Early supported discharge from hospital involves the majority of rehabilitation taking place at home and is therefore geared to the home setting, yet it is available in only 37 per cent of PCT areas. This is such an important area for progress and obviously a key way of refocusing resources into the community. How will the Minister ensure that this situation is addressed now and under the new health structures? Can he confirm to me that the CQC will continue to monitor the progress of the national stroke strategy and produce further special reviews, given that I understand the team which delivered this last report has now been disbanded?

[Earl Howe]

My Lords, the unwarranted variations in services are quite clearly unacceptable. The value of the CQC report is that it shines a spotlight on where variations in care need to be addressed. We believe that that will help all stakeholders involved in improving opportunities for people who have experienced a stroke. As regards post-hospital care, on which the noble Baroness rightly focuses, the accelerating stroke improvement programme, which is quite new, is already doing very good work. It was developed specifically to improve care in areas where progress needs to be faster, and that work will most certainly continue.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Wednesday 21st December 2011 Lords Chamber

[Baroness Wheeler]

My Lords, I broadly welcome these provisions, which deal with the new Health and Social Care Information Centre and put the existing special health authority on a statutory footing. The centre was established in 2005 by the Labour Government to improve information quality, data standards and access to information, to deliver the information required by front-line services and to support commissioning and clinical audit. The centre has had a large measure of success since its establishment, particularly in developing bedrock quality-improvement initiatives in the NHS—for example, indicators for quality improvement and patient-reported outcomes measures. NHS clinical teams have access to more than 200 indicators that are generally accepted as effective measures of high-quality care.

However, while welcoming the broad intent and purpose of this Section, I note that the provisions increase the directions given to the information centre about when it should and should not publish data and how data should be used. It is clear in this context that there are serious concerns that the Government needs to address among noble Lords, patients and doctors' organisations about patient confidentiality, and about whether the Government's proposals go far enough to protect patient data. These concerns were also voiced in response to the Government's statement on UK life sciences industries in the House on 6 December, in which they announced their intention to share much more patient information with the private and independent sectors in anonymised form to aid medical research and development. As we know, under that initiative from December onwards data regarding 250,000 patients will be released online.

I hope that the Minister will recognise these concerns and the need for what the chief executive of Cancer Research UK called,

“strict safeguards that instil public confidence”.

Clause 256 details when information should and should not be published by the information centre, and in particular that it should not publish data that could reveal a person's identity. Amendment 348B, tabled by the noble Lord, Lord Walton, would be the ultimate safeguard, but we recognise the need to find a way through that addresses concerns that doctor and GP-patient confidentiality could be harmed and provides safeguards that are strong enough to protect patients. It is certainly worth acknowledging that, if we are able to get the confidentiality issues right, the UK has a huge opportunity to lead the world in health research.

We support Amendment 348A, tabled by my noble friend Lord Kennedy and other noble Lords. It would create an additional duty that would allow the information centre to request the information required to conduct clinical audits. This requirement would make it explicit that the centre can collect information from organisations identified in the Bill as required to undertake national clinical audits, thereby strengthening its current role of collating such information into a duty to collect clinical audit data from a variety of providers. We welcome this.

Finally, in the debate on the UK life sciences industry Statement, my noble friend Lady Thornton underlined the difficulties with using anonymised data and sought reassurances from the Minister on how confidential patient data will be handled, stored and processed. I think it is right that the Minister repeats those assurances in the context of the provisions in the Bill for the information standards and the centre, and I will be grateful if he will do so.

[Earl Howe]

My Lords, the provisions in Chapter 2 of Part 9 will enable the information centre to become a focal point for health and social care information, linking data together, publishing them anonymously and helping to make information more accessible. I note what the noble Baroness, Lady Wheeler, had to say on Amendment 348, which we dealt with in the previous group of amendments, but I am grateful to her for her comments.

Amendment 348A seeks to provide a specific power in the Bill for the information centre to be able to require information needed for national clinical audits. Clinical audit is an essential mechanism for improving the quality of care patients receive. However, we do not believe that the amendment is necessary. We have mandated participation in national clinical audits within the National Clinical Audit and Patient Outcomes Programme through the NHS standard contract for acute services. This is reinforced in the operating framework for the NHS in England for 2012-13. In addition, there are already sufficient powers in the Bill for the information centre to be able to require information, where appropriate.

Amendment 348B seeks to prevent the information centre being able to collect information that identifies an individual. I am the first to recognise what a sensitive topic this is. Although my noble friend Lady Williams is not in her place, I hope she will allow me to address the question that she put to me earlier on in this connection.

Patients as a whole expect information about their care to flow between the professionals providing their health and social care to ensure that care is safe and effective as well as for other purposes, such as protecting the health of the general public. For example, PCTs currently use information, including patient-identifiable information, for commissioning. Some national clinical audits, such as the National Joint Registry, use patient-identifiable information to improve the quality and safety of patient care.

The noble Baroness, Lady Finlay, asked some extremely important questions about the functions of the information centre. The Bill sets out clear provisions controlling how the information centre can publish information. It would publish aggregated information, which is anonymised, and no information that identifies or could identify individual patients would be disclosed by the information centre, other than by dissemination or pursuant to further legal authority. Since its inception, the information centre has introduced strong security controls, published and implemented security policies and published information about its processing as required for compliance with the Department of Health’s information governance framework. It must at all times comply with the Human Rights Act, the Data Protection Act and any other applicable law. The centre would collect identifiable information within a secure environment but, as I have stressed, it would publish it only in anonymised form. This approach has been strongly recommended by several recent reviews, including the 2008 data-sharing review authored by the then Information Commissioner Richard Thomas and Mark Walport from the Wellcome Trust. That recommendation was reiterated in the Academy of Medical Sciences’ review published in January this year.

