Health: Cancer

Lord Campbell-Savours Excerpts

Monday 20th May 2013 Lords Chamber

[Earl Howe]

My Lords, I agree that it is important to have more information on the effect of cancer treatments on mortality. New data collections which will provide more detail in this area are under way. The systemic anti-cancer therapy dataset will enable better information to be collected about deaths after the delivery of chemotherapy, and the cancer outcomes and services data set will provide information in respect of death after surgical treatment. However, it is important to make one point here: it can be hard to identify the precise cause or sequence of progression of factors resulting in death, particularly for those with end-stage cancer or who are particularly frail and are experiencing physical deterioration. I do not think that it can ever be a precise science.

[Lord Campbell-Savours]

My Lords, what about the circumstances where a person awaiting treatment in a congested cancer clinic is surrounded by patients who are coughing and spluttering? There will be consequential effects on immunity for those being treated. It may well be the drop in immunity that kills the patient, not necessarily the original cancer.

NHS: Private Companies

Lord Campbell-Savours Excerpts

Monday 11th February 2013 Lords Chamber

[Earl Howe]

My Lords, regional pay is already allowed for under Agenda for Change, and has been for a number of years. The Government do not intend to change that.

[Lord Campbell-Savours]

What about the living wage?

[Earl Howe]

I am not sure what the noble Lord’s question about the living wage implies. I answered a question about the minimum wage, which is what the law entails. It is of course up to employers to ensure that they pay their employees in a way that is not derisory and that reflects the value of the work that they do.

Social Care: Funding

Lord Campbell-Savours Excerpts

Monday 21st January 2013 Lords Chamber

[Earl Howe]

My Lords, as my noble friend is aware, the universal deferred payments scheme will be part of the Care and Support Bill. No doubt, we will debate those provisions when the Bill comes before us. I cannot tell her when that will be, but, clearly, they will be the subject of close scrutiny by the Joint Committee.

[Lord Campbell-Savours]

My Lords, is not one of the unfortunate effects of the Dilnot proposals that they protect inherited wealth at a time when the NHS needs money?

[Earl Howe]

My Lords, the main benefit of the Dilnot proposals is to protect people from unpredictable and catastrophic costs of long-term care. While the noble Lord could interpret the raising of the means test as a way of protecting the rich, I see the combination of the cap and the threshold as a way of giving greater certainty and predictability for all concerned, because none of us, whether we are rich or less rich, can know whether we will be subject to catastrophic care costs at a later stage in our lives. That is the inherent unfairness which Dilnot and the rest of the commission attempted to address.

NHS: Hospital Services

Lord Campbell-Savours Excerpts

Thursday 6th December 2012 Lords Chamber

[Earl Howe]

I agree with my noble friend and that is why work is currently being done under the leadership of Sir Bruce Keogh in the Department of Health to examine the scope for greater 24/7 working. She is right that this is important, not just for the benefit of patients but also to make the NHS more efficient and effective in deploying its staff and assets.

[Lord Campbell-Savours]

If services are carried forward as the noble Earl suggested, how does that influence estimates?

[Earl Howe]

We have reverted to the previous Question, if I am not mistaken. The departmental expenditure limit is set by the Treasury. My own department is in the fortunate position of knowing that it has real-terms increases every year of this Parliament; however, if the department has an underspend that cannot be carried forward, yes, some money has to be returned to the Treasury.

Care Homes

Lord Campbell-Savours Excerpts

Monday 28th May 2012 Lords Chamber

[Earl Howe]

My noble friend makes an excellent point. I expect he knows that in the selection process for nurse training, greater emphasis is now placed on the applicant’s suitability as a person to undertake caring duties. As regards healthcare assistants who may not be qualified, it is of course up to the employing organisation to make checks of that kind. We believe that to be a variable practice. We need to focus on that issue more than ever.

