Health and Social Care Bill
Lord Davies of Stamford Excerpts(13 years, 1 month ago)
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Lord Davies of Stamford
My Lords, I think I am the first person to speak in this section of our proceedings this afternoon who is not either a doctor or a specialist in some branch of science very close to medicine—in the case of the noble Lord, Lord Mawhinney, biochemistry. An enormous strength of this House is that we can bring to bear such expertise and personal knowledge in our proceedings on a Bill such as this, and it greatly adds to our credibility in the nation as a whole. Equally, I am not a Platonist in any sense. It would be a disaster for democracy if the only people who took part in debating and determining legislation were those with a professional background or current professional involvement in the field concerned, so I make no apology for speaking.
It has been something of a tradition so far this afternoon to say a few words about one’s personal or family backgrounds in the field of the NHS. I will briefly follow that tradition. I am the third or fourth person to say this this afternoon, but my father also was a GP in the NHS, for 40 years, and an enormous believer in the NHS—he actually qualified a year or two after the NHS Act came into effect. I think that he believed that the NHS was a sacred institution, and I probably inherited some of that sentiment. His great political hero was Nye Bevan. Although he came to believe that something of a mixed economy, both on the supply and demand side, was necessary in the NHS—because otherwise great resources which were available to it would no longer be available to it—he avoided taking on private patients during his whole career. This was on the grounds that if he did not give them a better deal than his NHS patients he would be cheating the private patients; and that if he gave them a better deal than his NHS patients, he would be cheating his NHS patients. He was not prepared to put himself in that position, although of course he did treat his partners’ private patients when they were on leave. That says enough about my family background in this area.
The matter of education and training is fundamental to the NHS—and has been, as the noble Lord, Lord Walton, and others, have pointed out. It has been a symbiotic relationship since 1947. It has been absolutely understood that medical teaching and education were inextricably linked with the delivery of NHS medical care; not just the formal requirement on consultants in teaching hospitals to teach—obviously part of the quid pro quo for their prestigious appointments—but right through the system, including in non-teaching hospitals. This includes the obligation to take on junior doctors and train them properly—the anecdote of the noble Lord, Lord Winston, went to the heart of that tradition; the very fine ethos of the medical profession to take on trainees right through the primary and secondary systems.
That has been the case for all that time since 1947. It is so enormously important that it should continue. Quite clearly, education and training are an existential requirement of the NHS. What has also been in place since 1947 and which has been accepted by successive Governments—I am not sure to what extent it is practiced at the present time—is a willingness to plan forward, to look and see if one has to make assumptions —one is never going to be exact about this. To look and see, taking account of doctors coming from abroad, of British-trained medical students who then want to emigrate; what kind of numbers we are going to have in the future, what kind of numbers we might need, and to modulate the supply against that anticipated level of demand. That is called planning, a word which I know is a very negative word for the present Government. I do not know whether that itself has had some influence on the point I am coming to.
The astonishing point I now come to is that education and training were not originally considered by the Government to be an absolute primordial, elemental responsibility of the Secretary of State and of the NHS, going forward. We had obligations in the Bill as it was originally presented to us from another place, for the Secretary of State to ensure that there was proper consideration given to removing inequalities, to maintaining common autonomy, to encouraging the promotion of research, which is obviously very important, and I commend the Government for that; and to promote public health—again enormously important, and I again commend the Government for that. There is nothing at all about education and training. It was an afterthought.
Baroness Tonge
I do not have an answer for the noble Lord, but I am as horrified as he is that education and training were not in the Bill from the beginning. I had not noticed that the words were not there and I was incredulous when I saw the amendment. I could not believe it. Would he agree that it would be better, in case there are other huge omissions that at this late stage we have still not spotted, if the Bill were withdrawn immediately and rethought?
Lord Davies of Stamford
I certainly agree with the noble Baroness on that. If I have to speculate again, the only hypothesis that I can credibly come up with is that the education and training requirement was not initially in the Bill because the whole thing is a hurried, makeshift, politically driven, ill thought through and frankly almost frivolous exercise—an appalling way to treat a great national institution of which we are all so proud.