I agree with the noble Baroness that it is very important to protect identifiable information appropriately. However, as I hope she will accept, it is also critical that we are able to realise the enormous benefits of securely collecting and linking such information and publishing it in a de-identified form, as we intend the information centre should do. This will help professionals and the public better understand the quality and efficiency of services, enhance accountability, help enable people to exercise choice about the services they use and improve those services. In addition, I would like to highlight the safeguard in Clause 256(2)(b), which prohibits the centre from publishing any information it has collected which identifies or could identify an individual.

As I have said, while we do not believe that this amendment is appropriate, we recognise that there have been some concerns around ensuring that confidential information is appropriately protected. We have had, and continue to have, productive discussions with the BMA on this issue and we plan to bring forward amendments on Report that deal with confidential information in a way that balances patient confidentiality with the need effectively to share information across the system. I hope that those assurances will satisfy the noble Baroness.

Amendment 348C would require the appointment of a chair to the National Information Governance Committee, who would report to the Information Commissioner. The purpose of this committee would be to provide advice and assistance to the CQC in discharging its function to monitor information processing practice of health and social care bodies registered by the CQC from April 2013. The National Information Governance Committee is an advisory committee of the CQC, so it would not be appropriate for the chair of the committee to be accountable to an external body, such as the Information Commissioner. In addition, a reporting arrangement of that kind would be inconsistent with the Information Commissioner’s role as the independent and impartial authority responsible for promoting and enforcing the provisions of the Data Protection Act, the Freedom of Information Act and other legislation.

However, I would like to reassure the noble Baroness that the CQC can involve the Information Commissioner where appropriate and close collaboration between the Information Commissioner and the CQC will be important to support relevant organisations fully to comply with the requirements. I hope that those assurances will enable the noble Baroness to feel able comfortably not to press her amendment.

The noble Baroness asked about the Ethics and Confidentiality Committee of the NIGB, which provides essential support for research and other activities by advising the Secretary of State on whether to approve proposals to process confidential information without the need for patient consent, pursuant to the Health Service (Control of Patient Information) Regulations 2002 under Section 251 of the National Health Service Act 2006. We intend that the approval function will in future move to the following bodies: first, a new health research regulator, the HRA, for research approvals; secondly, the NHS Commissioning Board for service management approvals; and, thirdly, the Secretary of State for public health and social care approvals. Each of those bodies will need to put in place arrangements to secure the advice that they need to exercise their approval functions effectively. These arrangements are still being discussed but it seems likely that a body like the Ethics and Confidentiality Committee will continue to be required and officials are discussing future options with the NIGB. I hope that those comments are informative to noble Lords and that they will not press their amendments.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Wednesday 30th November 2011 Lords Chamber

[Baroness Wheeler]

My Lords, I am pleased to speak in support of Amendment 150B from my noble friend Lady Bakewell, requiring the annual report of the NHS Commissioning Board to include an assessment of how effectively it meets the needs of the older population. We know that nearly two-thirds of NHS patients receiving consultant-led care and 60 per cent of people admitted to hospital are aged 65 and over, so it is highly appropriate that this requirement be added in the Bill to the specific items that the board must report on to Parliament and the Secretary of State.

Under the umbrella of this amendment on the needs of older people, I would like reassurances from the Government on how they intend to improve commissioning for essential community and prevention services for older people. It is widely recognised that these are currently undercommissioned, specifically falls prevention, audiology and continence. In terms of community services, I stress the inclusion of older people in residential care. Age UK research shows that nearly 400,000 people living in care homes currently face real difficulty in accessing GP and primary care services.

We know that undercommissioning of community and prevention services is widespread and that the healthcare system needs to be much more effective in commissioning primary health and preventive services. For example, Age UK estimates that falls prevention services could save the NHS £2.3 billion per year in preventing hip fractures alone. Falls represent the most frequent and serious type of accident in the over-65s and are a serious cause of morbidity and mortality. A recent national clinical audit to investigate the organisation of services for patients who have fallen and fractured their hip, wrist, arm, pelvis or spine showed how variable commissioning of falls services is, rarely providing a co-ordinated falls and fractures strategy. Few GPs assess the risk of falling among older patients, and arrangements in hospitals for case finding and secondary prevention are inadequate. Half of all patients suffering a hip fracture never regain their former level of function and mobility. How is this situation to be addressed in future commissioning arrangements?

On hearing, the estimates are that up to 6 million people in the UK would benefit from a hearing aid but that only 2 million have one. Waiting times for hearing aids continue to be a major problem. In some areas people can wait up to one to two years between their GP referral and having their first hearing aid fitted or for a digital upgrade of their hearing aid. Audiology is excluded from the general 18-week NHS waiting time target. How will the current shortcomings in commissioning for audiology services be addressed?