[Lord Campbell-Savours]

My Lords, why does the Minister not reply directly to the question of my noble friend Lady Bakewell? What, in principle, is wrong with a “fit and proper person” test to apply in these cases?

[Earl Howe]

My Lords, as I made clear earlier, there is already a test for those people who are in charge of a care home. The CQC has procedures to verify the acceptable status of such people. Furthermore, there are very strict rules under the Financial Services Authority regulations, which require company directors to pass a “fit and proper person” test. We are not sure what added value might be conveyed by a further test, as the tests are already there.

Health Transition Risk Register

Lord Campbell-Savours Excerpts

Thursday 10th May 2012 Lords Chamber

[Earl Howe]

If you talk to any Permanent Secretary in any department I guarantee that they would take issue with the noble and right reverend Lord on his final point. It is firmly the view of departments across government that if civil servants believe that what they say will reach the public domain immediately, they will not wish to embarrass either themselves or their Ministers by expressing their concerns in graphic language. I understand the noble and right reverend Lord’s point, but I disagree with it for that reason.

He made a distinction between certain parts of the risk register—between the nature of the risks described, their ratings and so on. He was perfectly right to make that distinction. We reviewed the content of the transition risk register following the tribunal’s decision and decided that it would be possible to publish material taken from the register to inform both Houses, and members of the public, about as much of the content of the register as we could. That is why the document that we published on Tuesday, which I commend to the noble and right reverend Lord, included key information relating to the risk areas in the register, an explanation of why we considered that to be a material factor, and the actions taken to mitigate those risk areas. We were as candid as we could be, given the decision of principle that I outlined.

[Lord Campbell-Savours]

My Lords, perhaps I may take a stage further the point of the noble and right reverend Lord, Lord Harries. Is there not a converse argument that where civil servants feel strongly, one way or another, about whether there is a risk inherent in a policy initiative, there should be a mechanism whereby that view can enter the public domain so that the public should be informed of strong divisions of opinion, even between civil servants? Is not the risk register on this Bill precisely one of those areas where strong views may have prevailed?

[Earl Howe]

The noble Lord may correct me, but he seems to be advocating a world where all disagreements in private between civil servants become public property. With respect, I disagree with that point of view, which would be the consequence of his position. Section 35 of the Freedom of Information Act explicitly allows for those disagreements to be kept private. There is no doubt about that. Both the Information Commissioner and the tribunal agreed that Section 35 was engaged in this instance, and was there for a reason.

There are several other reasons why we felt that there was a need to withhold information. The need for candour was one. I referred to the risk that publication of the content of the risk register would distort rather than enhance public debate. Another reason was that disclosure could in some instances—including in this case—increase the likelihood of some of the risks happening. Some risks in the register were theoretical rather than real. If people had thought that the risk was real, they might have taken action that would have made the risk a self-fulfilling prophecy. Nobody wanted that.

Health and Social Care Act 2012

Lord Campbell-Savours Excerpts

Wednesday 25th April 2012 Lords Chamber

[Earl Howe]

My Lords, the plan is to conduct the post-legislative scrutiny three years from Royal Assent, so it will no doubt fall immediately prior to what one assumes will be the date of the next general election.

[Lord Campbell-Savours]

By whom is this post-legislative scrutiny on a five-year basis being conducted?

[Earl Howe]

My Lords, it will be conducted by the Health Select Committee of another place. The process is that the Department of Health will submit a memorandum to the Health Select Committee and that memorandum will include a preliminary assessment of how the Act has worked out in practice relative to the objectives and benchmarks identified during the passage of the Bill.

Health and Social Care Bill

Lord Campbell-Savours Excerpts

Monday 12th March 2012 Lords Chamber

[Earl Howe]

I am grateful to my noble friend because I do not believe that there were any. The Opposition sometimes point to the risk register relating to the third runway at Heathrow, but the key difference with that was that it was to do with policy implementation rather than policy formulation. Once you know what you want to do, there are risks associated with rolling a policy out. It is a very different matter when civil servants wish to have safe space to think the unthinkable and then advise Ministers.