I return to the publication of the White Paper in 1944, to which the noble Lord, Lord Walton, referred. He even lobbied the Minister at the time, Mr Willink. It was before I was born and it is wonderful to see the noble Lord in such great form all these years later, defending the NHS. It was an all-party achievement. I am afraid that the Conservative Party in its modern form no longer has the deep commitment to what many of us feel is a matter of national consensus that we hope will continue.
I repeat that this is in no way a personal attack on the Minister: far from it. He did everything that he could to remedy the situation. However, the Government right through the election campaign were against any kind of top-down reorganisation of the health service. They come out with a half-baked Bill, are immediately attacked from many sides and make concessions. People continually run to David Nicholson and say, “You’d better redraft this or that, we haven't thought about this, we have a problem here, what do we do about this?”. David Nicholson dashes off something on a piece of paper and we get another amendment. It is not the way to legislate on any serious matter. It is certainly a lamentable way to legislate on our great National Health Service.
Lord Kakkar
My Lords, I strongly support the amendment in the names of the noble Lords, Lord Walton of Detchant and Lord Patel. I remind your Lordships of own interest as professor of surgery at University College, London. I point out that of all the Members of your Lordships' House who have a background in medicine, I completed my training most recently, some 12 years ago, and am acutely sensitive to the fact that training is vital if we are going to deliver high-quality care. I still remember vividly, and benefit from, the instruction that I was given in my training as a general surgeon.
The purpose of the Bill is to ensure that we provide the highest quality healthcare, achieving the very best outcomes and always putting the interests of the patients of our country at the centre of everything that we do. For this purpose, we need to achieve two fundamental objectives. We need high-quality education of undergraduates to prepare them properly for a life in any of the healthcare professions and to inspire them to be excellent doctors and other healthcare professionals. We must also ensure in postgraduate training that we train future doctors and other healthcare professionals to develop the skills that they require to deliver the best for our patients, and the judgment to apply their skills in an appropriate fashion.
Our system of training is so good and respected throughout the world because it is clinically based. Throughout, those who are fortunate enough to be taken on for training in positions in the National Health Service are exposed to, and have the great privilege to be involved in, the care of the patients of our country. However, the delivery of education and training is a hugely complex issue. Not only must we have the matter in the Bill; it must be dealt with in detail. Notwithstanding the fact that Her Majesty's Government propose to introduce a further Bill to deal with education and training in healthcare, which will be hugely welcome, in the intervening period we must recognise that the delivery of healthcare is integral to the delivery of education and training.
I give an example from training in surgery. Consultants who wish to take on training responsibility have to be trained to do so. They must make time available to have the training to become a trainer. They need to organise the delivery of their clinical practice in the care environment in which they work in a thoughtful fashion, to provide training opportunities for their trainees. Frequently that will mean that the utilisation of NHS resources is less efficient than if the facilities and sessions were delivered purely by a consultant. Training takes time; trainees work at a slower rate; they interrupt what they are doing to seek guidance; and they must be provided with the confidence to become good practitioners.
Beyond that, we need to release those working in our healthcare systems to support medical royal colleges and other professional bodies to set and then supervise the standards of training that must be applied across the National Health Service. That takes them away from clinical practice and again makes the utilisation of the resource potentially less efficient. For trainees, we have to provide an environment that supports training. This is complex, because it requires not only release from service commitments—again, this has an impact on resource utilisation in healthcare systems—but time within the delivery of clinical practice to learn to develop judgment in a fashion that is less efficient than it would be if the clinicians had been fully trained as medical or other healthcare practitioners.
For this reason, I strongly support the amendment that education and training must appear in the Bill as a commitment, an obligation on the Secretary of State for Health. We must also spend more time dealing with the issues that might present problems between the enactment of the Bill and the subsequent appearance of a future health Bill that deals specifically with education and training.
