NHS: Hinchingbrooke Hospital
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Earl Howe
My Lords, so serious were the problems of Hinchingbrooke, both clinically and financially, that frankly the alternative to a franchising solution might have been closure of the hospital. I think that Ministers in the previous Administration reached that conclusion. It is one of the largest accumulated deficits that we have ever seen in any hospital. The problems facing Hinchingbrooke are therefore very significant.
Lord Beecham
My Lords, given the number of trusts that are in financial difficulties, can the Minister indicate whether he anticipates any further moves of this kind? If so, what processes would the department wish to see in place to ensure both value for money for the taxpayer and the highest possible clinical standards after any such transfer of responsibility?
Earl Howe
My Lords, we do not envisage any other solution of this kind in any other trust. Of course, close monitoring will be necessary, and the contract with Circle is very clear in this instance—it has to perform according to the specification. As I said earlier, if it does not turn the hospital around, the financial risk up to £5 million of deficit, cumulatively, lies with it. I believe that this is extremely advantageous for the taxpayer. On the clinical side, of course the CQC will be extremely concerned to ensure that quality of care is not just turned round but significantly improved.
Health and Social Care Bill
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Lord Beecham
My Lords, this has been an important and thoughtful debate which I am sure will inform the discussions which the noble Earl is about to embark upon with colleagues across the House. I rise to speak to Amendment 38 on a much narrower point. In the spirit of that amendment I will undertake not to impose any burden on the Committee in terms of taking a disproportionate amount of time to deal with it. The amendment refers to paragraph (b) of new Section 1C, which the noble Lord, Lord Mawhinney, also referred to in what I thought was a masterly and devastating critique of Clause 4 as a whole.
The amendment would replace “unnecessary” with “disproportionate” in terms of the relief of burdens on organisations within the framework of the health service. The noble Lord is quite right to say that “unnecessary burdens” could mean anything. He might think that “disproportionate burdens” could also mean almost anything, but at least it gives a sense of direction which would be more acceptable to your Lordships. The Government as a whole are somewhat obsessed with burdens in the belief that almost any duty—whether in terms of employment law or other issues, notional concerns about health and safety or even human rights legislation—is deemed to be somehow a dreadful burden. What is a burden to one set of people may be a perfectly reasonable duty in the eyes of others. In this particularly sensitive context of a key public service affecting everybody in the country as a patient or potential patient, it seems necessary to err on the side of caution when setting out a stall which could lead to great difficulty in any sensible degree of regulation. Of course one can overprescribe regulation. One can also underprescribe it. As it stands the clause appears to err very much in the direction of the latter. I hope therefore that the Government will look again at the drafting of the clause and that some move can be made in the direction set out in Amendment 38 in my name and in that of the noble Lord, Lord Rooker.
Baroness Wall of New Barnet
My Lords, I had not intended to participate in the debate because I did not arrive until it had started, but I have been here a long time now and want to share with people how it feels on the ground. What the noble Baroness, Lady Cumberlege, said is absolutely true. I do not envy the noble Earl because I think that the analysis that the noble Lord, Lord Darzi, gave is exactly how it feels. There is that dilemma. The noble Baroness congratulated us on now having a decision from the Secretary of State. We do, but the decision is bound up in another clause, which brings about another kind of action that we must take. It has not removed anything; it has just given us another dilemma and delay in what we must do.
I say to the noble Lord, Lord Mawhinney, that I only wish that everybody in his position did what he did. Though I have five years of experience, I am not medically qualified; I am just somebody who cares about the people that I have responsibility for as the chair. My experience from those years was often of political interference. I ask noble Lords to forgive me for being emotive about this, but it is absolutely true. We had consultation for many years, authorised by the independent review body. The Secretary of State at the time, Alan Johnson, said, “Whatever the review body says, we will go with it”. That was perfect. Then we had a hold-up and a change of government. The new Secretary of State, Andrew Lansley, then came to our trust and said, “This isn’t going to happen. We want people on the ground to be able to say, ‘Yes, if I want this service, I can have it here, and, yes, if I want my baby here, I can have the baby here’”. Both those services were questionable in terms of their clinical reliability. They were not unsafe, because we would not be doing it otherwise, but certainly questionable. And so we started all over again.
A year later, we have gone through not a consultation but the four tests, where the clinical members of the local authority team went through the same process as was involved in the previous consultation—is it clinically safe or is it not? It took a year or so for the Secretary of State to come back with another response to that. That was another stall until, just a matter of weeks ago, we received a letter from the Secretary of State addressed to the local authority—because it had put the case to him—which said, “Yes, I think that the BEH strategy should go ahead, but, actually, I think that you should consider other things as well”. Those things cut right through the BEH strategy.
Local MPs are very open about the fact that they have interceded and expressed their views. They are very proud to say, “I’ve spoken to Andrew about this and I’m not going to have that”. This goes on all the time—I am not sure that this is inappropriate language to use in this House I ask your Lordships to forgive me if I am saying things that I should not; I am just trying to tell noble Lords what it feels like as somebody who is working in the health service on behalf of patients. That is how it feels. I do not know whether political interference by the Secretary of State, as I see it, can be removed by having the national Commissioning Board make the decisions, because my view would be that MPs will always go to whoever can make an intervention in Parliament. That goes for MPs from all parties; it is not about the present Government.