[Lord Campbell-Savours]

Does the Minister intend to delay the Third Reading of the Bill?

[Earl Howe]

We have a Motion before us in the name of the noble Lord, Lord Owen. That question will be addressed then.

Health and Social Care Bill

Lord Campbell-Savours Excerpts

Thursday 8th March 2012 Lords Chamber

[Lord Marks of Henley-on-Thames]

My Lords, on these Benches we take the view that it was sensible to include this provision. The advice that we have is that the risk of the application of competition law is reduced by ensuring that the majority of income for NHS foundation trust hospitals will always be for the purpose of treating NHS patients. It is not an absolute guarantee but it is a sensible risk-reduction exercise and it was put in for that purpose. There is no point in taking a risk unnecessarily. The communication problem has frankly been the result of the efforts of opponents of the Bill, partly in the party of the noble Baroness, in stressing the 49 per cent and suggesting that it is the purpose of the Bill, which, as I say, it is not.

That is not to say that private income in NHS foundation trusts is bad. The Labour Government recognised that throughout. In her speech, the noble Baroness herself very properly recognised it. Private income represents an opportunity for foundation trusts to attract innovation, to buy new and expensive equipment and to develop world-class centres of excellence. We recognise and applaud those features of private income. However, when tabling Amendment 220B, we were concerned that there should also be an individual arrangement for foundation trusts by which individual limits would be subject to agreement with Monitor.

[Lord Campbell-Savours]

Will the noble Lord explain, in very simple language that people outside can understand, what is to prevent a central London teaching hospital with an international reputation ending up taking almost half its business from overseas patients who pay by private means?

[Lord Marks of Henley-on-Thames]

I take the noble Lord’s question to mean: why should a proportion not exceed 50 per cent? As I have explained, the reason is that we regard that as having a risk. If the question is why should a central London hospital not take nearly half its income from private patients, the maximum taken at the moment is, I believe, some 39 per cent. There is a limit of 5 per cent on any increase to be proposed, more than which the governors would have to agree to by a majority. It could not just be a simple majority; a majority of the governors must vote to approve the change. It may well be that some hospitals will wish to go nearer to 50 per cent, which is why there is a reference to 49 per cent.

[Lord Campbell-Savours]

So that we can have it absolutely on the record, is the noble Lord saying that a teaching hospital in central London—

[Baroness Rawlings]

My Lords, we are on Report.

[Lord Campbell-Savours]

It is a very important question.

[Baroness Rawlings]

My Lords, it must be a brief question.

--- Later in debate ---

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

My Lords, this has been a good and constructive debate on NHS foundation trusts. It is right that we should focus on the removal of the private patient income cap, as I am acutely aware that that is where the majority of noble Lords’ concerns lie.

We need to focus on one core point at the outset. Fears have been expressed that removal of the cap could see foundation trusts increasing private income at the expense of NHS patients—in other words, that it could create a two-tier NHS, with those who can afford to pay going to the front of the queue. That is wrong and, I believe, alarmist. There are robust safeguards in place to prevent that kind of outcome.

Allowing a foundation trust to generate more private income does not release it from its prime duty to its NHS patients. Foundation trusts will still have to meet their legally binding contractual obligations on waiting times and provide the highest standards of care for NHS patients. Foundation trusts themselves are very clear about that. Removing the private patient income cap would allow them to bring extra investment in infrastructure and leading-edge technology to benefit NHS patients. Today, foundation trusts can be prevented by the cap from treating private patients who wish to be treated at the trust even when the income that the trust would earn would support its NHS services. The point made by the noble Baroness, Lady Finlay, was absolutely spot on. The cap leads to the ridiculous situation where NHS consultants are forced to get into their cars to drive to independent providers to perform private patient work in their non-contracted hours. Removing the cap would improve clinical safety for all patients in NHS hospitals, because doctors would be more likely to remain on site for longer.

