Independent Medicines and Medical Devices Safety Review

Lord Greaves Excerpts

Wednesday 15th July 2020 Lords Chamber

[Lord Greaves (LD)]

My Lords, this is yet another outstanding report from the noble Baroness, Lady Cumberlege. The beginning of the “Implementation” section reads:

“Our recommendations are designed to pave the way for a future healthcare system that looks and feels very different.”


This is not only an outstanding report; it is a revolutionary report. Do the Government accept that this is not just another committee of inquiry but an investigation that found the facts and came back with recommendations? Are they going to set up the task force?

[Lord Bethell]

I completely agree with the noble Lord, Lord Greaves, that this is an important report. I pay tribute to my predecessor my noble friend Lord O’Shaughnessy, who commissioned it. We take it extremely seriously. No one could possibly read about the hardships suffered by the women described in this report without wanting to move swiftly on it. It has only been a few days so I cannot announce a strict timetable for every measure, but I assure the noble Lord that it is taken seriously and we will be moving on it in the very near future.

Health: Tick-borne Encephalitis

Lord Greaves Excerpts

Tuesday 5th November 2019 Lords Chamber

Asked by

[Lord Greaves]

To ask Her Majesty’s Government what assessment they have made of the appearance in England of a tick-borne encephalitis virus, and what plans they have to include advice about such a virus alongside that given on the tick-borne Borreliosis bacteria and associated Lyme disease.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, the risk from tick-borne encephalitis virus is assessed as very low for the general public and low for those visiting, living and working in areas where infected ticks have been found. Lyme disease is the most common tick-borne infection in the United Kingdom. Tick awareness campaigns are planned for early 2020, ahead of the seasonal increase in tick activity in the UK, and will include information on tick-borne encephalitis and Lyme disease.

[Lord Greaves (LD)]

My Lords, the history of Lyme disease, a bacterial infection called Borreliosis, has been riddled over many years with mistakes of understanding, recognition, testing, diagnosis and treatment. Tick-borne encephalitis—a viral infection—has now reached the UK for the first time, having been steadily spreading westwards across Europe for several years. What are the Government doing to make sure that the mistakes that have been made—and are still being made—on Lyme disease are not made on TBE, and in particular that new instances of TBE are not mistaken for Lyme?

[Baroness Blackwood of North Oxford]

The noble Lord is right to raise this issue. We have been making sure that action is taken quickly. Tick bite avoidance is a key message in this area and is the same for TBEV as for Lyme disease. PHE has worked with local authorities and key stakeholders in the relevant areas, informing them about TBE and the tick toolkit documents and guidance, so that they can remind the public, their staff and visitors to be tick aware. Specific awareness campaigns will come forward in spring 2020. The material for these will include information on Lyme disease and TBE. In addition, there will be research programmes on TBE, to ensure that we in the UK are as aware as we can be about it. To be clear, there has been only one probable case of TBE infection diagnosed —a European visitor bitten by a tick in the UK. At the moment, this is a very low risk to anyone in the UK and a low risk to those in the areas.

Sustainability and Transformation Plans

Lord Greaves Excerpts

Thursday 26th January 2017 Lords Chamber

Asked by

[Lord Greaves]

To ask Her Majesty’s Government what progress is being made with the Sustainability and Transformation Plans for England.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, proposals have been published for all 42 sustainability and transformation plans—also known as STPs—covering every part of England, with a goal of making the NHS five-year forward view a reality. NHS organisations have now submitted their operational plans for 2017-19. These are the next steps in turning STPs from proposals into practical action.

[Lord Greaves (LD)]

My Lords, with 42 areas, a huge number of meetings, a huge amount of report-writing and research and all kinds of things are taking place, diverting a large amount of time and resources. The Government see the operation as a way of slashing spending, but the professionals involved on the ground see it as a way of providing better services. Do the Government realise that they cannot carry out another huge wave of reorganisations in these 42 areas without extra resources, rather than less resources? Can they tell us how many staff are engaged on the STP process and at what cost, and how much is being spent on consultants and other outside support to carry out this operation? How much is it all costing?

[Lord O'Shaughnessy]

My Lords, the sustainability and transformation plans are operational plans for putting the NHS’s own five-year forward view into practice. They are about the community and clinically led redesign of services to do things such as make it easier to see a GP, improve cancer diagnosis and give faster mental health support. Noble Lords might be interested to know some of the big opportunities for service improvement identified by the Lancashire and South Cumbria STP, which is local to the noble Lord: 27% of people seeing their GP could have had their issue resolved another way; 25% to 50% of hospital beds were used by people who did not need to be there; and 30% of A&E attendances could have been avoided. It has said that about £176 million of efficiencies could be found in the acute providers within that STP area alone. There are huge opportunities for change. It is clear that any changes cannot be approved without public consultation or without delivering clinical improvements. The Government are backing these plans in two ways. First, with the £1.8 billion—

Lyme Disease

Lord Greaves Excerpts

Thursday 22nd October 2015 Grand Committee

Asked by

[Lord Greaves]

To ask Her Majesty’s Government what action they are taking to combat Lyme disease and other tick-related illnesses.

[Lord Greaves (LD)]

My Lords, Lyme disease, or Lyme borreliosis, is an infectious disease transmitted to humans and other animals by bites from infected ticks, which are small blood-sucking arthropods related to spiders, and I can tell you that they are pretty nasty things. Ticks occur throughout the UK. They live on vegetation, particularly damp areas of vegetation such as bracken. They are found throughout the countryside but they also appear in towns—in parks and increasingly in suburban gardens—and they appear to be increasing in number.

Lyme disease can cause debilitating conditions, both acute and chronic. Basically, it can knock people out, producing symptoms similar to ME, migraines, neurological symptoms and persistent flu-like symptoms—symptoms both physical and mental—so it is pretty serious stuff. At the moment, the only test for Lyme disease is a blood test, which is not wholly reliable since it produces many false negatives. The levels of knowledge about this disease within the NHS are inadequate—some would say woefully inadequate.

I thank all noble Lords who have put their names down to speak. The noble Countess, Lady Mar, would very much have liked to be here, but she is poorly; I am sure that we all wish her well.