Finally, effective and dignified continence care for older people is an essential service, particularly for those whose long-term conditions, such as cancer, stroke, spinal cord injury, spina bifida, Parkinson’s and other neurological conditions, require continence management to be integrated into their care and treatment pathways. Commissioning for managing these conditions in the home, in residential care and in hospitals, and for general continence services, requires specialist knowledge and understanding of the different needs of continence care in primary and secondary care settings. The system is so often geared towards containment through pads and catheters rather than assessments or treatments of incontinence, or recognition, for example, that patients in hospital using catheters or other products over a short term will need reassessment and probably different products and support to cope with day-to-day life at home or in residential care. As a trustee of our local carers’ support organisation in Elmbridge, I know that effective support for carers who are managing a person’s continence issues can often make the difference between whether that person can be supported and cared for at home or has to go into residential care. Is the Minister confident that clinical commissioning consortia will have the expertise and the will to prioritise much-needed improvements in effective continence care?

My noble friend Lady Bakewell’s separate amendment calls for a commissioner for older people, and I hope the Minister will take this away and give the proposal serious consideration. In particular, we need to see what we can learn from similar posts in Wales and Northern Ireland, and the observations of the noble Baroness, Lady Finlay, are very helpful on this. The intention behind the proposal is to provide a cross-government overview and strategy on the needs of older people. It is why my own party has appointed a shadow Minister for care of older people. We also know that making progress on improving NHS care and treatment of older people, addressing the future funding of social care through Dilnot and other key measures all require champions and leadership at the highest level of government, and I look forward to the Minister’s—we hope sympathetic—response.

[Earl Howe]

My Lords, let me begin by saying that I am sympathetic to these amendments, moved with customary persuasiveness by the noble Baroness, Lady Bakewell. I completely understand what has prompted them. The improvement of services for older people is vitally important and I can reassure the noble Baroness that this will continue to be a priority for the Government.

I have written to the noble Baroness following the debate in Committee on 7 November on her Amendment 18B, explaining how the NHS outcomes framework will hold the NHS to account for improving the effectiveness of care for older people. It will act as a catalyst for driving quality improvement and outcome measurement throughout the NHS by encouraging a change in culture and in behaviour, including a renewed focus on tackling inequalities in outcomes. There may well also be specific objectives in the Secretary of State’s mandate to the board in relation to services to be provided to older people.

Now, the real question posed by the noble Baroness’s amendments is how can we improve older people’s care and how can we ensure that services are joined up? The UK Advisory Forum on Ageing, co-chaired by my honourable friend the Minister of State for Care Services, Paul Burstow, and the Minister of State for Pensions, Steve Webb, already provides advice across government on the additional steps that the Government and their partners need to take to improve well-being and independence in later life. We already have a champion for older people’s health, and that is Professor David Oliver, the national clinical director for older people. In order to ensure quality outcomes for older people during the transition to the board and CCGs, Professor Oliver and relevant bodies and partners will function as a motor for change to encourage best practice locally and to promote the messages around QIPP—Quality, Innovation, Productivity and Prevention —and long-term conditions.

Professor Oliver’s overall remit is to promote better care of older people across the NHS and social services, and to provide clinical leadership for cross-government work on older people. He is doing good work. Nor, as I say, is he working in isolation. Regular meetings take place between officials, Professor Oliver and organisations including Age UK and WRVS. Recent examples of co-operation include Age UK’s active participation in reference groups chaired by the national clinical director and the director of social care leadership and performance on the draft social care and public health outcomes frameworks.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Monday 28th November 2011 Lords Chamber

[Baroness Wheeler]

My Lords, I am pleased to support the spirit, intention and thrust of all the amendments in this very large and, I hope, uncontroversial group, which are intended to ensure that provisions in the Bill to involve the public, patients, carers and specialist professionals and patient groups in the development and decisions about services, care and treatment are reinforced and strengthened. We recognise that the duties proposed by the Government for the NHS Commissioning Board and clinical commissioning groups—to promote the involvement of each patient and to enable patients to make choices on the services provided to them and obtain advice from specialist professionals—are a significant step forward from the original provisions in the Bill. They build on the foundation work on this issue undertaken by my own Government. However, it is clear from this excellent debate that these general duties do not go far enough to mark the significant step change that we need in getting genuine shared decision-making and participation of patients, carers, and patient groups in decisions about care and treatment, and on how services are planned and developed.

We also now have the added complexity of the reorganisation itself. Senates, networks and health and well-being boards are acting as the system integrators, all alongside our newly enlarged CCGs with their giant private sector support organisations behind them, as we now know from the Government’s recently issued draft guidance on commissioning which was referred to in the previous debate by the noble Baroness, Lady Williams. This will be a highly complex raft of interactions and interconnections with no notable route to accountability. I would be grateful if the Minister could give me some insight into how he envisages the voice of patients being heard among all the clamour and shouting that will go on between these different spheres of interest.

We must try to achieve real involvement. For individuals, that means involvement in care planning and support for patients with their carers, relatives and support groups to manage their conditions and share in the choice of treatment. On collective involvement, this means that knowledgeable patients’ groups should be able to advise commissioners on how to design services, rather than to have token consultation after decisions have already been made, which is the case now in so many situations. We must make sure that we harness fully the collective experience and knowledge of patients and specialist care organisations.

We recognise that this will involve a major cultural change in the behaviours, approaches and attitudes of key professionals from across the specialisms, moving away from seeing patients as units of disease, not as people with rights to information and to participation in discussions and decisions about their care and treatment, as the Health Foundation puts it. We need to change the way that patients and clinicians, in particular, relate to each other, and change the way that the NHS relates to patients in terms of, for example, information provision and the organisation of clinics, and in the style of consultations that professionals have with patients.