Earl Howe
No, my Lords, that is not the case. I completely reject not only that remark but also the remark of the noble Lord, Lord Davies of Stamford. Our plans for education and training have been moving forward ever since the election. The White Paper in July 2010 set out the broad principles underpinning education and training reforms. A consultation paper was then published in December last year, with the consultation finishing in March of this year. The Future Forum then listened to further views. It recommended the new duty which we are discussing today in the form of Amendment 43, and we accepted that recommendation. Meanwhile, the Future Forum continues to listen to the views of the wide range of stakeholders and its report will feed into future legislation on this topic. We have consciously deferred the meat of this issue to a future Bill, because we have to get it right. We have committed to publishing further proposals on education and training once the Future Forum has concluded its report and there will be a chance for noble Lords and others to feed in at that point if they so wish.
Lord Davies of Stamford
I am afraid that I must stress this point a little further. This debate has revealed a fundamental contradiction in the Government’s position. The Minister argues that Amendment 43 adequately defines the responsibilities that the Secretary of State will have for ensuring that there is an adequate system of medical training and education in this country. It may or may not be the case that the formulation in Amendment 43 is adequate, and we must decide on that matter today.
At the same time, though, the Minister is confessing that the powers that will be given to the Secretary of State in order to fulfil those responsibilities have not yet been defined. We do not know what they are. They have not been decided yet. Surely it is a fatal mistake in life to give anyone responsibility without being clear that they have the powers to undertake it. That is precisely the position in which the Government are placing the Secretary of State.
Lord Walton of Detchant
My Lords, before the debate on these amendments concludes, it had not been the intention of my noble friend Lord Patel and me, on coming to the Committee today, to divide on our Amendment 2. However, our view has been changed a little in the sense that the support that that amendment has had from all sides of the House has been very powerful. I shall read again what the actual Bill says. Under the heading,
“Secretary of State’s duty to promote comprehensive health service”,
it says:
“The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement … in the physical and mental health of the people of England, and … in the prevention, diagnosis and treatment of illness”.
All that we have suggested in Amendment 2 is the addition of a paragraph (c) to secure improvement,
“in the provision of education and training of the health care workforce”.
I find it difficult to suggest that any Government could refuse that amendment. It could be complementary to government Amendment 43. Will the Minister, who everyone in this House feels great respect for, take the amendment away, talk to the Government about it and see whether they might accept it as a government amendment on Report?
Lord Davies of Stamford
My Lords, I congratulate the noble Baroness, Lady Williams, as she could not possibly have come forward with an amendment that is more pertinent, necessary and urgent in the light of the discussion that we have had already this afternoon on medical training and education. It was clear from that discussion that some extraordinary things are happening as a result of this Bill. One extraordinary thing is that duties are being placed on the Secretary of State without any consideration having been given, or certainly no decision having been made, as to what powers he will need in order to carry out those responsibilities. That is a very serious matter and I will come back to it in a moment.
The second serious matter is becoming clearer and clearer. One of the agendas of this very curious Bill—and one asks oneself what its real meaning and hidden agenda are—is obviously to decouple the Secretary of State steadily from political responsibility for the management of the NHS by creating an insulating barrier and a series of quangos. The Minister said this afternoon, in answer to the case put to him by the noble Lord, Lord Warner, about a repetition of the crisis in jobs for junior doctors that occurred a few years ago, that the Secretary of State would not be able to intervene, or to do anything at all, until he had determined that there was a failure by Health Education England. That means that, if he had Questions in the House, he would simply say, “It’s not my fault, Guv. Go and talk to the quango. I don’t know anything about it. I haven’t yet determined that there is a crisis”. That is an extremely unsatisfactory situation.
Earl Howe
My Lords, the noble Lord is caricaturing the position. The Secretary of State, in the case of education and training, would continuously hold Health Education England to account against a set of pre-agreed outcome measures. That is not standing at a distance from what Health Education England does. It is being intimately concerned with what it is doing. I do not want the noble Lord to caricature the Government’s position. I understand that he is not happy with the separation of functions, but that is a matter of policy; his policy differs from that of the Government. I do not want him to go away thinking that this is a totally hands-off affair. The Secretary of State will have legal responsibility and accountability for what Health Education England does and that will be manifested through the outcomes framework.