My interest in this disease came originally from outdoor activities—from a life spent mountaineering, walking and climbing. My interest in it was rekindled about a year ago by an article I read in Le Monde, which led me to put down a number of Written Questions last January, which I trust have been circulated by the Library. The point that I got from that article was that knowledge of Lyme disease is not only insufficient but very controversial in health services in different parts of the world. I pay tribute to Lyme Disease Action, a small charity, which provides assistance to people with Lyme symptoms and with Lyme disease. It also campaigns for improved services within the NHS and provides some extremely useful material, both in pamphlet form and on its website. Without its resources, I think we would be in an even more difficult position.

After I tabled this Question, I spent three weeks last June—skiving off, as they say—in the French Pyrenees, in the mountains. One morning, I woke up in bed to find this nasty creature burrowing deeply into my stomach. It was the first time that I had been head to head with a tick—or should I say her head and my belly?—and it was not a pleasant experience.

Too little is known about Lyme disease, and there is controversy over its incidence, its diagnosis, its treatment and the relative success of different treatments. There is also confusion because there are other tick-related diseases which we appear to know even less about than Lyme disease, and which we might well be talking about in this way in a few years’ time.

Things have been improving. The understanding and importance that the NHS gives to Lyme disease has improved in the past year or two. However, ticks are spreading; there is no doubt that there are more of them. The question is: can anything be done about that, or do we simply have to accept that it is part and parcel of the wildlife out there and we have to live with it?

Information and public education are not as good as they ought to be, although happily this debate coincides with quite a lot of publicity in the media about ticks and Lyme disease largely because a number of celebrities appear to have caught it. John Caudwell, the founder of Phones 4u—I confess that I have never heard of it before—and his family are running a campaign and other celebrities have been found to have this. So, this is causing a useful outbreak of publicity and one which I hope the Government will take advantage of.

I have one or two high-level questions for the Government. First, is it time for a major Government-sponsored inquiry into the growing incidence of ticks in the environment and tick-related diseases? It is not just the countryside—it is happening in people’s gardens. Secondly, is there a need to promote much better knowledge of ticks and Lyme disease among doctors, nurses and health professionals generally? I think it is obvious that there is a very great need for this. Certainly, an increasing number who know about these things, but there are many doctors whose knowledge is woefully inadequate.

Thirdly, what can be done to make the general public more aware? I am talking about the outdoor fraternity, organisations such as the Ramblers and the British Mountaineering Council—I declare an interest as a vice-president—as well as farmers, gardeners, and schools that take their children out into the countryside. There is scope for much better information and understanding out there. Lyme Disease Action has asked for five things to be done and I would like to put these on record and ask the Government for their response to them.

First, it stresses the need to find out how many people in the UK are infected and affected by Lyme disease. We need to know the true scale of the problem and, at the moment, we do not know that. There are something like 1,200 positive test results a year in the UK. The NHS believes the number of people infected with Lyme disease each year is about 3,000, but it might be a lot more. There is a lot of misdiagnosis. People are diagnosed with Lyme disease when they have something else and a lot of people who have Lyme disease, whether it is the immediate form or the chronic form, are not being diagnosed.

Secondly, there is a need for the NHS to acknowledge the uncertainties with diagnosis and treatment. There is a lot of anecdotal evidence of being people being told, frankly, nonsensical things. A classic case was somebody who was told they could not have Lyme disease because they lived in London. People are also being told that the tests are accurate and reliable, and they are not. Too many consultants are saying the blood tests are perfect and the treatment always works. Neither is true.

Thirdly, there needs to be a better working partnership between LDA and the NHS. One of my daughters’ partners has a lot of Lyme-type symptoms and has been passed from pillar to post by doctors, consultants and clinics in different places in North Yorkshire, where they live. The problem is that nobody is taking responsibility for sorting out what is wrong with that person. That is a typical experience in a lot of places.

Fourthly, guidance for UK health professionals needs to be developed, especially for those in secondary care. I am aware that Public Health England and NICE are working on this, but some interim guidance is needed urgently. Fifthly, regional centres of experience need to be established so that the burden does not all fall on one small charity.

I shall finish with a quote from LDA:

“The current level of knowledge is appalling. Doctors do not understand the tests, the epidemiology or the disease itself”.

I am impressed by the number of people who have been in contact with me since this question was tabled. I would love to read out a lot of what they say, but I have not got time. There is a serious problem. I look forward to the debate and to the Minister’s response.

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I echo other noble Lords in thanking the noble Lord, Lord Greaves, for raising this important issue. I, too, have read a lot in the media over the past two or three weeks; that has been good in raising awareness of the whole issue, and I hope that this debate today will also do so. A big theme in the contributions from noble Lords has been the need to raise awareness, not just with the public but with GPs and clinicians.

I seem to be almost the only person in this room who has not had—if I may put it this way—a head-to-head relationship with a tick, but I can imagine that it was not a happy occasion for the noble Lord, Lord Greaves, or for others.

The briefing by the Lyme Disease Action group was excellent. It was measured, well-informed and very constructive, so I thank the group. Secondly, I know that Dr Tim Brooks, the head of the Rare and Imported Pathogens Laboratory at PHE at Porton Down, is very happy to meet with noble Lords or others who are interested outside the Chamber to discuss this in more detail.

I would like to deal with two issues before I talk more generally about the importance of awareness, treatment and research. First, the noble Lord, Lord Greaves, raised the issue of a national inquiry. I do not think that we will go down that route at this stage. Secondly, on the point raised by the noble Lord, Lord Patel, about the NICE guidelines on how early we should start treatment with antibiotics, I will take that up separately with NICE.

We recognise that Lyme disease is overwhelmingly the most important tick-borne infection in the UK, and we are aware that its incidence has risen severalfold over the past couple of decades. Even so, the UK has a much lower incidence of tick-borne diseases than the rest of Europe or North America—indeed, I believe it was in Lyme in New England where it was originally discovered. Many of the more deadly diseases do not occur here at all. However, as noble Lords have mentioned, Lyme disease can be acquired almost across the country now—in Richmond Park or in North Yorkshire. Therefore, it is important that doctors across the country can recognise the features of these diseases even if the patient lives in an area not hitherto associated with Lyme disease.