In respect of the NHS Commissioning Board, we support Amendment 121, which calls for the board to have the duty to secure rather than promote the involvement of patients, carers and their representatives in decisions about the provision of health services. This is important, and Amendment 150C—which seeks to ensure that the board’s annual report includes accounting for how it has carried out its duties in involvement, choice and advice—complements and underlines the importance of this duty.

Amendments 125 and 126, tabled by my noble friends Lord Warner, Lady Thornton, and Lord Patel, turn the focus on clinical commissioning groups and call for a published guidance to CCGs to ensure that they are clear about what is required of them to meet the duty to promote the involvement of each patient. I also pay tribute to the work of National Voices on the principles of integrated care and on other patient and involvement issues relating to these matters.

We know that many commissioners, both nationally and in CCGs, are unaware of the increasing evidence that involving individual patients in their care and treatment is proven to be more clinically effective, provides better patient experience and makes much better use of healthcare resources. In other words, it is the vital underpinning for the Nicholson challenge and for commissioners’ other duties to improve quality. A far stronger signal is needed in the Bill and in statutory guidance to draw commissioners’ attention to the proven interventions that they require from their providers. I would be grateful to hear from the Minister how he intends to do this.

Clearly, many CCGs will not make the changes that we need without help and support. Amendment 125 is therefore crucial, as it calls on the NHS Commissioning Board to draw up guidance to CCGs which will enable patients, carers and their representatives to make informed decisions. This includes patients having the means to express their views on the quality of services provided, opportunities to consult with service providers, access to appropriate information about their care and treatment, opportunities to consider available treatment options and their risks and benefits, and to participate in decisions about their care and treatment and its managers. The information they receive about these areas must be simple and well presented—not league tables or comparison charts, but clear information about treatment options, how effective they are and what the consequences might be for the patient. As other amendments underline, these rights of patients must be accessible to all patients.

Amendment 126 stresses how important it is to have information on access and location and about the providers of health services and performance if informed decision-making is to become a reality for the majority of patients. We fully support Amendments 127A and 197A, which would give expert patients’ organisations equal status to professionals in providing advice to commissioners. This would help ensure a patient voice in the clinical senates and networks. It is an approach that was supported by the clinical work stream of the Future Forum but overlooked in the Government’s response. We also strongly support Amendments 175A and 175B from the noble Baroness, Lady Finlay, which calls for regulations providing for the governing bodies of CCGs to include individuals who are fully aware of the different aspects of specialist provision in the areas covered by CCGs.

Amendments 140 and 142, tabled by my noble friends Lady Thornton and Lord Hunt, require the Commissioning Board to ensure that patients are involved and consulted in the development and planning of commissioning and in the consideration of how proposals for change in health services are organised and delivered. Most importantly, Amendment 205 secures the involvement of the local healthwatch in these decisions, vital if HealthWatch is to be able to fulfil its key watchdog and patients role. The importance of this role was ably underlined by my noble friend Lord Harris, so I will not expand further on it.

On patient choice, we support Amendment 127, which proposes a definition of patient choice. Research shows that patients care most about being able to exercise choice about the care and treatment they receive, but currently the NHS performs poorly in involving patients in this way. A full definition of patient choice should be included in the Bill to ensure that commissioners provide opportunities for patients to exercise choices that go beyond the choice of provider. Does the Minister accept the need for this definition in the Bill, and if not, how will he seek to achieve the cultural change in systems and attitudes that we all want to see?

All these amendments seek to ensure that the NHS Commissioning Board and CCGs understand fully their responsibility, and that they commission for involvement. These changes would give a clear signal to the system that the Government mean business in wanting meaningful patient participation and involvement, and that real change can be achieved.

[Earl Howe]

My Lords, this large group of amendments all relate to the different ways in which patients, the public and others will be involved in decision-making, and although I shall be suggesting that noble Lords should not press them, I am very much in listening mode on the themes that they raise. The only thing that I cannot promise to take forward is the suggestion of the noble Baroness, Lady Masham, that I should introduce an amendment on the death penalty, but, no doubt, she can persuade me.

The issues that noble Lords have covered are central to our vision of informed and empowered patients, and responsive commissioning that is clinically led. These are also issues that were considered in great depth as part of the listening exercise, in response to which significant improvements were made. Those improvements created much stronger duties than currently apply to primary care trusts, so it is important to begin by recognising how this Bill takes us forward from the current position. Nevertheless, I recognise that some confusion remains about what we mean when we talk about involvement, and what the different duties in the Bill are intended to achieve. The noble Lord, Lord Warner, has tried to frame an all-embracing definition of involvement through Amendment 125, and I find little to criticise as regards the purpose and intent of that amendment. However, I would argue that much of what the noble Lord intends through this amendment is already provided for in the Bill. Indeed, it is because there can be different elements to involvement that would be appropriate in different situations that I would be cautious about trying to wrap them up in a single definition.

It will be helpful to begin by considering the duties on the board and clinical commissioning groups to involve patients in decisions about their own healthcare. The noble Lord, Lord Harris, made some useful distinctions on this point. These new duties reflect our vision of shared decision-making, referred to by the noble Baroness, Lady Finlay—“no decision about me without me”, and an NHS where patients are involved fully in decisions about their care in partnership with clinicians. This is primarily about the relationship between the individual patient and their clinician; it does not extend to commissioning decisions. Therefore, I do not think that it would be appropriate for HealthWatch or indeed any other body to have a role in what are meant to be sometimes very personal decisions.