I do not envy the noble Earl in the decisions that he has to make about this, but the view of the noble Lord, Lord Darzi, is very much attuned to what I see in reality. There is a dilemma; there is that interference. But, on the other hand, there are major decisions that have to be made that can be made only by the Secretary of State in the sense of his or her national perspective. I have no words of wisdom, but I have a lot of feelings. Please can we get this right?
Health and Social Care Bill
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Lord Newton of Braintree
My Lords, perhaps I may intervene briefly in support of the general thrust of the amendments without necessarily saying that I agree with every dot and comma. I also agree, not least, with the remarks of the noble Baroness, Lady Hollins. The noble Lord, Lord Rix, and I have known each other for quite a long while in the field of learning disabilities and, indeed, through my role many years ago as Minister with responsibility for disabled people, so I am happy to lend a sympathetic word on this point.
I ought to declare an interest in that several times I have told the House that I am the chair of a mental health trust. Of course, mental health trusts often deal with learning disabilities as well, as indeed does the health trust that I chair, although happily last year it transferred most of its residents on old-style campuses to Suffolk County Council for a more complete version of genuine living in the community and community care, and I am rather pleased that we did that.
We need to recognise that, although there are overlaps—the word “co-morbidities” is used in one of the amendments—between mental illness and learning disability, they are not the same, and we need to make sure that we take particular and appropriate account of the needs of learning disabilities in all this. I hope that the Minister will be able to assure us that that will be the case.
Lord Beecham
My Lords, I begin by congratulating the noble Lord, Lord Rix, who has been such an outstanding champion of people with disabilities, alongside my noble friend Lord Morris of Manchester. The two of them have been in the vanguard of public policy-making and of informing and involving people in this crucial issue.
The noble Lords, Lord Rix and Lord Newton, both implied that learning disability is something of an overlooked condition. The noble Lord, Lord Rix, referred to the degree of prejudice and ignorance surrounding learning disability, which sometimes leads to the rather disgraceful treatment of individuals who suffer from that complaint, as we read from time to time. It is therefore right that they should be included in this broad request for the Secretary of State to have a duty to promote the equality of and improvement in treatment for people with all kinds of disability.
The noble Lord, Lord Rix, and to a degree the noble Baroness, Lady Hollins, questioned whether this might be rather too much of an issue for local commissioning groups to undertake. I am not so sure about that, and think that this area needs exploring. After all, the general practitioners, who will be a significant part of clinical commissioning groups locally, are the first line of service providers for people with a disability, and I am not clear that a commissioning body operating nationally would be the appropriate mechanism to promote such commissioning. Something like the shortly-to-disappear SHAs might have been, and it is not clear—at any rate, to me—the extent to which the national Commissioning Board will be operating at that sub-national level in the future. However, at all events, somebody has to assume an overarching responsibility, and local authority health scrutiny committees should certainly be ensuring that this group is not neglected in their statutory responsibility of reviewing the efficacy of local arrangements and local provision.
The noble Lord referred to the important issue of data collection in Amendments 117 and 143 and of drawing on the experience of people with the condition. I think that he would probably accept my suggestion that both of the amendments would be slightly improved by reference to carers, as their experiences should also be shared and brought into the picture. The amendments suffer a slight defect which I believe the noble Baroness, Lady Hollins, implicitly touched on. The amendments relate very much to the clinical and medical side of the conditions with which the amendments are concerned, but, of course, there are other agencies and other services that are important and must play a part in improving life for people with any of the range of conditions covered by the amendments.
Health and Social Care Bill
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Lord Beecham
“( ) For the purposes of this Act “the health service in England” is defined as those services provided under section 3 of this Act.”
Lord Beecham
My Lords, I rise to move this amendment in my name and those of my noble friends Lady Thornton and Lord Hunt of Kings Heath. As we make steady progress through this Bill, your Lordships will encounter many amendments more elegantly drafted than this one, I have to admit. Given the evident affection in which lawyers are held in your Lordships’ House, I trust that this member of the junior branch of the profession will be forgiven for the drafting of this amendment, especially as I was not responsible for it—
Lord Beecham
But I did subscribe to it. There is a sort of collective responsibility on these Benches, too.
This is a probing amendment—it could hardly be anything else in the circumstances—that tries to deal with what actually constitutes the health service. Of course, this phrase runs through the Bill but there is not within the Bill a definition of what constitutes the health service, let alone “a comprehensive health service”—the words used in Clause 1, which we will be returning to on Report. The amendment seeks to add to Clause 1(3) and the intention is to reflect Section 3 of the 2006 Health Act, which laid out clearly, to a reasonable extent at any rate, the scope of the Secretary of State’s duties. The Secretary of State was obliged to,
“provide throughout England, to such extent as he considers necessary to meet all reasonable requirements”
broadly six categories of service, amplified in Schedule 1 to the Act by more detailed requirements around medical inspection for pupils at schools and issues of that kind.