I will talk first about public awareness, an issue that all noble Lords have raised, particularly the noble Baroness, Lady Parminter; she described her daughter going off on a Duke of Edinburgh’s Award trip, which is a good illustration of the need for public awareness. To raise awareness among the public, the first line of attack should be on the tick. Public Health England is working with Liverpool University and others to survey tick populations and the organisms they host to determine risk areas across the UK. PHE, the charity Lyme Disease Action and various local councils and national park authorities produce public information leaflets on how people can protect themselves against tick bites and on what to do after a tick bite. Noble Lords might like to look on NHS Choices, for example, where they can see what a tick bite looks like, and if anyone would like any materials on this horrible disease, I would be very happy to distribute them later.

Early diagnosis and treatment of Lyme disease is the best way of limiting complications once a patient has been infected. GPs are, of course, at the front line of this. NICE and Lyme Disease Action produce guidance and training modules for GPs, and PHE has a helpline for doctors, as well as running GP training days. Specialist doctors have access to the literature on Lyme disease and are trained in the recognition and management of the disease within their higher professional training and continuous professional development. There is clearly much more that we can and should do in raising awareness. Of course, one of the difficulties is that many GPs never—or very rarely—come across a case of Lyme disease. Nevertheless, we can and must do more to raise awareness. That is possibly the most important thing that we should be doing.

Public Health England has a long and distinguished history of diagnosing infectious disease and developing tests for this purpose. A key principle is that the test should be able to recognise true cases of the disease and distinguish it from other conditions that might cause the same symptoms.

In Lyme disease, current tests rely on finding the organism, which is rarely present in the blood and so it would be looked for in tissue samples taken by a biopsy. This is impractical in general practice and, of course, not popular with patients. Rather than finding the organism, looking for the antibody response is the most productive diagnosis. The body produces the antibodies as it tries to clear the infection. If a patient is treated early, there will be insufficient antibodies in the blood so the test will also be negative. Tests taken early in infection, before enough antibodies have been made, also will be negative. Therefore, doctors should be aware that if symptoms persist a second sample should be taken at a later date when the antibodies have developed.

There is a routine test used by PHE of a commercial product used by many other national laboratories across Europe. Through an international, external, quality assurance scheme, the performance of these tests is compared regularly against more than 70 other state laboratories in Europe and meets the current high standard. Tests used by private laboratories may not be subjected to the same rigorous quality control and I think this is an important issue that has been obscured in some of the reporting by the media. There is no requirement for these labs to demonstrate the evidence base for their test and some tests inevitably will give a very high rate of false positive results. This is why some GPs and infectious disease specialists frequently will not accept test results from independent laboratories because they wish to avoid unnecessary or inappropriate treatment. Of course, I can totally understand how frustrating and upsetting that is for individual patients. PHE recognises limitations in the present tests, especially in early disease and in the subset of complicated cases, and is working with national and international partners to develop and evaluate new testing methods. It is a complex disease, it is a difficult disease and I do not think we will be doing ourselves any favours if we try to oversimplify it.

Turning to treatment, oral antibiotics are the mainstay of treatment for Lyme disease and are successful in the majority of cases. Of course, the earlier that the bite or disease is treated, by and large, the better. However, it is becoming increasingly apparent that in complicated disease, especially where there are significant neurological symptoms, more than one course of antibiotics may be needed and a course of intravenous antibiotics may sometimes be indicated. PHE has published a referral pathway for GPs to follow to ensure that problem cases are seen by appropriate NHS specialists.

Some patients suffer debilitating illness with symptoms that persist after treatment for several months or longer. What therapy is appropriate for these patients depends on whether symptoms are a function of persisting pathogen or a legacy of damage that the pathogen has left behind. More research is needed to identify the basis of these persistent symptoms and define effective treatments. As the symptoms may be non-specific, a key part of management is a careful investigation to ensure that other serious conditions are limited. I am reminded by a question this week in the House of Lords about post-polio syndrome. It seemed to raise very similar issues.

Patients need to have access to physicians with an interest in Lyme disease. Since the disease can be present in many different ways and can be confused with other more life-threatening conditions, in future this could be best done by establishing a network of interested NHS practitioners across the country with multidisciplinary experience. This issue was raised by a number of noble Lords and clearly is important.

On research, PHE has a long track record in infectious disease research both through its laboratories at Porton Down and in partnership with universities and international groups. This provides PHE with deep background knowledge and specific expertise and techniques. With the University of Liverpool, PHE is looking at new markers of Lyme disease infection and this is supplemented by work in the Czech Republic to evaluate potential test methods at different stages of disease by accessing a large clinic with a high throughput of Lyme patients. PHE is also exploring new concepts for both diagnosis and treatment through its relationships in the United States. Having a network of interested professionals across the country will enable further clinical studies to be undertaken if funding can be secured. Funding is clearly going to be extremely tight within the NHS. If we could secure funding from private sources as well, that would be a very sensible way forward.

This has been a very good debate. Just having the debate itself helps raise public awareness. A lot is being done but clearly there is a lot more that needs to be done. I reiterate the offer from PHE that if noble Lords would like a more detailed discussion with it, perhaps along the same lines as the discussion the noble Countess, Lady Mar, had at Porton Down with members of Lyme Disease Action, we are very happy to organise that.

[Lord Greaves]

Before the Minister sits down, will he comment on the suggestion that the pressure on the small charity LDA to provide help and advice in individual cases might be lessened by some sort of regional organisation: clinics, groups of GPs or whatever?

[Lord Prior of Brampton]

I think I mentioned that the intention is to have people with specialist knowledge of Lyme disease around the country. We feel that that would be a better approach than having a single centre.

NHS: Accident and Emergency Services

Lord Greaves Excerpts

Thursday 15th January 2015 Lords Chamber

[Lord Greaves (LD)]

My Lords, I will follow up the remarks that have just been made by the noble Viscount, Lord Simon, on ambulance response times.

Pendle Borough Council in Lancashire—I declare an interest and remind the House that I am a member of it—has made full use of its new statutory scrutiny powers concerning the health service as laid down in the Health and Social Care Act. A meeting of its health scrutiny panel this week received evidence from councillors and members of the public. For Pendle as a whole, in the three months at the end of last year the number of ambulances arriving within eight minutes was only just over half, at 55.7%. However, in the West Craven area of Pendle—the towns of Barnoldswick and Earby and surrounding villages on what might be called the Lancashire-Yorkshire border country—it was 10.7%, which is clearly not satisfactory.