There is clearly a role for CCGs as commissioners, as distinct from the role of general practitioners, in supporting and encouraging this personal involvement. However, it is not completely within their control, so I do not think that it can be for them to secure, as the amendment proposes. Nor do I think that there should be any sort of hierarchy, where the board is in the lead with a weaker duty on CCGs. That would run counter to what we are trying to achieve, which is after all a more personalised service. Therefore, I am afraid that I cannot agree with Amendments 121, 123, 124A, 191 and 192. However, such a service might include giving patients greater control over their medical records, as Amendment 124 suggests. The noble Lord, Lord Patel, may know that this was a key theme of our consultation on an information revolution. Responses to that consultation showed a clear desire to enable people to be more in control of their care, supported by greater access to the information held about them in their care records. We are committed to this and our forthcoming information strategy will set out how we propose to achieve it.

These duties are of course closely linked to those relating to enabling choice. As noble Lords will be aware, patient entitlements to choice are set out in the NHS constitution. These are underpinned by directions by the Secretary of State, which will in future be the standing rules and regulations under Clause 17 which we have already discussed.

I reassure noble Lords that, as now, the role for commissioning bodies in respect of enabling choice in the future will include acting with a view to making people aware of their rights and entitlements, giving them the information that they need to make informed decisions and working with providers to ensure that these are delivered. I did, however, listen with considerable care and sympathy to the noble Lord, Lord Neill, regarding patients who need advocates to speak on their behalf. This will be further reinforced by the new duty that the board and clinical commissioning groups will be under in relation to promoting the NHS constitution among both patients and staff. The board will set the choice offer, establishing the parameters for choice and competition, based on the choice mandate that the Secretary of State will set as part of the annual mandate to the board. I remind the Committee that we recently sought views on these issues through the consultation, Liberating the NHS: Greater Choice and Control. This is an important approach because it allows the Secretary of State and the board to manage the rollout of choice in a controlled way—something that I know many noble Lords are anxious to ensure. That is why we have deliberately used broad terms in describing the types of choice that patients can exercise. Indeed, I think that defining them in more detail, as some of the amendments attempt to do, could paradoxically limit their scope. They could also be unsuitable or indeed unfeasible in particular circumstances, and that is why, although I am in sympathy with the spirit behind them, I am unable to agree with Amendments 126, 127, 193, 196, 197 or 197ZA.

Greater choice means, among other things, patients being able to choose between a greater range of providers. Amendments 125A, 125B, 195A and 195B are particularly concerned with the impact that greater choice and provider plurality might have on the viability of existing services—a matter that we discussed at our last session in relation to amendments tabled by noble Lords opposite about the interdependency of services. That is an issue that I completely understand. In securing healthcare services to meet the needs of their patients and populations, commissioners must have regard to the stability and financial viability of those services, including taking account of the interlinkages between services, where relevant, on an ongoing basis. Commissioners will need to commission high-quality integrated care that will deliver value for money for local communities and promote opportunities for patients to exercise choices in relation to their care. In taking commissioning decisions, they will have to consider what the noble Baroness, Lady Pitkeathley, reminded us of—that is, what will be in the best interests of their patients. This would always be their primary concern, and we would expect the board to ensure sufficient competency over these issues in authorising CCGs to take on their new responsibilities and in holding them to account for doing the job.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Wednesday 9th November 2011 Lords Chamber

[Earl Howe]

My Lords, we value the pay review bodies, and there are no plans to disturb them at the moment. I sought to indicate that we continue to look at how pay arrangements are best structured. The pay review bodies do an extremely valuable job at present, as they have done for many years.

[Baroness Wheeler]

My Lords, I thank the Minister and other noble Lords who contributed to the debate, particularly my noble friend Lord MacKenzie for his reminder to us of the history of the establishment of the pay review bodies and the contribution that they have made, particularly to improving pay and industrial relations in the NHS.

I also thank my noble friend Lord Rooker for a number of comments that he made in support of the amendment, particularly the point that he made about operating the same job in a nearby locality for different pay and conditions, which would be likely to cause serious detriment to industrial relations. We are very concerned about that.

I deeply disagree with the noble Baroness, Lady Murphy. This is not a pedalling-back amendment. The foundation trusts, I would contend, have not implemented local pay bargaining because they know the implications for industrial relations and local employment rates and so on. Agenda for Change has introduced equal pay, as the Minister said, and provided a good framework for addressing issues of equal pay for equal value. It has certainly proved its worth.

I regret that the Minister is unable to offer any real comfort to those in the House who believe that honouring the long-standing pay and bargaining arrangements for NHS staff at national level is not only the fairest thing to do but the wisest course if we are to ensure that NHS staff morale does not plummet even further. It is an important issue and I give notice that I intend to raise this matter at a later stage. I beg leave to withdraw the amendment.

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Monday 7th November 2011 Lords Chamber

[Baroness Wheeler]

My Lords, I begin by paying tribute to the excellent work of the charities, Action against Medical Accidents, National Voices and the National Association of LINks Members on this important issue. I also thank the noble Baroness, Lady Masham, and other noble Lords who have supported and sponsored the amendment and have spoken so forcefully in favour of it. They have put forward the strong arguments for a statutory duty of candour, and I do not intend to go over them or to repeat the detail of the many harrowing cases that have led to the huge support among the general public and patients' organisations for the measure.