Lord Davies of Stamford
I am very grateful to the Minister. I will just respond to him before giving way to the noble and learned Lord, Lord Mackay. Indeed, I must not caricature the Government’s position; believe it or not, I do not want to do so. I want to reveal the Government’s position. I am trying to draw out the Government. We succeeded in doing that this afternoon; perhaps the latest intervention from the Minister is part of that. It was extremely useful, but I think it is clear that the Bill imposes certain duties on the Secretary of State and we have often heard, when it comes to the powers that he has, that it is not quite clear what the position is.
What I am particularly concerned about in the area of health education and training, but also in other areas, is, first, that the Secretary of State will be in a position to answer parliamentary Questions about anything to do, in this case, with health education and training. It might be on planning for numbers, public health or whatever, but there should be no sense in which he will simply say, “That is the responsibility of somebody else. I cannot answer that”.
Secondly, I am concerned about the actual powers that the Secretary of State will have to intervene—the ability he will have simply to give directions to one of these quangos, to override it in certain circumstances. The circumstances in which he would be able to override it need to be clearly defined. They should, of course, be defined already so we can look at them at the same time as we look at the new duties. However, they are not defined and we need to know that they will be. I will give way to the noble and learned Lord, Lord Mackay.
Lord Mackay of Clashfern
I did not intend to intervene; I was hoping that the noble Lord might have finished.
Lord Davies of Stamford
That is a very tactful way of putting it. I do not intend to speak for very much longer, but I want to complete my remarks. I simply want to say that any self-respecting person—and I am sure that the Secretary of State is one—would not accept being given duties and responsibilities without being clear about the powers that he or she had to fulfil them. I would not do so. This is a very anomalous position, where we are told that future consideration will be given to what exactly the powers will be, that future Bills will define them. I do not think that is a satisfactory situation at all, if that is the position.
Earl Howe
I made that point in connection with education and training where, as I have said repeatedly, we are still in consultation. As regards the Secretary of State’s powers and duties in this Bill, they are very clear; there is no ambiguity about them. We are going to be debating an amendment in the name of my noble and learned friend Lord Mackay, and I do not want to pre-empt that, but that amendment seems to set out very satisfactorily what the Secretary of State’s powers are. It draws them together very well.
Lord Davies of Stamford
It seems to me that the text of the amendment put forward by the noble Baroness, Lady Williams, differs from the Government’s position in the Bill in that it makes it absolutely clear that the Secretary of State has the duty to intervene. That is stronger wording, and I just wonder why the Government cannot accept it.
Baroness Jay of Paddington
This must not develop into a private discussion about the finer points of our report or the law, in which the noble and learned Lord would certainly be more expert than me. Surely the difference now is that, as it says in the guidance on this Bill,
“the commissioning and provision of services will no longer be delegated by the Secretary of State, but will be directly conferred on the organisations responsible”.
So the organisations responsible cannot have the legal duty that is embraced by the present Act. Therefore, the legal responsibilities of the Secretary of State are automatically fragmented. The straight line of legal enforceability and responsibility, through the bodies who have rightly—as the noble and learned Lord has said—been delegated over a number of years to other providers, has been broken. That link in the chain has gone.
Lord Davies of Stamford
Before the noble Baroness sits down, I wonder if she could just help me with—
Lord Williamson of Horton
I thought it would be nice to hear another voice, having been here since 3 pm or earlier. I should like to come back to these points and follow on directly from the intervention by the noble Baroness, Lady Jay. The word “provide” has not been used by the Secretary of State in the past; none the less it is there in the long history of this way of handling the operation of the National Health Service. We have continually heard here how in the past it has not been used, and I understand that. However, we are not legislating for the past here; we are legislating for the future. I feel that the retention of the word still has some value if we are looking ahead to the future. In this Bill we are not making special arrangements so that the Secretary of State can provide, but what will be the consequences of unexpected events which could hit us in the future when it might be sensible for the Secretary of State to provide? I do not think that that should be ruled out and, for that reason, I am attracted to the amendment of the noble Baroness, Lady Williams. It also has the advantage that in law it is highly intelligible to an ordinary person, which I always appreciate.