Evidence was also received from members of the public on 999 calls that on at least two occasions, on 17 November and 14 December, 999 calls were put through to the ambulance service, but then went on to an answering machine. Clearly that is totally unsatisfactory. I wonder whether the Minister will have a quiet word and find out whether something is seriously wrong in this part of the North West Ambulance Service.

The rest of what I want to say comes from a hands-on account by a worker at a Greater Manchester hospital who works nights in A&E, which I have very kindly been supplied by UNISON North West. I would like to read out the account that this worker has provided, which shows the pressure that workers such as this are under. The account says:

“We work as a team—there are doctors, nurses, mental health specialists, radiologists. It’s challenging and rewarding work. Staff work 12 hour shifts and rarely get to take their scheduled breaks. I just have to grab something to eat and keep going.

We never know what we’re going to encounter … but some things are predictable … a lot of alcohol-related cases up until about 3am. From 5am we begin to get broken hip or fractured neck cases where elderly people have had a fall. These are often people in care homes who are having ‘unwitnessed falls’ when they get up. I think that if there were enough staff in care homes some of these accidents would never happen.

Sometimes people come in with minor ailments like colds because they can’t get a GP appointment … But our main problem is that we don’t have enough capacity for people who really need to be admitted.

We see most patients within 4 hours. If they need to be admitted they should then go to the MAU (Medical Assessment Unit) for the first 24 hours, but sometimes there isn’t space … We have some bays on A&E where people can wait on trolley beds, but if we have too many then patients can have to wait for 2 or 3 hours on corridors. Ambulance paramedics help to provide the care that patients need while they wait, but it is a frustration to us that they are not being treated in the right environment. Detaining the paramedics also has a knock-on effect for the time it takes to respond to new emergency calls.

When MAU is full, the registrar will come to A&E and discharge people when they can. This can be a problem and we can sometimes see the same people in A&E the next night and even the night after that.

If they need to be admitted and there is no room in MAU, patients might be moved out of MAU after less than 24 hours. Other patients who are sleeping on wards can be moved during the night to make space for them to be accommodated. It can be that people end up on a ward that is not best placed to meet their needs.

We are struggling to provide the level of care that we want to because we don’t have enough capacity. We want to provide the best but the service is always stretched … We feel that we have to work flat out all the time just to keep things going … I sometimes can see that staff are so stressed that they should really be off work, but they won’t take time off as they know that will make things even worse for their colleagues”.

In a sense, that shows the strength of what is traditionally known as the public service ethos but really it indicates that it is not just when the four hour target is being breached that these kinds of stressful situations and pressures exist, but week-in, week-out through the year, as many of us know from the experience of the people we speak to.

Health and Social Care Bill

Lord Greaves Excerpts

Monday 19th March 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, it is with a very heavy heart that I feel I must stand up and record that many of the voices outside, who are very scared about this Bill and what it means, are people who are of no particular political persuasion. Yet they are worried about the problem of lack of financial transparency, about the number of private healthcare companies incorporated in offshore jurisdictions—which they see may evade taxes of various types—and about the commissioning process. They are also concerned that the use of public money in the healthcare system will slowly be obscured like a great iceberg wrapped in fog. They will work to deliver whatever is needed for the patients in front of them. The vast majority of them stand to gain nothing by this Bill passing, but to gain nothing either if it does not pass. They want to improve the standards for their patients, and indeed they argue for change.

The noble Earl has worked tirelessly and has confidence across the whole House. Everybody, however much they have been concerned about this Bill, owes him an enormous debt of gratitude for the way that he has listened to every single one of us, at all times of the day and night, and weekends and so on. But we should not let this Bill pass without recognising the enormous concerns there are outside this House among those who will be delivering healthcare, now and into the future, in whatever form it takes.

[Lord Greaves]

My Lords, this has been an extraordinary parliamentary process. When this Bill was introduced, I said at Second Reading that it was a bad Bill. It was a bad Bill when it came here; there has been a growing tide of opposition to it and concern throughout the process while it was in the Commons and the Lords. There was the pause in the Commons and the Future Forum, which resulted in a large number of changes, and at that time Nick Clegg said that no Bill is better than a bad Bill. What we all individually have to do now—I speak very much for myself and not my party—is to assess whether it has now moved over from being a bad Bill to perhaps being, as Nick Clegg said last week, a much better Bill.

There is no doubt at all that on a spectrum of bad to good, it has shifted very considerably. It shifted in the Commons; it shifted far more here in the House of Lords. I believe that the process in your Lordships’ House has been the House of Lords at its best. This House can be proud of the work that it has done throughout the gruelling Committee stage, then during Report and again today. I regret that I could not take a detailed part in much of that, because I was then spending time as a patient of the NHS, but I have been watching it all and I believe that the work this House has done has been absolutely superb.

If I can make a party political point here for a moment, the work that our team has done on the Bill, led by my noble friend Lady Jolly with all my other noble friends who have taken part, has contributed well. I refer not only to the Liberal Democrats but to Cross Benchers and everybody around the House. Tribute has been paid to the Minister. I pay particular tribute as a Liberal Democrat to our person on the ministerial team, my noble friend Lady Northover, who from our point of view has played a very important part by being a link into the Government and getting many of the changes which have taken place.

It is about not just the changes to the Bill but the implementation—the work that starts after this Bill has been passed, as no doubt it will be today. A huge number of ministerial assurances have been made, which may or may not be put upon people’s bedroom walls as the noble Baroness, Lady Cumberlege, wants to do with hers. Nevertheless, this is a Bill which has had more outside scrutiny and involvement from people out there, as far as the House of Lords is concerned, than any other Bill I can remember in 12 years in your Lordships’ House. That will continue with the implementation, and it is absolutely crucial how the Government now implement this Bill. Will it be gung-ho privatisation, which is what people were very frightened of when the Bill was first introduced and many are still frightened about, or will it be implemented in a cautious and careful way to allow the health service to breathe and to cope with the changes? This will be absolutely crucial, and we will know the answer to that in a year or two’s time.