The instances of serious failure in care and treatment that have led to the campaign in support of a statutory duty of candour are dramatic, shocking and deeply tragic. The need to ensure openness and transparency of instances of patient care which lead to harm or adverse impact on the patient's future care quality of life apply to both those major cases and to everyday care and treatment solutions. I am sure that, in respect of the latter, many of us will have had personal experience of pursuing instances of poor care and treatment, communication and ordination of services, through the PALS hospital complaints system, only to find how quickly the shutters come down, as has been said, and how hospitals can seem to go into automatic denial and obfuscation as soon as an event occurs.

This is a probing amendment. On behalf of the Front Bench, I urge the Government to look closely at the issue and respond positively on how the Bill can be strengthened to enshrine the right of patients, their carers and families to know when things have gone wrong. In April 2010, my Government established responsibility for the Care Quality Commission to require health providers to report incidents which harm patients to the national reporting system of the National Patient Safety Agency. We recognise that that was a first step. The requirement to report the incident to the patient within a specified period would be a major second step that should be considered to ensure that all information about such incidents is shared with the patient and their family.

Many, both inside and outside the Chamber, have worried about the extent to which patients actually feature in the Bill and whether it will really achieve the Government's objective for patients of “no decision about me without me”. Surely, underlining in the Bill the rights of patients to be truly involved in decision-making about their care, to participate in decisions about their future treatment, and to be told honestly and openly when something goes wrong should all be part and parcel of the “no decision about me without me” mantra.

There is clearly growing momentum and enthusiasm for the current CQC regulations to be extended to provide a related duty to share all information about incidents which cause harm with the patient concerned or their family. As we have heard, the House of Commons Health Select Committee in June of this year specifically recommended that a duty of candour to patients from providers also be part of the terms of authorisation from Monitor and of licence by the CQC.

As for the Government’s consultation on how a proposed contractual duty of candour should be implemented, it is regrettable that the consultation does not allow for consideration of whether the duty should have a different status. The concerns of the Health Committee and patient groups that a contractual duty alone will not be effective need to be addressed. A powerful argument for the duty being in the CQC registration requirements is that that would then cover all providers, not just those with a standard NHS contract.

The consultation document does not adequately address a number of issues in relation to the proposed contractual duty. For example, it does not make clear how the Government envisage a contractual duty working in practice; or how commissioners should act when a provider has failed to be open; or what effective remedial measures they will be able to take.

We recognise that further work needs to be undertaken on the amendment. For example, the CQC powers should not interfere with or duplicate the role of the health staffs’ professional regulatory and disciplinary bodies. The noble Lord, Lord Winston, and other noble Lords have spoken about their concerns. This is a probing amendment. It is designed to raise issues and to seek ways to take the matter forward.

It has been an excellent debate. We strongly support the suggestions that noble Lords have made on taking this matter forward, and we urge the Minister to give urgent consideration to them.

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

My Lords, Amendment 20, introduced by the noble Baroness, Lady Masham, looks to place a new duty on the Secretary of State to ensure transparency when something goes wrong in the treatment of a patient. I hope that she feels gratified by the quality of the contributions to which we have listened this afternoon.

I absolutely agree with the noble Baroness, the noble Lord, Lord Harris, and other noble Lords that ensuring full candour on the part of the medical, nursing and allied professions and NHS organisations is essential. We know that achieving an open and honest system is vital to ensure that the health service learns from its mistakes and that patients and their families are treated with the dignity and respect they deserve. I take no issue with the powerful arguments from noble Lords about the need for openness and candour between health professionals and patients. That is a real concern.

To emphasise that, in our response to the Future Forum’s report we made a clear commitment to introduce a duty of candour—a new, contractual requirement on providers to be open and transparent in admitting mistakes. This will be the first time that such a requirement has been specified in contractual agreements with providers. Contracts are increasingly the key way in which providers will be held to account for the quality of the care that they are providing by those who best understand local healthcare—clinicians and patients. The contracts give the people who are actually spending NHS money on behalf of their populations the power and the levers to require quality improvement and to scrutinise the performance of providers. Therefore, placing a duty of candour in the NHS and contracts reflects the importance we place on the issue. I cannot agree with the noble Baroness that it is somehow a snub or an insult to patients, as she put it. Nor do I think that it is an obligation with a lesser status than a statutory obligation would be.

Accordingly, I support the intention behind the noble Baroness’s amendment, but I do not agree that the most effective way to achieve it is through a duty set out in the Bill. The amendment suggests that the Care Quality Commission should have a role in ensuring that health service providers comply with a duty of candour. However, we do not believe that the CQC overseeing compliance would be the most effective way to underpin a new requirement. The CQC itself has said that it would not be able to enforce such a duty routinely and that it would not fit in with its role as a risk-based regulator.