It clearly is impossible to lay down in legislation everything that might be brought within the purview of the Secretary of State or indeed any other body for the purposes of defining precisely what a national health service should be and what would constitute a comprehensive health service. Clause 10 in any event transfers some of those responsibilities to commissioning groups, as the noble Lord, Lord Marks, has pointed out, but it is not entirely clear from the clause, to put it mildly, what functions will be included in their responsibilities.
Lord Newton of Braintree
Will the noble Lord explain what he actually wants, because I am now thoroughly confused? First, he seeks the reincarnation of a section of the 2006 Act, which, if I remember rightly, was a consolidation Act—in other words, merely a record of what had already happened in history. He then goes on to say that he does not want to ossify—although he did not use that word—the service; he wants flexibility but accepts that it is not possible at any one time to define everything that the service provides. I simply do not know what he is saying.
Lord Beecham
My Lords, I am saying that the Bill should lay down at this stage a range of services that will be part of a national health service but that that should not be limited by reference to a particular moment. There will have to be flexibility, but the Bill should clearly indicate, as the 2006 Act did, areas that, taken together, constitute a national health service. It is a simple enough proposition. The content would have to be debated as we go forward, but this is a probing amendment that is designed to ventilate the issue in the hope that some consideration might be given in the course of proceedings on the Bill to the changes that are required.
Ultimately, some decisions will have to be taken about what services are to be provided, not least about the services in Clause 1(3) that must be provided free of charge. People are entitled to know what services they will get free of charge at any given time. As I have said, at some point these matters should be elaborated. There is also an issue about how public health services are to be regarded in the light of the Bill’s current proposals; for example, in relation to the role of Monitor, competition issues and the like.
Amendment 7 seeks to establish a method of taking this discussion forward so that all of us may be clearer about what we are entitled to expect of a National Health Service and, for the purposes particularly of new Section 1(3) of the National Health Service Act 2006, what services would be provided free of charge. I hope that we can look at that matter and perhaps return to it on Report. In that light, I beg to move.
The Earl of Listowel
I thank the noble Lord, Lord Beecham, for moving this amendment and for giving us an opportunity to discuss a definition of the services of the National Health Service. Perhaps the Committee will forgive me if I make now the arguments that I had hoped to make in the later debate on mental and physical health in the health service, for which I am unable to be present. Those arguments are also pertinent to this amendment.
I seek reassurance from the Minister that the new arrangements for the health service will have a specific duty to focus on support of the relationship between the parent and the child, or whoever is acting in loco parentis for that parent, particularly during the early years and in adolescence. Professionals say that adult mental health hinges on the relationships between the primary carers and the child in early life and in adolescence.
The Government’s White Paper highlighted that mental health is important to public health. It follows that in the future we have to be even more careful to ensure, without being overly intrusive, that the relationships between parents and children in the earliest years and in adolescence are as supportive as possible. The health service should have an important role in that. For instance, there is tremendous pressure to generate more early years nursery places. In a recession, we want parents to work and to help build capacity. Nurseries need to be cheap, yet we know that high-quality early years intervention is crucial to better outcomes for children. We also know that the people who work in those settings are often underpaid and not properly supported, and that there can be a high turnover of staff. In driving people, for understandable reasons, to use nursery provision more, there is a danger that the relationship between the parent and the child could be undermined.
The evidence indicates that high-quality early years education produces better outcomes in school for children. Professor Jay Belsky at the University of London investigated this issue. Exposure to poor-quality early years education and nursery care over a number of years can have serious, although small, deleterious effects. But if a lot of children go through these experiences, the overall impact can be significant. It is very hard to measure—this is probably why it does not get prioritised enough—what difference it makes if there is not sufficient support for relationships between parents and children in the earliest years and in adolescence. It is easy to measure cognitive performance in schools, whereas the relationship between parent and child in the earliest years and adolescence is hard to measure. However, qualitatively I am very clear, after consulting with colleagues in the mental health profession, that it is hugely important to get that support right.
I know that the Department of Health works closely with early years services to try to offer such support, but there are still shortcomings. For instance, there is not sufficient support in adult mental health services for adults as parents in children’s centres, and more work could be done. An old chestnut is that, if a parent is presenting with mental health issues, thought is not always given to the fact that the parent has children who will have needs. If a parent is mentally ill, what are the mental health needs of the children? Again, if a child presents with mental health problems, a proper assessment needs to be made to look at whether perhaps the best input is to support the parents. That may help the child to get better.
Noble Lords will be pleased to know that I will not say much more. A few years ago I remember working with a young man who was just coming out of adolescence. His father was an alcoholic and he had experienced domestic violence in his home. I was seeing him and working with him once a week for six months. The issues he had were that he was experiencing growing paranoia, he was fearful and distrustful of the staff, he was mercurial and unpredictable in his behaviours and he had a difficult relationship with women. If there had been better support for that family, perhaps the nascent problems we saw at the time could have been nipped in the bud and he would not have had those difficulties.
I am sorry if I am not explaining myself sufficiently clearly, but I would be grateful if the Minister could reassure the Committee that in any of the new arrangements there will be a particular focus on getting in early to support families, both parents and those acting in the role of parents, in their relationships with their children to make sure that those relationships are strong. Children will then have a good basis from which to grow and enter adulthood. I hope that that will be a priority in the new arrangements.