The noble Earl, Lord Howe, said that we have had debates of unparalleled length and scope, and that is true. However, as I have just said, the public interest and lobbying on this from outside has been unprecedented. One of the lessons that we all have to learn is that we—whether the House of Lords, members of the Government or our party—have not coped with that very well. I do not think that the Opposition coped with it terribly well either because, even this morning, I was getting e-mails telling me what the Bill did, some of which was absolutely untrue. They were still telling me that the Bill removes the duty on the Secretary of State to provide health services. We are still getting that, and the amount of education or information which goes out from debates within this Chamber to the outside world is pretty poor.

Several people have said, “We have been trying to follow this Bill. We have been trying to follow your Marshalled Lists, having discovered where to find them on the internet. We have been trying to follow the parliament channel, and we haven’t understood a word of it. It is interesting, but we can’t understand it”. I have to tell them that that applies to quite a lot of Members of your Lordships’ House while the Bill is going through.

[Lord Winston]

Could the noble Lord tell us whether he intends to vote for or against the amendment?

[Lord Greaves]

I am coming to that. So having said all this, why am I going to vote for the amendment moved by the noble Baroness, Lady Thornton? I will do so very unhappily because I do not like voting against my noble friends, particularly when they have done so much hard work and achieved so much. I do not like voting against the party anyway but, having looked at it, it seems to me that the safeguards which have been achieved are not sufficient. Having read the latest version of the Bill which we got at Third Reading, I think it is inevitable that this Bill will lead to greater commercialisation. It will lead to a greater emphasis on competition rather than integration, and to a continuing incursion of private sector-based companies into the provision of NHS services. It is undoubtedly a radical top-down restructuring, in direct contradiction of the coalition agreement that I signed up to. That is being imposed on the health service at the same time as it is struggling with the biggest financial problems that it has had for many years. This is all in the face of the overwhelming opposition of NHS staff, professional groups, patient groups, public opinion and, indeed, a majority of people in my own party and of people who vote for us.

I believe that the new structures at local level will be no less bureaucratic, less open and accountable—

[Noble Lords]

Sit down.

[Lord Greaves]

I am just saying what I think, and I have a right to do that. I believe that my party is being extremely brave in supporting this Bill as it now exists. I also believe that my party has had a bit too much of being extremely brave in recent times, but nevertheless, it is. I voted against this Bill at Second Reading; I will do so again now in favour of this amendment.

Now I feel very much like little Johnny, marching along, and all the rest of my party are out of step. I think that I am in step, and I think very hard indeed about this. Your Lordships’ House as a whole, and the Government, are the people out of step—certainly out of step with opinion in the country and in the health service. However, I agree entirely with what the noble Baroness, Lady Thornton, said, about what now matters if the Bill is passed—[Interruption.] I do not know whose phone that is; it is not mine. That is someone who is out of step.

There has been a lot of alarmist talk. It probably will not amount to much, but it is up to everyone in the health service, and to us here as we scrutinise the regulations, to ensure that it does not. I am frightened by this Bill and I shall vote against it.

[Noble Lords]

Hear, hear!

Health and Social Care Bill

Lord Greaves Excerpts

Tuesday 28th February 2012 Lords Chamber

[Earl Howe]

Far be it from me to say that the noble Lord, Lord Martin, would ever miss anything; he is too wise a head for that. I see nothing strange or amiss in a party leader wishing to address his parliamentary colleagues on the eve of a party conference to bring them up to date on a major Bill and its progress in the House and to set out some of the remaining concerns that he has that we need to settle. These concerns came as no news to me as I have been talking about them regularly not only with Liberal Democrat colleagues but with other Members of your Lordships' House and members of the medical profession. I see nothing amiss in the letter spelling out those concerns. How we arrive at a resolution of those issues is yet to be seen. As I have said, amendments have already been tabled which we shall debate. It is possible that more will be tabled over the days ahead—I do not rule that out at all. However, the noble Lord should not forget that there are non-legislative ways of reaching the destination that some of my noble friends would like to get to. There are many ways of achieving some of these objectives. It is entirely possible that we shall agree amendments to do that but that is not by any means the only course open to us.

[Lord Greaves]

My Lords, I am a little confused about all this, and I wonder if my noble friend the Minister can help me. I received the letter yesterday. At the top it stated, “Keep this completely secret and do not tell anybody”. I switched on the television and there it was. I am confused because I watched and listened to the exchanges in the House of Commons this afternoon, which, I have to say, were a great deal more vigorous and bad-tempered in many ways than the exchanges here; and I congratulate the noble Baroness on the Labour Front Bench who did a much better job of responding on this matter than her colleagues in the House of Commons.

However, here we have the Labour Party, which in government made major strides towards introducing competition, privatisation and commercialisation of the health service, and now has been very strong indeed in opposing those matters when it comes to the Bill. I do not understand that. The other thing that I do not understand is that if what the noble Baroness says is correct—that many of the things she and her colleagues have been putting forward at Committee stage and have been saying outside this House are now being put forward by Liberal Democrats in the amendments that we were told about in the letter from my noble friend and my party leader—why is she not standing up and offering her help, with some enthusiasm, instead of being so grumpy about it all and the way in which this has been done? There seems to be huge confusion on the Opposition Front Bench and in the opposition party, and I wonder if my noble friend can suggest any gentle therapy that it might take up to help it with this problem.

[Earl Howe]

I am very happy to pick up that challenge from my noble friend; in fact, I have been using all my charms and skills on the Benches opposite without any effect at all. I feel that I may have arrived at an impasse. My noble friend is absolutely right because the situation that we inherited from the previous Government was in many ways one that we embraced—it was they who opened up choice in the NHS and indeed put a right of choice into the NHS constitution. However, they did not roll out competition and choice in the way that was appropriate and right, because it cannot be right to impose competition on the NHS whether it wants it or not. It cannot be right for there to be preferential prices for the private sector, with the NHS being disadvantaged. It cannot be right to have an explicit target of increasing private sector provision in the NHS, which is what the previous Government had. It cannot be right for private providers to cherry-pick the easy cases and leave the NHS with the hard cases. We do not approve of fragmenting care pathways.

We do not think that the previous Government thought nearly hard enough about how this was all to be regulated, which is why we want a sector-specific health regulator. That is the reason for having Monitor and is why we think the provisions of Part 3 make sense because they are in the interests of patients and the NHS. I still hope that in our debates I can engender some movement on the Benches opposite to recognise that we are actually trying to improve the situation that we inherited for the benefit of everyone.