It may well be, as the noble Baroness, Lady Murphy, pointed out, that most foundation trusts will not be affected at all by the removal of the cap. Many of them are earning below their caps at the moment. It is worth noting that NHS trusts, as distinct from NHS foundation trusts, which are not subject to a cap at all, are not earning proportionately more than corresponding foundation trusts. The point is that removing the cap gives the most innovative organisations the opportunity to boost income for NHS services.

I can also assure the House that we have put in place substantial safeguards to protect NHS patients. NHS foundation trusts will remain first and foremost NHS providers. Their principal legal purpose, to treat NHS patients, has been in legislation since 2003. I tabled an amendment in Committee to clarify its legal meaning. A foundation trust’s principal purpose requires it to earn the majority of its income from the NHS. That is very different from saying that 49 per cent of the work of foundation trusts will be with private patients, as some have misinterpreted it. The Bill does not mention 49 per cent, as I hope the noble Baroness is aware. Amendment 220A would remove the clause. That would be most unfortunate, because its effect would be to leave governors and local communities unclear that foundation trusts must remain predominately NHS providers.

There have been worries that the internal governance of foundation trusts will not be strong enough to exercise the requisite control in that area. I hope that I can provide reassurance on that point. As the local community's representatives, it is the responsibility of the governors to hold the board to account for its management of the trust. The governors should also consider whether the level of private activity is in the best interests of their organisation. The Bill will ensure that governors are better able to do that. It strengthens their arm by giving them new powers to hold directors to account and, if necessary, to remove the chair and non-executives of the board of directors. It would be entirely appropriate for the governors to use these powers if they felt that non-NHS activity was not operating in the interests of NHS patients.

At this stage, I should like to thank my noble friend Lord Clement-Jones for setting out a very persuasive case for adding to governors’ powers to oversee a foundation trust’s private income. I have tabled an amendment, which I hope will address his concerns, requiring directors to detail in the trust’s annual plan—that is, the forward look—any proposals to earn private income and the income that they expect to receive. By law, directors already have to take into account governors’ views in preparing this plan, but this amendment would place an explicit duty on governors to consider the plan and be satisfied that any proposals to increase private income would not significantly interfere with their foundation trust’s principal legal purpose to treat NHS patients.

With regard to the point raised by the noble Lord, Lord Campbell-Savours, a plan to increase private income substantially—that is, to increase by 5 percentage points or more the proportion of total income earned from non-NHS activity—must secure agreement by a majority of governors in a vote. For example, governors would be required to vote where a foundation trust planned an increase in non-NHS income from 2 per cent to 7 per cent or more of its total income, or from 3 per cent to 8 per cent or more. To make it quite clear, the vote would be triggered by plans for large increases in non-NHS income. Other matters, such as significant transactions, are for foundation trusts to decide. These proposals would complement the amendment that we introduced in Committee to require directors to explain in a foundation trust’s annual report how private income had benefited NHS patients.

[Lord Campbell-Savours]

We all know of cases where in the real world GPs have said to their patients, “Go private and go early. Effectively, jump the queue”. That is going on all over the country and in certain parts it is happening on a great scale. If that is the case, what is to stop GPs working with governors and consultants to try to move patient activity more towards the development of private operations within National Health Service facilities? Will the impetus not come from GPs working in conjunction with consultants and governors who might be sympathetic to the cause?

[Earl Howe]

With respect to the noble Lord, perhaps I may point to a later group of amendments in the name of my noble friend Lord Phillips, which gets to the heart of that question. I do not think that the noble Lord’s question is directly related to the private patient income cap but, if I may, I should like to cover the answer to it when we reach the later group.

--- Later in debate ---

[Baroness Northover]

He certainly did to me. Perhaps the Minister would like to make it clear—if he wishes to be interrupted many times and not develop his argument, so be it. Perhaps my noble friend would like to clarify—

[Lord Campbell-Savours]

I object to the procedures of the House of Lords being changed by a junior Minister.