The Earl of Listowel
I thank the Minister for providing me with the strong assurance that to him and his colleagues the strengthening of the parent/child relationship is absolutely crucial in what they are doing. There is strong agreement with that point and I thank him for that. I will look forward to reading with interest in Hansard the later discussion on mental health.
The Minister mentioned the availability of essential services. To highlight the current concerns, an effective and well respected foster care charity operating in all the nations of the United Kingdom had to create its own child and adolescent mental health services in Wales because there was so little available in that nation. On children’s homes, it has been recognised for a long while that often our most vulnerable children are placed in children’s homes with staff who are poorly equipped to meet their needs. There have been important steps forward in improving that situation but, crucial to that, is ensuring that those staff get the mental health support they need. That is becoming more widely available over time, but it is still piecemeal. We need to ensure that those kinds of situations do not continue into the future.
I am grateful for the Minister’s assurances about the Government’s priorities in this area and, as I say, I look forward to reading the debate in Hansard.
Lord Beecham
My Lords, I am grateful to the noble Earl, Lord Listowel, for once again bringing his expertise on this issue. He is perhaps the leading proponent in your Lordships’ House of the concerns around children’s health and other matters relating to children, and his contribution today certainly falls in line with our experience of his many contributions in that area of policy.
I am also grateful to the Minister for his reply. I did not, and the amendment does not, suggest that we should have an exhaustive, finite list of responsibilities or functions which comprise the National Health Service. That would clearly be inappropriate. I thought I had made that clear but perhaps failed to do so. The noble Lord rightly pointed out that, under Clauses 10 and 11, responsibilities are effectively transferred from the Secretary of State to clinical commissioning groups. Had this amendment been taken forward, it would have identified for those groups the services which they should carry out. Of course, the transfer imposes the duty to arrange for the provision of services to the extent that each commissioning group considers necessary. That provision raises the question of the extent to which there is still a commonly accepted view of a National Health Service. That is an open question that we will no doubt return to in different forms as we go forward, but in the circumstances I beg leave to withdraw the amendment.
Health and Social Care Bill
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Baroness Armstrong of Hill Top
I want to intervene briefly. I support much of what my noble friend Lord Warner said in his opening speech. There are some things on which we need to tread carefully. Integration is critical, but it can become a phrase that is used but is not backed up by good practice. We have to be sure that we introduce or develop integration in ways that improve the outcome for patients. I serve as a non-executive on an acute trust in the north-east of England, the County Durham and Darlington NHS Foundation Trust. It has just merged with, or taken over—I am never very sure—the community trust. The Government have been encouraging this throughout the country. There are mergers and a coming together of community services and acute services. In some places, the community services are joining the mental health trusts and so on and so forth. We have been very conscious throughout that process that in the private sector the majority of mergers do not succeed. Very often that has been shown to be a problem in the health service. That is not a good idea. When we are looking at integration, we have to be very aware of what outcome we want. We should not just say, “If we bring all this together, it’s bound to save money and it’s bound to be a better service”. It will end up that way only if it is exceptionally well planned, if the outcomes are worked out and are absolutely clear to people, and if we do it not just because it is the fashion of the day, or because the Government are asking for it to happen, or because the words are used in the Bill.
I entirely agree with my noble friend Lord Warner. This should not be used as a means of excluding or cutting out competition. One of the best examples of integrated care that I have seen was when I was Minister dealing with social exclusion and had the real privilege of going to Preston. I was able to give £1 million to the local mental health voluntary organisation. It was working with people with learning difficulties who were trying to make sense of individual budgets. It was inspirational to meet the individuals who had been part of that development, which had been co-ordinated by the voluntary organisation—I think it was Mencap. It offered and provided one person to work with the patient, the client or whatever label you want to put on them. That person’s job was to help the client negotiate their way through all the different organisations from which they needed care and to work out more effectively what they needed.
I spoke to one young woman who had been living at home with her father. He was very concerned because she was becoming housebound, obese and more mentally ill, and she also had learning difficulties. Technically, every agency was working with her but nothing was actually happening to change her experience of life and her ability to get out and contribute, as well as her ability to find the right way through the organisations. She talked to me at great length with incredible enthusiasm and took me round the places that she now had contact with. She was volunteering in a group for severely disabled children, where she was simply holding someone’s hand, being there and being a friend throughout the process. She told me she had reduced the number of hours of care she needed because she did not have time for it because she was so busy. She was busy being active as a volunteer in a whole range of things because the care she needed was now properly integrated and she had an advocate to help her work through the myriad of different things that she wanted; for example, where she needed particular drugs or care because of some physical illnesses. I was able to see true integration, with incredible enthusiasm from the patient, but it needed to be negotiated by the voluntary organisation. They were then able to get a pattern of care—a pathway, as we now call it—that made sense to her, that reduced her dependence on carers and professional intervention, but which worked for her. She was simply one example.
I also think that the integration of care for children is really not as good as it should be. I have seen some examples of where it works brilliantly and others where it simply does not work at all for some of our most disabled and disadvantaged children. Again, we can do it better. Integration is absolutely where it should be but it will have to be organised in different ways for different types and groups of patients. There will need to be people who can help negotiate the way through the pathway.