I now come to the amendment of the noble and learned Lord, Lord Mackay. I fully understand why he has put it forward and why he thinks that it is better to avoid putting something into the law which has not been operational, replacing it with something which is a more accurate description of what the future situation might be. However, I have one question, which I shall put to the Minister and indirectly to the noble and learned Lord, Lord Mackay.
In paragraph (b) in his amendment there is a cross-reference to Amendment 8, which lists the various intervention functions of the Secretary of State. Basically, all these interventions will be necessary because we will have been struck by some terrible problem—a failure by the Care Quality Commission or NICE. There are all sorts of terrible failures in which the Secretary of State has to intervene. However, I am still anxious about whether, under this formulation, the Secretary of State can intervene proactively—that is, without having to wait until disaster has struck in the various forms listed in Amendment 8. I make that point because I think it is of interest and importance to the people who have raised all the questions in relation to what we are now discussing and what was discussed at Second Reading and in relation to the previous amendment, which was not carried but was in fact discussed very widely in the press. Therefore, I am interested to know whether there is a possibility of proactive intervention by the Secretary of State.
Lord Davies of Stamford
I listened with great attention to the noble Lord and took on board what he said. Of course, the position of Monitor is not entirely comparable because under the Bill it has vastly more powers.
Lord Davies of Stamford
Monitor under the Bill will have vastly more powers than it had. As a result, the situation is not entirely comparable. That is my point.
Lord Newton of Braintree
Monitor has extended responsibilities—and, importantly, a much clearer remit to be concerned with the quality of patient services—beyond what it had when its overwhelming focus was on financial matters. I regard that as an improvement. The Secretary of State under the Bill has more powers over Monitor than it had under the original proposals introduced and passed by the Labour Government. I see that the noble Lord, Lord Warner, is nodding his head.
This is a difficult and complex area. We could argue for ever about the best way to deal with it. I say to my noble friend on the Front Bench that I hope that we can find a way forward. I also hope that many noble Lords will recognise that some things said about the Bill are simply not true.
NHS: Standards of Care and Commissioning
Lord Davies of Stamford Excerpts(13 years, 7 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Turnberg, for tabling a Motion which has occasioned such a fascinating and often moving debate. As has happened previously, the breadth and depth of the contributions create their own problem in that, when there is such a short time available for me to reply, I am up against the clock. To the extent that I am unable to answer specific questions today, I apologise but I will of course happily follow them up in writing.
There are many reasons why we believe it is necessary to modernise the National Health Service. With rising costs of new treatments, an ageing population and rising public expectations, the system is simply not sustainable in its present form. Most importantly, however, the NHS must modernise in order to focus relentlessly on what matters most to patients: improving health outcomes. In so many ways it is a wonderful service, but we know that it can do better and we believe that it must do better. For our ambition is not limited to maintaining the current quality of services, it is far greater—to have health outcomes that are consistently among the very best in the world. I suggest to the noble Baroness, Lady Thornton, who said that now was not the time to do any of this, that the financial situation that we face provides even more of a reason to modernise swiftly. I hope that she and other noble Lords will agree with me that this debate is really about quality.
The noble Lord, Lord Turnberg, began by raising the Parliamentary and Health Service Ombudsman’s report, Care and Compassion? I am sure that all of us can identify with the concerns that he raised about nurse training and accountability for what happens on the hospital ward. I am sure I was not alone in being very moved by the noble Lord’s speech. I fully intend that we should learn from the ombudsman’s report, which is why its findings have been highlighted to NHS boards and why the Care Quality Commission will be commencing unannounced inspection visits shortly. However, I also submit that the changes that we are making to the NHS—placing the patient at the heart of everything we do—will help to guard against this happening in the future.