Health and Social Care Bill

Lord Greaves Excerpts

Wednesday 30th November 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I certainly support the amendments tabled by the noble Baroness, Lady Williams, who has just spoken, and they go further than the amendments to which I have added my name. I would just draw the attention of the House to the conflicts of interest guidance from the General Medical Council, which makes it quite clear that doctors,

“must be honest in financial and commercial dealings with employers, insurers or other organisations or individuals”.

It goes on to say:

“If you have a financial or commercial interest in an organisation to which you plan to refer a patient for treatment or investigation, you must tell the patient about your interest”.

I would also remind the House that the ultimate sanction is to be struck off, and that if you are struck off, you lose your livelihood. I have a concern that when it comes to the implementation, warnings may actually be issued rather than stronger sanctions taken against those who might breach such guidance, because this is guidance, and it is therefore subject to interpretation.

This whole group of amendments has really gone to the heart of the problem of conflicts of interest, both for the individual general practitioner, who would be on a clinical commissioning group, but also their families and all those others around. It may be friends of theirs, who they know really well, with whom they are inclined to place some commissioning contract, or enter into some arrangement. There is a really fine line between having a personal interest, and going to that person because professionally you think that they are the best person to do the job.

Of course, I will say as a doctor, we all know the doctors that we would like to be referred to, and we all know the people who we want to work with in our teams. That is human nature. It is a mixture of competence and attitude, but there is also something about having a shared set of values, and so on, because you tend to gravitate towards people who share the same set of values as yourself. The highest principles and values would of course fall, I would hope, outside of the conflicts of interest, but financial interest is a really difficult one.

While I would suggest that none of these amendments are absolutely perfect, this group of amendments illustrates the fact that we need to come back to this at Report with a definitive amendment that really crystallises the whole problem around conflict of interest in commissioning.

[Lord Greaves]

My Lords, I spoke on an earlier amendment this afternoon about issues that come round and round, and this one comes round across Bills. We had a great deal of quite difficult discussion on these matters in the Localism Bill—now the Localism Act—and achieved what we hoped will be a satisfactory compromise in the Bill.

It is all about standards in public life and the importance of all bodies that deal with public funds and public functions being part of the regime of standards in public life. I assume that clinical commissioning groups, while not part of local government, are certainly part of local governance, or they will be part of local governance as far as the health service is concerned. They will deal with a lot of authorities that have the standards of public life regime as part of their own practice. I wanted to go very quickly through the basic principles that need to be established in my view before this Bill is finished. First of all there have to be clear rules. In The Localism Act they are set out in Part 1, Chapter 7, across 11 pages and in parts of the schedules. There need to be set out on the face of the Bill so that everybody knows where we are.

There needs to be a code of conduct, whatever it is called, which is based on the Nolan principles. We came to the view in the Localism Bill, now the Act, that those principles needed to be set out again on the face of the Act: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. In my view they ought to be set out on the face of this Bill.

There needs to be a system which members of commissioning groups have to register appropriate interests and again in the Localism Act some of these were pecuniary interests, going back to the old wording which is now on the face of the new Act. There are interests other than pecuniary interests which also need to be registered even if they do not debar people from taking part in decisions. If we are going to be open about what interests people have, then they ought to be there on record. There needs to be a register of interests—there is no point in registering if there is not an open public register. Then there needs to be a system in which people taking decisions and taking part in decision-making meetings have to declare interests at the point of that decision, as in the system that we have in your Lordships’ House. As the noble Baroness said, it needs to involve close families and partners as well as the individuals concerned.

Then there is no point in having that unless you have a system of dealing with complaints. It needs to be very clear what the system is, how such complaints are investigated and what penalties there are for breaching the rules. There may be different penalties for different rules. Clearly breaching the system in relation to financial pecuniary interests is much more serious than breaching one for non-pecuniary interests.

The penalties need to be clear and understood and the system for judging on them needs to be clear. The whole system has to be in the public domain. The system itself has to be open and transparent and all the actions taken under the system, whether it is just registering an interest or dealing with a complaint and the results of that complaint, have to be open, transparent and in the public domain. It seems to me that those are the principles. The details will quite rightly differ according to different organisations and different contexts. I am not suggesting the details of the local government scheme, although the amendment of my noble friend Lady Williams picks up some of the wording from the Localism Act, I think. Clearly CCGs are different from local authorities, but they are not sufficiently different that the basic principles should not apply, or the basic rules and regulations about avoiding conflicts of interest and declaring those interests when they exist and enforcing those interests within the framework of a broad code of conduct. That in my view has to apply and I hope that when the Bill leaves this House, it will incorporate sufficient detail to give those assurances.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, there is an additional area which I think means that the provisions in this Bill have to be different from other previous legislation. We face a huge financial challenge across the whole of healthcare, with budgets squeezed in a way they have not been squeezed before. So the potential for conflict of interest will go up as very difficult decisions are made. One can envisage the situation where somebody on the governing body of a clinical commissioning group will have a relative with a certain condition—and I refer back to the example I used previously, motor neurone disease. Say that person needs end-of-life care, and say that is a clinical commissioning group that has decided that it is not commissioning it in its area. There would be a direct personal conflict of interest, because that person would obviously want that care for their relative, but they would need to stand back. With the financial stringencies, the proposed amendments become even more important. While they are probing amendments, I hope the Minister in responding will recognise the importance of this area and agree to come back to it—hopefully, with a Government amendment—at a later stage.

[Lord Greaves]

My Lords, in brief response to the noble Lord, Lord Warner, I am not suggesting in any way that the regime should be identical to the local government regime, but that the decision-making body in clinical commissioning groups will be the board. Under the new Section 14A, the board will include lay members and possibly other people. So merely relying upon professional standards and professional systems of discipline will not be sufficient.

[Baroness Masham of Ilton]

My Lords, I spoke on Second Reading of the need for safeguards. These are important amendments. They are safeguards which are necessary. Many people are worried about the conflict of interest.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I have a number of amendments in this group. I will start with Amendment 159A which questions why, on page 9, line 36, it is possible for non-providers of primary medical services to be eligible to apply to establish a clinical commissioning group. Particularly in the light of my noble friend’s comments on Amendment 159, one would surely only want applicants who had experience of providing GP services to be able to apply to form a clinical commissioning group.