My experience in the County Durham and Darlington NHS Foundation Trust is that you have to be absolutely clear about what your outcomes will be. However you organise the different pathways and different coming together in groups—we are in the middle of doing that at the moment—there needs to be clarity about what you are trying to do in enabling the individual who is the concern of the local authority, the acute trust and the community trust. Someone has to negotiate that pathway with them, and that will frequently be someone who is not embedded in any of those areas of responsibility, although it may be someone from there. There will have to be different ways of doing it.
The Government are going to have a very difficult job in making absolutely sure that integration is working for the patients rather than simply saying, “Well, we are doing yet another reorganisation which we hope will save money”. My experience is that if that is all people think of at the beginning, it does not work, it saves no money and it becomes increasingly frustrating for the person whose care it is supposed to improve.
I went to see someone in a community hospital that I have a lot of experience of. It is a fabulous place that traditionally takes patients from a number of different areas. The local authority recommends people, the GPs recommend people, and of course the acute trust recommends people it wants to get out of acute care and into the community hospital. Trying to get that knowledge and understanding into the acute trust, now that it technically runs the hospital, is quite difficult. It rings up at the beginning of the day and asks how many beds the hospital has. The hospital might say four, and the trust rings again at the end of the day and says that it needs those four beds. The community hospital matron might say that the GPs have taken two of them and the local authority has taken another, so the beds are no longer there for the acute trust.
We need to make sure that we get integration right and recognise that we have to get the best and not simply use integration as a term that will cover everything.
Lord Beecham
My Lords, the hour is late and I will not speak for long, but I want to address one issue in this very important debate from the perspective of local government, in which I have so far spent two-thirds of my life. The issue is social care services, which are referred to in so many of the amendments.
This is partly a question of definition. What do we mean by social care? Do we mean the services provided by adults’ services departments, or do we take a broader view, such as the position of children’s services, which were split away from social services departments, having first been integrated after the Seebohm report in the early 1970s? I have had and continue to have misgivings about that separation, but I take it that, for the purposes of these amendments, we should look at children’s services as well as adults’ services in relation to social care.
As the noble Baroness, Lady Masham, has pointed out, there is also a housing aspect, which needs to be taken into account. That, of course, is a function of all principal councils. It is not a function of county councils, which are basically responsible for adults’ services and children’s services. It is, however, a function of district councils, and their role in relation to this provision also needs to be looked at.
There is also the issue of finance and budgets. The National Health Service benefited enormously from investment by the previous Government. There was very much greater investment in that than in social care, so there are questions about how the funding of integrated care between local government and health is to go forward. Perhaps when he replies the Minister will comment on the experience of community budgeting, which in some cases has been looked at, to see how that can be developed. If it has not been sufficiently piloted, perhaps he will indicate whether the Government will consider using that mechanism for community budgets to pilot further integration along those lines. The Government should also bear in the mind the impact of their proposals for the reform of welfare and the benefits system on the position of people requiring social care.
The noble Baronesses, Lady Cumberlege and Lady Armstrong, mentioned personal budgets, which clearly have considerable potential in the promotion and use of integrated care and for avoiding the cost-shunting that sometimes occurs. There is clearly a requirement for the kind of support to which the noble Baroness, Lady Armstrong, referred in helping people to navigate their way through that system and to maximise the efficiencies that can be obtained from it.
Therefore, while I certainly support the first of these amendments, I think we need to be clear about what we are looking to integrate beyond simply adults’ services.
In that context, finally, in relation to role of the health and well-being board, there is the responsibility of producing joint strategic needs assessments. It is not clear to me—perhaps we will debate this issue later—the extent to which those boards will be able to redirect the provision of services as opposed to providing an assessment and being consulted on the commissioning that clinical commissioning groups will carry out.
Health Authorities (Membership and Procedure) Amendment Regulations 2011
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Lord Beecham
My Lords, first, I apologise for not being present for the opening part of the debate. I have just a couple of questions to put to the Minister. The first relates to the appointments to these very large bodies. Four bodies now cover the whole country, which is half the number of the Anglo-Saxon Heptarchy of some centuries ago; they cover very wide geographical areas. I wonder whether the noble Earl can indicate what steps are being taken to strike a geographical balance for the executive and non-executive appointments so that local knowledge across these very wide regions is reflected to the best degree possible—it is of course not completely possible, given their size—in the new arrangements.
The second question relates to the issue of scrutiny and the extent to which, if at all, the new bodies will be subject to the scrutiny of local authorities’ health scrutiny committees under the existing framework. I am not sure the extent to which they would want to pursue that, but there may be cases when they would, and of course geography may play some part in that. It would certainly be welcome if the Minister could be clear that, in principle, the new SHAs, pending the creation of the new special health authorities, will be subject to the scrutiny process.
Baroness Williams of Crosby
Perhaps I may take this opportunity to ask the Minister a couple of questions as well. I am grateful to the noble Baroness, Lady Thornton, for raising this issue with a statutory instrument.