The Government want the duty of candour to be as effective as possible in promoting openness. Rather than rushing to insert what may be an ill-thought-through and impractical duty in primary legislation, we are currently consulting on how best to implement a duty of candour through contracts with commissioners. The consultation explores how we can best support patients and clinicians to demand candour from healthcare organisations and how commissioners would enforce and report publicly on it. If appropriate, there may be an opportunity in future to include such information in the CQC's quality and risk profiles. Incidentally, I encourage the noble Baroness to take part in the consultation, if she has not already done so. The consultation also explores what we should expect commissioners to report publicly in terms of their enforcement of the requirement. As I said, if appropriate, there may be an opportunity in future to ask the CQC to report on that.

Transparency is important, but I assure noble Lords that measures are already in place to ensure transparency within the NHS. For example, as has been mentioned, clinicians have a professional duty to act openly and admit mistakes. In addition to their professional duty, the NHS Constitution sets out the responsibility of health service staff to aim to be open with patients, their families, carers and representatives, including if anything goes wrong. The majority of clinicians are open with their patients and will, despite the difficulty of the conversation, admit mistakes to patients, so patients receive an apology. Where openness does not happen, it is usually as a result of a closed culture that exists within an organisation rather than a case of individual clinicians simply covering things up. I agree with the noble Baroness, Lady Hollins: clinicians must be able to work in a supportive environment where they are encouraged to admit mistakes and learn from them. It is this culture that we aim to foster in the NHS. The question is how best to promote that culture.

--- Later in debate ---

[Earl Howe]

Our intention is that any provider supplying services to NHS patients should be subject to this duty of candour in the contract, but my noble friend will know that we are consulting on how best to do this.

[Baroness Wheeler]

Perhaps I may ask the same question about clinical commissioning groups and GP contracts.

[Earl Howe]

I will come on to talk about GPs and primary care providers in a moment, if the noble Baroness will bear with me. I listened with great care—

Health and Social Care Bill

Debate between Earl Howe and Baroness Wheeler

Wednesday 2nd November 2011 Lords Chamber

[Baroness Wheeler]

My Lords, the hour is indeed late and I have done my best to cut back on bits of my speech. On behalf of the opposition Front Bench, I commend these amendments for beginning the process of retipping the balance of the Bill from its current predominance of measures dealing with NHS structures, governance and competition. Today’s amendments start to explore ways of addressing in the Bill the need for the NHS, public health and social and community care to work together to achieve improvements in quality of services in diagnosing and treating patients. Integration is a means for achieving this and is not an end in itself.

It is worth reminding ourselves of the recent warning from Chris Ham, chief executive of the King’s Fund, of the very real risk in the Bill of integrated care being,

“a sideshow involving small-scale pilots, with competition the main game in town”.

He also said:

“If the Government is serious in its endorsement on the Future Forum's advocacy of integrated care, it must demonstrate its commitment by putting the best civil service brains on the case and ensuring that the mandate given to the NHS Commissioning Board has the promotion of integrated care at its heart”.

We are certainly not at that stage yet, as the contributions in this debate have demonstrated.

The Bill offers the opportunity for the promotion and enabling of integration to be embedded into the work of the Secretary of State, the NHS Commissioning Board, clinical commissioning groups, health and well-being boards and Monitor, and further amendments throughout the Bill will allow for debate and development of these areas. The Royal College of Physicians has referred to these bodies needing to have, under the Bill, an explicit duty of mutual co-operation and collaboration, and this should be the aim. The Secretary of State, the Commissioning Board and Monitor all need to ensure that national policy promotes, not just enables, the supporting context for integration.

We support working towards a strategic definition of integration that encompasses the NHS, public health and social and community care. Nuffield, the King’s Fund, National Voices and the Local Government Association are all undertaking comprehensive work on producing clearer definitions, so there is no shortage of expertise in this area. Our hope is that this work will help lead us to a more coherent approach and ensure that current provisions in the Bill can be strengthened. As we know, the Future Forum is currently consulting on what now turn out to be the non-legislative steps that can be undertaken. But whatever recommendations it comes up with need to be in the context of a Bill which provides the strategic context, framework and direction. The National Voices key principles of integration have much to commend them in taking this work forward.

Amendment 18A has a particular focus on integrating public health with local authorities. We strongly support the proposed role for local authorities for public health and this amendment would help to address fears of some public health professionals that this might lead to public health becoming divorced from the NHS. Amendments 182 to 184 look to clinical commissioning groups having particular regard for outcomes which show “effectiveness and integration” and integrating “assessment and delivery” by those who provide health and social care services. CCGs need to demonstrate that their commissioning plans address the physical health, mental health and social care needs of their local population under the joint strategic needs assessment.

In this regard, one of the major ways of promoting integration will, as many noble Lords pointed out at Second Reading and today, be by strengthening the powers of health and well-being boards. We strongly support giving health and well-being boards the power to sign off the commissioning plans of CCGs and will be supporting amendments to achieve this later in the Bill. If health and well-being boards own the health and well-being strategy, they must also own the plans to deliver it.

Finally, at the beginning of the debate on how we use legislation to promote integration of services and care, as a carer myself perhaps I may endorse noble Lords who have underlined the importance of this issue to carers. Carers, particularly of people with long-term conditions, oversee care packages across the NHS, local authority social care, the independent agency and provider sector and the voluntary sector. Carers are often the principal players in organising the care package and the ones who fight to hold it together. Hours can be spent going over the same information for different parts of the system or ensuring that one part of the system is aware of decisions and developments, and any possible knock-on effects, taken in other parts of the system involved in the care pathway. Joined-up support is the key enabler for people with severe disabilities or long-term health conditions to remain at home and it is crucial that the Bill gets this important issue right.