Amendment 160A requires the board, before considering an application to form a clinical commissioning group, to consult with the general public, the relevant local authority, the relevant health and wellbeing board, and patients receiving primary medical services from providers within the clinical commissioning group. The noble Lord, Lord Greaves, raised some pertinent questions about transparency in the formation of clinical commissioning groups. It is extraordinary that there seems to be no process by which putative CCGs consult with their patients before they make an application. The decision is, essentially, being made by bureaucrats within the National Health Service system—who put constraints on CCGs,—and the GPs themselves. Where on earth are the public in all of this?

[Lord Greaves]

The noble Lord very kindly referred to what I said. Is it not also the case that a group of GPs could go ahead and put forward proposals without even consulting all the GPs in their area?

[Lord Hunt of Kings Heath]

From reading the Bill, it is only when two or more are gathered together that they can make such an application. So the noble Lord is quite right. The amendment is seeking assurance that there will be public consultation and consultation with patients. We are told this is all about patients. Can patients therefore be consulted before GPs commit themselves to forming a clinical commissioning group? Or are we just to be told at some stage, “That’s it, you are in that clinical commissioning group because you are in that practice and you have no choice”. It is remarkably high-handed for it all to be done with no public involvement whatever. It is remarkable how many changes are already being made without any statutory authority given by this legislation.

I want to continue the theme of consultation, because I have a number of amendments in this group which come back to the same point: Amendment 164A in relation to the board’s determination of applications; Amendment 166 in relation to variations in the constitution of clinical commissioning groups; Amendment 166B in respect of variations made in the area covered by a clinical commissioning group, as specified in the constitution; Amendment 167A in respect of mergers, and Amendment 167B as regards the dissolution of clinical commissioning groups.

If I as a patient am part of the clinical commissioning group, one would have thought that I would have a role in deciding whether it is appropriate for that clinical commissioning group to be dissolved, or is that again just for the GPs to decide? What about Amendment 216ZZA as regards commissioning plans? Perhaps I have misread the Bill and there are crucial points which would envisage members of the public and patients within a CCG area being consulted on all these matters.

--- Later in debate ---

[Lord Patel]

My Lords, I thought that I might get up to say one sentence to stop this conversation from going further. My name is on several amendments, particularly those proposed by the noble Lord, Lord Warner, about competency. I have a simple question, which I am sure the Minister will be able to answer easily. What competencies do the commissioners have to demonstrate before they are authorised to become commissioners? I know that there will be guidance, but what competencies will be looked at that demonstrate that they can be commissioners? I am being very brief today because of being chastised for talking too long; but now I have evidence that suggests that I was not the worst, so I will carry on another time.

[Lord Greaves]

My Lords, I want to say one or two things about the consultation and go back to what I was saying before dinner. The question of patients is a bit of a red herring. To that extent, I think that the noble Lord, Lord Hunt of Kings Heath, was asking to be tripped up over it. Everybody is a patient to some extent, but the important thing is that the residents of an area, or citizens—whatever they are called nowadays—should know what is going on and that there should be an opportunity for a public debate to take place in the normal places—local newspapers, local radio, public meetings—about the future, structure and organisation of the health services in their area.

The noble Lord, Lord Hunt, was absolutely right when he said that there is a huge amount going on at the moment. It is not going on in complete secrecy; people involved in it know what is happening and are telling other people, and people in local authorities and others are having some discussions. However, by and large, there is not a proper process for providing people with open and full—or even partial—information about the proposals that are taking place. I do not think that it is a question of patients being able to tell their doctors which CCG they want to be part of, because the CCGs will be area-based, as we all know, and the doctors will be part of the CCG in their area. The questions are: what area is that going to cover, where is the CCG going to be, and how is it going to fit in to the health service? That is a fundamental question. So to that extent the noble Lord, Lord Hunt, is absolutely right. I think that the question of patients is a red herring.

Whenever I go to see my doctor, I consult him about what is happening in the health service, he consults me about that and all sorts of other things, and occasionally we get around to talking about my health; but I do not suppose that I am a very typical patient. That is a fact of life. However, it is a fundamental problem, and the source of a huge amount of the mistrust about what is going on at the moment is that people simply cannot find out what is going on. That is not in the amendments to this Bill. The Minister and his colleagues simply need to tell the health service to be a lot more open and transparent about what is going on and allow local debate on it.

[Earl Howe]

My Lords, these amendments are all concerned with the process of the establishment of CCGs or changes to the established organisation. The Bill lays the groundwork for the NHS Commissioning Board to establish CCGs. Ensuring the competence of an applicant group to exercise the functions of a CCG is a key part of that process.

In the first instance, the board may publish guidance on the making of applications and this may include details of how it will assess the fitness of CCGs for establishment and therefore their suitability to assume responsibility for exercising their commissioning functions. That is really what Amendment 159 is trying to get at. The whole process is intended to ensure that the CCG has made appropriate arrangements to discharge its functions competently. If the board is not satisfied about that, it will not grant the CCG’s application, or else it will grant it subject to conditions under the transitional arrangements.

I can confirm that we intend to make provision in regulations to require the NHS Commissioning Board to take the views of the shadow health and well-being board into account when they consider the establishment of a CCG. Health and well-being boards will be able to provide insight into the willingness and ability of a prospective CCG to be involved in partnership working and engaging with the local population. That is the theme of Amendments 160A and 162.

However, in my view, wider mandatory consultation with the public, either by a prospective CCG or by the board on receipt of an application to be established, would be completely disproportionate and add unwarranted delay to the establishment of new arrangements. We already have intelligence that early implementer health and well-being boards are engaging in constructive dialogue with CCG pathfinders about the right size, area and configuration to best meet local patient needs. That is fine, but problems arise when you start to mandate it. I am very uncomfortable about that. Consultation with the public has its rightful place but I was completely unconvinced by the argument of the noble Lord, Lord Hunt. For my money he simply has not made the case.