I am delighted to hear that some form of the SHAs will continue in the interim period—I think that they have, on the whole, done a very good job—and that there is a real sense that they can continue to play a significant part in the transition. It looks very much like, with the clustering, we are making a clear transition from where we are to where we are going. I, for one, would not object in the least to their remaining like that.
I have a couple of questions for the Minister. The first is whether he envisages that the regional offices of the NHS Commissioning Board—which, admittedly, we have not yet passed through Parliament—are likely to be very closely aligned to where the strategic health authorities are. Obviously, there is a lot to be said for continuity.
The noble Earl also mentioned the need for flexibility, on which we could not agree more. Perhaps I may ask specifically whether one could raise the question of March 2013 not being a final date. There has, as we know, already been some softening of the original timetable as a result of the Future Forum and the listening exercise, which I think was broadly very much welcomed, partly because it enabled the new system to keep some of the quite distinguished and very experienced staff from the past. The noble Earl had the kindness to say that one of the problems is how one maintains experienced and well qualified staff. The more the transition can copy the strategic health authority structure, the more likely it is that we will be able to retain some of those very qualified and experienced staff. We know that quite a few of them have been lost and that the NHS could do with not more being lost. Is there any prospect of greater flexibility about the timetable, which was strongly supported by the Future Forum?
The second question is a more specific one about SHAs. As the noble Earl knows, SHAs have a large part in education and training, which is still a major area of uncertainty until the education and training legislation comes forward. Under Regulation 2.2 of the 1996 regulations, there was a specific commitment that where a strategic health authority contained medical or dental schools, a member of the authority would come from that background. They specifically stated that he or she should come from the background of education in the medical or dental school that was part of the strategic health authority. Will that be respected in the new circumstance? That would clearly be helpful in addressing future education and training issues.
My last question is a broader one about the Government’s feeling that there was no need for an impact assessment. I confess that I am a little worried about that, because the clubbing together of membership has certain possible impacts. Lastly, as the noble Baroness properly mentioned the issue of the involvement of HealthWatch, will there be an insistence that at least one member of the cluster should be someone with a background on the health and well-being boards—in other words, representing the HealthWatch interests—in the decisions of the new cluster groups?
Let me say loud and clear that all of us regard the cluster groups as a good development; I did not want to quarrel with that. Our questions cluster around the cluster, rather than concerning the cluster itself.
Health and Social Care Bill
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Lord Beecham
My Lords, we heard a good deal about cats last week, but your Lordships will recall the famous story in which Sherlock Holmes referred to the “curious incident of the dog in the night-time”. His perceptive medical companion pointed out that the dog did nothing in the night-time, to which Holmes replied that that was the curious incident. The failure of the dog in the story to bark has not been emulated in the response to the Bill, which has evoked the equivalent of a veritable canine cacophony.
The noble Lord, Lord Ribeiro, called on his medical colleagues to stand up and be counted, but they have. In overwhelming numbers doctors, nurses and the royal colleges have rejected the Bill. No less than 70 per cent of general practitioners in the most recent survey called for it to be abandoned.
Like many of your Lordships, I have been deluged with briefings, letters and e-mails about the Bill of which precisely one has been in support of it. The Bill at inordinate length creates structures embodying organisations that are often either too big or too small to function effectively. They appear to be designed primarily to meet ideological rather than medical or social purposes. I must point out in passing that, despite its title, there is very little about social care in the Bill—another non-barking dog. Thus it creates the massive bureaucracy of a national Commissioning Board vested both with national responsibilities and the oversight and commissioning of primary care, dental and pharmaceutical services for localities. Monitor becomes an economic rather than a quality regulator, charged no longer with promoting competition but with repressing anti-competitive practices, a distinction that noble Lords might think is without a difference. The very name is apt because it was the name of the US navy vessel that in the civil war sank a Confederate warship in the first battle of ironclads and it is also the name of a carnivorous reptile.
Clinical commissioning groups have been established in a troubling act of pre-legislative implementation. They are not coterminous with local authority boundaries and, and in the case of my own city, Newcastle, for example, there are already two commissioning groups. This raises serious issues about how the commissioning of services in hospitals within a regional or sub-regional reach will actually work.
Strategic health authorities have similarly disappeared, to be replaced in effect, at least for the time being apparently, by four super-SHAs responsible to the national Commissioning Board. Health and well-being boards, which are welcome in theory, will not include representation from district councils in shire areas, despite the latter having important functions relating to communities and individuals alike. The boards moreover are effectively consultees, not decision-making bodies.
As the noble Baroness, Lady Williams, pointed out, the Bill is strong on autonomy but weak on effective accountability, whether at national or local level. It is strong on competition, for which the evidence of benefit is perhaps less than compelling, but it is weak on failure. It replaces around 150 statutory bodies with something over 500. Perhaps its most welcome proposals are in the realm of public health, reversing the wrong turn taken in the 1973 reorganisation that did away with medical officers of health and chief public health inspectors who were powerful figures, as I can testify as someone who served on a health committee in my own authority at that time.
Even in the realm of public health, however, there are a number of concerns. Thus again, districts in two-tier areas are excluded, despite having specific responsibility for housing standards, food inspection and other environmental matters. There should be a register of qualified public health professionals and a public health appointee to the national Commissioning Board, on which, for that matter, the Chief Medical Officer should serve ex-officio.