As the noble Lord, Lord Warner, rightly reminded us, effective commissioning is a key piece of the jigsaw. Currently, commissioning decisions are taken by primary care trusts—remote organisations that frankly few people have heard of and fewer still understand. We propose to hand responsibility for commissioning to GP-led consortia. Why are we doing so? It is because GPs and their clinical colleagues are the people who best understand the health needs of their local populations, and, in partnership with healthcare professionals from across primary, community and secondary care, they are ideally placed to design clinical services that provide more effective, integrated and preventive care.
Lord Davies of Stamford
I am very grateful to the Minister for giving way. Will the present system of “choose and book”, which seems to me to be working extremely well, be perpetuated under the new commissioning consortia regime?
Earl Howe
Yes, my Lords. However, if the noble Lord will forgive me, I do not propose to take many interventions as the time is limited. As I say, the answer to his question is yes.
Those who question the effectiveness of these arrangements should focus on the new framework of accountability that we are proposing as it is central. The new NHS will be more directly accountable than it is now. Because of that our reforms introduce a stronger national framework for driving quality improvement than ever before. How will this accountability work? The Secretary of State will hold the NHS Commissioning Board to account for delivery against the NHS outcomes framework, published in December. The NHS Commissioning Board will then hold individual consortia to account for their performance against the indicators set out in the more locally focused commissioning outcomes framework. There was widespread and strong support for such a framework during our consultation.
The NHS Commissioning Board will decide on the shape and content of the commissioning outcomes framework over the next two years, working closely with emerging consortia and with professional and patient groups. To help maintain momentum, the department will shortly publish a discussion document, seeking more detailed views on possible features of the framework. The Health and Social Care Bill contains a new duty of quality. The NHS Commissioning Board and GP consortia will be required continually to improve the quality of NHS services. Underpinning that, the Care Quality Commission will regulate providers on safety and quality, with wide-ranging enforcement powers to protect patients should providers fail to meet requirements. Accountability works in its fullest sense only if there is transparency. We will publish clear, easy to understand information on the quality of healthcare services and the progress being made to reduce health inequalities. We also propose, subject to the passage of the Bill, that the NHS Commissioning Board be able to make payments to consortia in recognition of the outcomes they achieve collaboratively through commissioning and the effectiveness with which they manage their financial resources.
How will quality be driven through the commissioning system? Quality standards, prepared by NICE, will be at the centre of it. Quality standards bring clarity to quality, providing definitive and authoritative statements of high-quality care, based on evidence of what works best. Quality of care does not cover just the effectiveness of that care but also includes patient safety and patient experience. The three domains of quality are interconnected: they cannot exist in isolation. The Royal College of Physicians reflected on this point in its response to the consultation on the NHS outcomes framework and acknowledged that healthcare that is not safe could not be described as efficient, effective or sustainable.
Our reforms will allow a re-established NICE to produce a broad library of quality standards that will cover the majority of NHS services. NICE will also develop quality standards for social care and public health. The Secretary of State and the NHS Commissioning Board will be able to commission quality standards jointly, which will open up the opportunity for standards to cover the whole care pathway, from public health interventions in primary care through to rehabilitation and long-term support in social care, and will support the integration of health and social care services. It is important to understand that quality standards will do more than just bring clarity to quality: they will have real traction within the system, underpinning the duty of quality and linking with the new best practice tariffs that will see providers paid more for better care.
GP consortia will have a duty to support the NHS Commissioning Board in continuously improving the quality of primary medical care services. That does not alter the board's overarching responsibility for commissioning GP services and holding GP contracts. But it does mean that consortia will play a systematic role in helping to monitor, benchmark and improve the quality of GP services, including through clinical governance and clinical audit. It means also that consortia will have a core role in improving patient care across the system. That will include both the quality and accessibility of the care that GP practices provide and the wider services that consortia commission on behalf of patients.