--- Later in debate ---

[Lord Ribeiro]

I have one question for the noble Lord, Lord Phillips of Sudbury. I agree with the comments made about management. When I worked as a surgeon, during a period when we were desperate to get patients into hospitals because we had already completed our NHS quota of work by January and had from January to April to make money, pressure was often placed on us as consultants by management to bring private patients into the NHS so that we could make the income. I hear “Oh!” from the other side. However, one problem that came from separating and withdrawing private beds from the NHS was that most consultants have established private practice in private hospitals outwith the NHS. The point that the noble Baroness, Lady Finlay, made was that part of the reason for removing or adjusting the cap and why she supported earlier amendments was to try to get integration of care to allow consultants to be on the spot.

The amendment refers to NHS foundations trusts. As we know, there are trusts that are not foundation but ordinary. What would apply to them? Would they therefore be free to undertake private work in a way that has been described here? This refers only to NHS foundation trusts.

[Lord Campbell-Savours]

I want to intervene briefly because we want to vote on these matters today. The amendment subtly gets to the problem at the heart of the Bill, which totally underestimates the new pressures that will build up within foundation trusts on management to change the nature of the patient body that comes into the trust for financial reasons. The noble Lord who has just spoken in many ways let the cat out of the bag. Pressures are exerted on clinicians by management to take actions that they do not necessarily want to take. If a trust is building up a substantial body of patients referred to it by insurance companies, it will want to be sure that within that trust’s operation some element of priority is given to its patients if only to minimise the liability that the insurance company has to the patient to pay their bills. In 10 years’ time, when the Government review the Bill, they will find that the pressure on management to change what happens in hospitals will lead to the beginning of the destruction of the National Health Service as we know it.

[Lord Hunt of Kings Heath]

My Lords, I have a great deal of sympathy with the amendment. When I first worked in a hospital in 1974, the Nuffield Orthopaedic Centre in Oxford, we had a private patients’ ward called Mayfair. The succession of senior consultants, the head OT and head physio, gave me an impression of the priority that was given. There will always be debate about the phasing out of paid beds—this was the case even under Barbara Castle—but some of it arises from real concerns over differentiation in equity of treatment.

I take the amendment to be very focused on the board of an NHS foundation trust, not on individual clinicians. It is an important safeguard regarding the way in which the board of a foundation trust may wish to deal with the financial pressures that it is under. We should not be under any doubt, and I speak as an FT chair, that many foundation trusts are facing financial pressures alongside the rest of the NHS. They are required to make efficiency savings and, probably, to move resources from acute hospitals into primary care without any reassurance that primary care is going to demand-manage. There is a real worry that GPs will give more money to themselves but with no guarantee that that will impact on the flow of patients through acute hospitals. There is concern that the pressure on acute hospitals, instead of reducing, which we would like to see, will actually grow.

Health and Social Care Bill

Lord Campbell-Savours Excerpts

Tuesday 28th February 2012 Lords Chamber

[Earl Howe]

My Lords, I completely agree with my noble friend. I feel that the debate and discussions that we have had in your Lordships’ House have made this a better Bill, as I said a moment ago. Again, a prime example of that is the clauses relating to ministerial accountability. With regard to the Royal Colleges, we have made all sorts of improvements, such as those in response to concerns about the integration of services, education and training, research, health inequalities, ensuring that competition is never an end in itself and a number of other important issues. I am glad that these changes were all welcomed by a wide range of Royal Colleges.

[Lord Campbell-Savours]

My Lords, in the light of what the Minister has just said, if I came to him over the next couple of days and handed him a document about the problems that it is felt will be experienced in specialist services, would he then deal with it before the completion of Report and let me have an answer?

[Earl Howe]

I would be happy to talk to the noble Lord about specialised services, and I speak as the Minister in charge of that policy area. If he would like to contact my office, I would be very glad to see him.