There are also questions about duties. The Bill declares that:
“Each local authority must take steps as the Secretary of State considers appropriate for improving … health”.
The Secretary of State, on the other hand, “may” take steps, although the Bill in listing some possible steps makes no mention of sexual health, obesity, nutrition, alcohol or substance abuse, air and water quality, housing standards or occupational health. There is no duty on the NHS to co-operate with local authorities on public health issues, or on councils to co-operate with each other over, for example, disease prevention. There is a real concern about the status of Public Health England as an executive agency of a department to which it really must be free to speak plainly and publicly. In the words of Paul Burstow on Third Reading in another place:
“In legal terms, Public Health England and the Secretary of State are the same thing”.—[Official Report, Commons, 7/9/11; col. 412.]
He makes the case, unintentionally, for having Public Health England as a separate body that is able to speak to the Secretary of State, rather than having the Secretary of State, as it were, speaking to himself.
There are also issues about the funding of public health services, and the funding being ring-fenced. It is unclear how the level of funding will be determined and on what basis it will be allocated. It will be essential for the Government to work with the Local Government Association on this, and to avoid limiting funding to nationally prescribed outcomes. Funding will have to reflect local circumstances. It will also be necessary to avoid the impact of the proposed health premium, which is designed to reward health improvement but may penalise councils and their citizens in disadvantaged areas whose efforts to improve health may be frustrated more by the impact of matters outside their control than the policy decisions that they take. Those matters might well include government policies and, of course, the state of the economy.
There is also a question about how funding might be affected by the impact on children's services departments of the increasing numbers of academies and free schools opting out and taking away with them a proportion of the central support funding that the local authorities will apply.
We are in danger of moving from a national health service to a patchwork of fragmented health services, which will not be at all the same thing. The health service is of great utility to the people of this country. It is not a utility like gas, water or electricity—still less an insurance fund. It falls to this House to preserve the principles of the National Health Service and facilitate its continuous improvement in the service of the people.
Southern Cross Care Homes
Lord Beecham Excerpts(13 years, 4 months ago)
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Earl Howe
I am grateful to the right reverend Prelate. I do not think any of us feels comfortable if the directors of struggling companies take substantial bonuses. I have to say that I do not have a briefing on whether the directors of Southern Cross have taken substantial bonuses in recent months, but I shall make it my business to try to ascertain that. But of course the right reverend Prelate is right to say that we must be clear that the stability of care homes, looking after frail, vulnerable, elderly people, should not be put at risk by mismanagement. I am afraid that Southern Cross has been a story of mismanagement since it was established in its present form.
Lord Beecham
My Lords, my noble friend Lady Thornton referred to the fact that the owners of many of these properties are offshore companies. Is the Minister comfortable with the fact that according to a claim by the GMB union, some 336 of these care homes—just under half the total—are owned by companies outside the UK, with 325 of them registered in tax havens? Does the Minister agree, as I asked yesterday of his ministerial colleague about the Statement on the White Paper on public service reform, that the high proportion of residential care places managed by Southern Cross—some 18 per cent of the total of places, with roughly a further 18 per cent managed by another five companies—does not represent diversity of provision and increases the risk of things going seriously wrong on a large scale, as has happened in this case? Does that not lead to the possible conclusion that to talk about diversifying without any indication of a limit on the number of places that might be operated in a field like this needs to be rethought?
Earl Howe
I think the noble Lord and I are at one in wanting to see diversity of provision. The restructuring that I suspect we are likely to see emerge from this will result in just that, as a matter of fact. It appears that Southern Cross is to be split into a number of smaller enterprises, and that in itself should, we hope, lead not only to a more diverse arrangement but a more secure one. However, I do not take issue with the thrust of the noble Lord’s remarks at all.
On the issue of the ownership of some of these care homes, our concern as Ministers is not so much where the shareholdings lie as on whether that in itself has implications for the quality of the care that residents receive. I am not aware that that has been a factor. As long as the ownership of these care homes is legal and we are not seeing tax evasion as opposed to tax avoidance, to an extent it is not an issue for the Government. But it is something that is likely to be examined quite closely as the restructuring takes place.
Southern Cross
Lord Beecham Excerpts(13 years, 5 months ago)
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Lord Beecham
My Lords, I thank the noble Earl for repeating the Answer to the Question raised in the other place. While news of yesterday’s agreement is welcome and will, I hope, reassure Southern Cross’s residents and their families, a number of questions arise.
First, it is understand that Her Majesty’s Revenues and Customs is a major creditor. Has it been involved in the discussions and is it comfortable with the outcome to date? Secondly, will the Government ensure that both they and the Local Government Association—representing the interests of many of the residents, including but not limited to those who are publically funded—will be involved in any further discussions over the future of the company’s operations? Thirdly, what steps if any have the Government taken or will they take in relation to the company’s workforce, for whom this is also a most anxious time? According to today’s Times, 42,500 of them have already had their contracts ripped up and are facing the prospect of 3,000 jobs being lost.