Where does the Secretary of State sit in all this? The Health and Social Care Bill strengthens the accountability of the Secretary of State to Parliament for the provision of the comprehensive health service. For the first time, the Secretary of State will have to report each year on the performance of the health service, consult on the annual objectives set for the NHS through a mandate, and lay both documents before Parliament. The NHS Commissioning Board will be accountable to the Secretary of State for delivering against that mandate.
Nursing has been a strong theme in the debate. The noble Baroness, Lady Emerton, asked when the Government's response to the report of the commission on nursing will be published. I can assure her that the Government will respond soon to the commission's report and I apologise for not having given her an undertaking to that effect sooner. The noble Lord, Lord Turnberg, and the noble Lord, Lord Winston, raised concerns about nursing standards in hospitals. As they know, we now have matrons in post. They have a specific remit for quality of patient experience and should be accessible to patients and carers. Matrons are directly accountable to directors of nursing, who should present ward-to-board reports. We launched the Principles of Nursing Practice in November last year. This sets out an agreed set of standards and behaviours that were developed by the Royal College of Nursing in association with patient groups. These principles reinforce the NHS constitution.
The noble Lord, Lord Turnberg, asked about the duty of consortia to improve the quality of care for older people. There is no specific duty in the Bill relating to consortia and older people. However, we propose a new duty for consortia to seek continuous improvements in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience. That extends to all aspects of care.
The noble Baroness, Lady Sherlock, spoke about the recent King's Fund report. The report highlights particular variation in relation to patient involvement in decision-making, and in co-ordination and continuity of care. It also highlights the need for changes in leadership and culture. We have a strong system of general practice in this country, but we agree absolutely with the report that there is too much variation in quality. This reinforces the case for GP decommissioning, because one of the key aims behind the development of GP commissioning is for consortia to play a central role in helping to reduce variation and drive up the quality of general practice. There will be strong incentives for GP consortia to want to tackle these variations, because with lower-quality primary care one achieves poorer outcomes for patients and one has greater pressure on more expensive secondary care services.
The noble Baroness, Lady Sherlock, questioned whether the Government were allowing enough time to see whether the changes would work. With the introduction of shadow bodies and early implementers, we are allowing almost three years to consult, to dry-run and to put our reforms into practice on the ground, so that by 2013 the new organisations will have had time to secure capability collectively. Therefore, it is wrong to say that the house is being demolished; in many senses, we are refashioning some parts of the existing edifice.
On that theme, the noble Baroness, Lady Pitkeathley, asked how consortia will be authorised, given their different states of readiness. The pathfinder programme is, I think, central to sharing learning across emerging consortia, and it is a crucial part of their development to take on full commissioning responsibilities. Consortia will not have statutory responsibility for commissioning until April 2013, so the intervening period will allow all consortia to be ready by that time.
We listened to an impassioned speech from the noble Lord, Lord Owen, who criticised the Health and Social Care Bill on a number of fronts. Time prevents me setting out a detailed set of counterarguments but perhaps I may just say to him that we have tabled amendments to the Bill that will put beyond doubt that competition will be on the basis of quality and not price. Far from challenging the principles of the NHS, we have consistently made it clear that we are absolutely committed to a comprehensive National Health Service which is free at the point of use and is based on need rather than ability to pay. Nothing in our plans changes that.
The noble Lord criticised the policy of “any willing provider”, or “any qualified provider” as we are now calling it, because we think that that is a better description of the policy. The noble Baroness, Lady Thornton, did the same. “Any qualified provider” is about empowering patients and carers, improving their outcomes and experience, enabling innovation, and freeing up clinicians to drive change and improve practice. Introducing a choice of any qualified provider will give patients more control. That is what all the research evidence tells us they want and increasingly expect from the NHS. Why should not someone with MS be able to choose the physiotherapist they want and be treated at the time and in the setting that best suits their need? Why should not a patient, at the end of their life, choose their hospice provider? Patients are already able to choose from any provider that meets NHS standards and prices when they are referred for a first out-patient appointment to a consultant-led team. That was an innovation brought in by the previous Government. “Any qualified provider” will extend that principle to more providers and more services, including social enterprises and charities, particularly in community care. For the life of me, I cannot see what is wrong with that. Money will follow the patient and the choices they make about where and by whom they are treated.