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

My Lords, all the amendments in this group have the entirely laudable aim of improving the integration of services across health and social care and improving access to services. I agreed strongly with many of the messages which the noble Lord, Lord Warner, delivered in his excellent speech, and with so many of the powerful contributions from other noble Lords. The only person with whom I felt seriously out of sympathy was the noble Lord, Lord Davies of Stamford. I would simply say to him that the Bill contains a number of provisions to encourage and enable the NHS, local government and other sectors to improve patient outcomes through far more co-ordinated working.

For example, the reformed system that this Bill will give form to—the provision of high-quality, efficient and fair services—represents the fundamental goals of the health and care service. This clause puts on to a statutory footing the three domains of quality identified by the noble Lord, Lord Darzi, in his next stage review: effectiveness, safety and experience. Every aspect of healthcare quality fits into the Darzi domains, and that is a tribute to the noble Lord’s work in co-producing the quality framework with patients and the professions, and it is also why the domains still provide the framework for quality.

In answer to my noble friend Lady Jolly, or at least to give her a partial answer, we seek to measure success in meeting these fundamental goals through the transparent accountability mechanisms of the outcomes frameworks for the NHS, public health and social care. Integration and access, though laudable objectives that I share with all those noble Lords who have spoken about them, are a means to this end. If integration and access help the NHS to meet the quality and fairness duties—and by fairness I mean reducing inequalities—then integration and access will need to be factored in to commissioners’ plans. Commissioning guidance will set out how best to achieve this based on the accredited evidence of what works best that NICE is developing in its quality standards and other guidance.

The point is often made that high-quality care must surely be integrated care. Integration is not an outcome, it is a possible feature of the process. Where it will improve outcomes and reduce inequalities, integration should most certainly happen, and this Bill provides for that. But we must not sacrifice outcomes for process. I thought the noble Baroness, Lady Armstrong, injected a welcome dose of reality on that theme borne out of her considerable experience, and although I did not fully agree with everything that the noble Baroness, Lady Wheeler, said, she also made some very sensible comments on that point. Indeed, the NHS Future Forum’s Phase 1 report highlights well the practical rather than legislative challenge of bringing about more integrated services for patients. I shall quote from its summary report, which states that,

“legislating or dictating for collaboration and integration can only take us so far. Formal structures are all too often presented as an excuse for fragmented care. The reality is that the provision of integrated services around the needs of patients occurs when the right values and behaviours are allowed to prevail and there is the will to do something different”.

Health: Stroke Care

Debate between Earl Howe and Baroness Wheeler

Monday 4th July 2011 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they will take to address geographic variations in stroke care identified by the Royal College of Physicians and detailed in the National Stroke Audit Report 2010.

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

My Lords, the 2010 audit shows ongoing improvements in stroke care in England. To achieve the high-quality care described in the national stroke strategy and the NICE quality standard, the NHS is continuing to implement the accelerating stroke improvement programme. This aims to go further and faster in delivering improvements in stroke care across England.

[Baroness Wheeler]

I thank the Minister for his response and his recognition of the tremendous progress that has been made in the past three years with the national stroke strategy. I am sure that he agrees that progress has been most marked where strategic health authorities have provided strong leadership to drive forward strategy. With their abolition, how will the new system, through the subnational elements of the NHS commissioning board—the clinical senates—help facilitate the necessary improvements, and where will accountability lie? Also, I am concerned that the future of the stroke strategy team at the Department of Health seems to be uncertain. I have heard that the national clinical director for strokes will shortly stand down. Will the Minister confirm this and explain, if that is so, who will be responsible for providing strong leadership on stroke improvements at national level both in the short term and under the proposed new system?

Health: Alcohol Minimum Pricing

Debate between Earl Howe and Baroness Wheeler

Tuesday 1st March 2011 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what is their assessment of the impact of minimum pricing policy on the level of alcohol-related conditions and admissions to hospital.

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

My Lords, the Home Office review of pricing policy found that increases in alcohol prices are linked to decreases in alcohol-related harms. The review also highlighted that this is a complex issue. The Government intend to ban sales of alcohol below the rate of duty plus VAT. This is a pragmatic first step towards setting the lowest level at which different strengths of alcohol can be sold. We estimate that it would mean about 1,500 fewer alcohol-related hospital admissions per year.

[Baroness Wheeler]

I thank the Minister for his response. However, two leading advisers from the Department of Health’s own network of experts recently wrote in the Lancet that the Government,

“lacks clear aspiration to reduce the impact of cheap, readily available, and heavily marketed alcohol on individuals and on society”.

They estimate that failure to tackle drink-related problems could cost 250,000 lives over the next 20 years. How will the Minister ensure that in future the health, well-being and recovery of people with drink-related problems take precedence over the lobbying of the drinks industry?

[Earl Howe]

My Lords, I make it clear that we neither have nor intend to have any sort of cosy arrangement with the drinks industry. The view that we have taken is that the food, drink and fitness industries, together with charities and public health experts, all have a huge role to play in improving our health. The industry has enormous influence in its own right. However, more than that, we believe that we have a collective responsibility to do something about this problem. That is why the industry has joined the Government in a partnership to promote and empower us all to adopt a healthier lifestyle. Through the public health responsibility deal, we are challenging industry to take action that will help consumers to live healthier lives in some areas where it is not possible or effective to regulate.