As for the underlying, systemic issue, do not these events underline the folly of the previous Conservative Government in effectively driving local authorities out of the provision of residential care by deliberately financially disincentivising such provision in favour of the private sector? Can it be healthy for five or six private companies to dominate the market to the extent of around 36 per cent, with Southern Cross alone supplying 31,000 out of 170,000 places? Is it not totally unacceptable for frail and vulnerable elderly people to be treated like commodities, to be bought and sold as part of some ingenious financial engineering?
Did not Mr Hammarberg, the Council of Europe Commissioner for Human Rights, have a point, as reported in the Telegraph, when he singled out for criticism the UK model of privatised social hair combs—sorry, I meant to say care homes; I am not too familiar with combs these days. He went on to say that privatisation, “is not the solution”, with a high number of privatised care homes in crisis. Is he not right to express concerns that,
“the quality of services in these homes had ‘deteriorated to a worrying degree’”,
and that companies,
“running the care homes have reduced services in order to remain solvent”?
The Answer to the Question proclaims:
“this is a commercial sector problem and we look to the commercial sector to solve it”.
Is that not too narrow—one might almost say, too much like an accountant’s view of the problem? Would not the Minister agree that this is first and foremost a health and social care issue? Is not the commercial aspect very much part of the problem? Does not this in fact send out warning signals in relation to the role of the private sector in the provision of healthcare and whatever emerges as the reborn Health and Social Care Bill?
Finally, will the Government support and encourage co-operative, mutual and third sector organisations to engage in the future running of at least some of the Southern Cross care homes, if the rescue package does not succeed? In the longer term and in any event, will they promote a mixed economy of such care provision across the country to include local authorities and the private, voluntary and community sectors?
Contracting Out (Local Authorities Social Services Functions) (England) Order 2011
Lord Beecham Excerpts(13 years, 5 months ago)
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Lord Beecham
My Lords, in 51 years in active politics, I have never before spoken in support of the SWP. This, however, is a different SWP, and I am happy to support the initiative, which, as the Minister has rightly said, follows an equivalent process in children’s services. However, there are one or two questions that I should like to ask.
First, I assume that it will be open to council health and adult services scrutiny committees, if they wish, to look into the operation of the scheme in their individual authorities. That would be a helpful addition to the process. Secondly, it would also be helpful to be assured that the terms and conditions of those to whom this work will be contracted in adult care services will be comparable to those in current adult services departments. One does not want to see—as has sometimes happened, for example, in my own authority—the contracting out of domiciliary care services even to voluntary sector organisations that pay barely above the minimum wage. That is compared to somewhat above it, although not vastly above it, at the moment.
Thirdly, in respect of the possible formation of new bodies by local authority employees, a matter on which the Minister touched, there might be problems with the European Union procurement and competition laws. We have touched on this from time to time, and will no doubt revert to it in the event that a Bill dealing with the National Health Service comes to this House in due course. I assume that, for the purposes of these experiments, it is perhaps unnecessary to worry too much about that, but is it a factor that might have to be taken into account later?
In relation to the right to control, again, this is a sensible way to proceed. This is a matter not only for the individual and the organisation that helps him but also, I suspect, for the local authority in helping people navigate the various providers and alternative courses of action. For that matter, they must also ensure that sufficient information is available to provide value for money for the applicant. Would it be intended to extend this experiment to provision by the health service for disabled people, either from GP practices or trusts? Presumably at the moment some functions are provided by such statutory organisations as well as by the local authority. If it is not intended to bring that in at this stage, is it something that could be looked at, maybe within the trailblazers working with their local health partners, to see whether this right to control might be extended?
I am reassured to hear that monitoring will take place for individual projects but the document says:
“The Trailblazers … will evaluate the best ways to implement the Right”.
I am not sure whether that means a collective view will be taken by the trailblazers or individual trailblazers will report. In either event, who will decide, and with whom, how matters are taken forward? For example, is it the department’s intention to consult patient groups or groups representing the people affected? I assume that that is probably the case but it would be as well to have it spelt out.
Finally, we should bear in mind what currently worries so many people about Southern Cross and reflect on the difficulties that arose as a result of local authorities effectively being driven out of the provision of residential care for the elderly in the 1980s and 1990s when they became heavily dependent on largely private sector providers. I emphasise the need, whatever happens, in a mixed economy of care, which most of us support, for a local authority role to remain in provision. It is worrying that there is now little direct provision of residential care by local authorities. That leaves not just the system but, of more concern, the individuals who are in care and being looked after vulnerable to the pressures of the market. I am sure that the Minister would not wish to see problems of that kind arising so it would be helpful to be given encouragement that local authorities, in conjunction with other providers, will be able to remain on the field, as it were. As I understand it, at the moment it is not possible for people to use direct payments to procure services from their local authority. Perhaps that could be looked at in the context of these experiments as matters go forward.
Lord Lee of Trafford
My Lords, these Benches are happy to support this pilot. However, I wish to ask my noble friend one or two questions. First, will the resources currently spent by local authorities in assessing social care needs and arranging care be passed on in their entirety to the organisations to which this duty is being contracted out? If so, for how long will this contractual arrangement last? Who is conducting the independent review of the pilots and will the findings be made available to the House?