The noble Lord, Lord Owen, indicated his belief that the policies that the Government are advancing will damage clinical professionalism and remove the intimacy inherent in the doctor/patient relationship. I say to the noble Lord gently and with huge respect that I do not believe he has any basis whatever for suggesting that. I would argue, on the contrary, that clinically-led commissioning brings the design of services closer to patients.
NHS: Global Health
Lord Davies of Stamford Excerpts(13 years, 11 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank the noble Lord, Lord Crisp, for calling this debate and express my gratitude for his strong and continuing commitment to issues of global health. I found his speech extremely helpful and thought provoking.
The Government are deeply committed to issues of international development. In this year’s spending review we confirmed that, as well as protecting the NHS budget, we will keep our promise to spend 0.7 per cent of gross national income on aid from 2013, helping the billion people who live in extreme poverty around the world. We are equally committed to doing everything we can to meet the millennium development goals. In particular, we are taking bold action to tackle malaria and to improve reproductive, maternal and newborn health. In answer to the noble Baroness, Lady Thornton, we are currently reviewing the previous Government’s cross-Whitehall global health strategy to ensure its relevance and effectiveness in the coming years.
The noble Lord, Lord Crisp, has linked issues of development with those of the appropriate education of health professionals, which itself has enormous implications both for our nation’s health and for that of the rest of the world. As he knows, there are many aspects of the education of health professionals, encompassing pre- and post-registration training, as well as continued professional development. The responsibility for setting the standards required for professional pre-registration sits with the professional regulators. The higher education institutes then design training curricula to meet these standards in partnership with NHS service providers and the regulators. The Department of Health, along with the local NHS bodies that commission professional training, continues to work with the regulators and higher education institutes to ensure that their standards and curricula reflect the changing needs of patients and service delivery.
In terms of pre-registration education for doctors, we look to the General Medical Council for leadership. Its 2009 publication Tomorrow’s Doctors provides the framework that UK medical schools use to design detailed curricula and methods of assessment. I was glad to see the framework was well received by the authors of the recent Lancet Commission publication, Health Professionals for a New Century. The framework also highlights the importance of a global dimension. New graduates must be able to demonstrate awareness, from a global perspective, of the determinants of health and disease and of the variations in healthcare delivery and medical practice. Postgraduate medical training curricula are developed by the medical royal colleges for approval by the GMC. Most of the topics highlighted in this debate are covered in the foundation programme curriculum and core competence framework for doctors developed by the Academy of Medical Royal Colleges.
We have come a long way since the noble Lord wrote his report on medical training, Global Health Partnerships, in 2007. My noble friend Lord McColl is absolutely right that there is already significant good practice in the UK in terms of incorporating the global dimension into pre- and post-registration training. This is one part of the answer to the noble Lord, Lord Crisp, who asked me to consider what more might be done to support this type of activity. Medical students can study global health; they can spend a year studying international health as part of an intercalated degree or can choose to travel to developing countries for the elective component of their undergraduate training. There are also opportunities for post-registration medical doctors to spend part of their specialty training in developing countries, as part of the out-of-programme training and research arrangements. Here, I reassure my noble friend Lady Tonge and the noble Baroness, Lady Hollins, that, if prospectively approved, training of this type counts towards the certificate of completion of training. Details of this initiative are provided in the Gold Guide, a guide for postgraduate specialty training in the UK agreed by the four UK health departments for core and/or specialty training programmes. This sets out a clear process as a guide for post-graduate deans.
My noble friend Lord McColl—
Baroness Northover
This is a time-limited debate and the Minister has 12 minutes to reply. There is no possibility of intervention.