We also need to ensure that we do not have a cumbersome process for agreeing changes to CCGs, which may evolve over time as organisations and may choose to merge formally or to adapt their constitutions, which of course would need to be agreed with the board. A number of amendments in this group seek to require consultation, with the public, the relevant local authority, the relevant health and well-being board and patients receiving primary medical services from providers within the CCG, for different processes: establishment, variation, merger or dissolution of CCGs. The Bill as it stands would set clear duties for patient and public engagement in new Section 14Z. CCGs would have to engage the public in their planning of the commissioning arrangements; in the development and consideration of commissioning proposals, which would have an impact on the manner in which the services are delivered to the individuals; and in the range of health services available. They would also have to engage on decisions of the CCG affecting the operation of the commissioning arrangements where implementation of the arrangements would impact on individuals or the range of services available. The CCG would also have to consult the patients it is responsible for on its commissioning plan. That is quite right and proper and I hope that, in that area at least, there will be some agreement across the House.

As regards local authorities and health and well-being boards, these boards will include representation from the local authority and CCGs. I suggest that is the ideal forum for CCGs to discuss proposals such as mergers with their fellow members. However, it would not be appropriate to impose an explicit requirement for CCGs to consult the board on such matters.

Turning to Amendments 164B, 166A, 166C and 167C, tabled by the noble Lord, Lord Hunt of Kings Heath, I commend the report of the Delegated Powers and Regulatory Reform Committee of your Lordships’ House. These amendments would make the resolution procedure for certain regulation-making powers relating to applications between CCGs and the board affirmative. This approach was rejected by the DPRRC, which found that the negative resolution procedure would give noble Lords ample opportunity to consider regulations laid before the House covering determination of applications for establishment of a CCG, for variation of CCG constitutions and on dissolution of CCGs.

The noble Lord, Lord Patel, asked me about competencies. In September the department published Developing Clinical Commissioning Groups: Towards Authorisation, which sets out our current thinking on the domains that the Commissioning Board may wish to use as indicators to judge the competencies of prospective CCG commissions.

While I know that there will not be a meeting of minds over this, I hope that I have at least fleshed out what the Government’s intentions are. There will, obviously, be opportunity for further reflection on these matters.

Health and Social Care Bill

Lord Greaves Excerpts

Wednesday 30th November 2011 Lords Chamber

[Baroness Murphy]

I agree; they were too small. However, if you want to get that balance and that advantage of the clinical commissioning, it seems that, with a different sort of central support, it would be possible. With some local responses and reconfiguring of commissioning groups and the old PCTs, it can work. I do not feel quite as depressed about the clinical commissioning groups as other people.

[Lord Greaves]

I was going to make merely a brief intervention on this group on the question of coterminosity. However, this has extended into a much more important debate, which is coming down to some very fundamental issues in relation to clinical commissioning groups. The noble Lord, Lord Hunt, is to be congratulated on introducing this debate because it is absolutely crucial. We have to have it some time—if we are having it on this amendment, fine.

The noble Lord said in passing that the same issues keep coming round at different stages of the Bill. On this Bill the same issues keep coming round in different sessions in Committee. This is the second time we have talked about coterminosity. I think previously it was on an amendment from his colleague, the noble Baroness, Lady Thornton. I will not repeat everything that I said then, except to say that there has to be some flexibility. There are very good arguments for saying that CCGs should not cross local social care authority boundaries. However, the point I made previously was that in very large counties, like Lancashire or North Yorkshire or, if I think about the south of England—which I force myself to do occasionally—Hampshire and Kent perhaps, at the very least they ought to have the ability to not have a very large CCG forced on them that covers a whole county, which would be very remote indeed.

We have heard about Cornwall and Devon from my noble friend. We have heard about Birmingham. I am going to say a few things about Lancashire. I am very interested to know whether there are any noble Lords in Committee today who are very clear about what is happening in relation to setting up CCGs in their own areas, how it will work and what will come out of it. Asking colleagues on the Liberal Democrat Benches while this debate has been going on, nobody seems to know; chaos and confusion seem to be the impression. I am not saying that it is chaos and confusion, but as far as ordinary members of the public are concerned, let alone other people like myself who try to take a more direct interest, it is not very clear at all what is happening, or if what is happening is clear, it is not clear why and how it is happening. This comes back to the points raised by the noble Lord, Lord Hunt, about the fact that there are very clear pressures from above that are moulding the system that is going to take place. I very much take the point from the noble Baroness, Lady Murphy, that there ought to be local discretion and local decision-making here. However, that is not happening. People are being forced into decisions, and that goes against what she was saying.

Let me tell you about where I live, in east Lancashire. At the moment there are two PCTs. There is a Blackburn with Darwen PCT, because Blackburn with Darwen escaped from Lancashire County Council at some stage in the past and became a small unitary authority, so it has its own PCT. The other five districts, which are part of Lancashire County Council, have an East Lancashire PCT which, as the noble Baroness pointed out, had been formed by amalgamations over the years. There is one East Lancashire Hospitals NHS Trust that effectively covers the two PCTs, so there are two PCTs and one hospital trust at the moment. The PCTs have been combined with the rest of Lancashire into a county-wide cluster, but the East Lancashire PCT still exists.

I have recently been given a whole set of minutes and agenda papers, a great big thick file, from a relatively recent meeting—in the last few weeks—of the East Lancashire PCT. Although they find it increasingly difficult to keep going because all their chief officers have gone, there are still functions taking place at the PCT level; there are functions taking place at the cluster level, and for somebody like me who takes an interest in but is not directly involved in the health service nowadays—I used to be on a district health authority, an area health authority and a community health council, but am not now—I find it very difficult to find out where the decision-making is taking place.

Back when CCGs came along, the original idea was that they would be quite small, as the noble Lord, Lord Mawhinney, quite rightly said. They would be groups of GP practices within a recognisably local area. Whether that was a good or a bad idea—and in many ways it was an attractive idea—that has clearly now gone by the wayside. People were told that the minimum that you could get away with in east Lancashire was district-wide—that is the lower tier—so people were getting together and forming proto-CCGs at the district level.

In terms of population, Rossendale is about 70,000 and Pendle is probably the biggest of the five at about 90,000; it is that sort of range. The doctors who were getting together and working on these CCGs—and certainly in both Burnley and Pendle they were working closely with the district authorities to share back-room services and so on when they were set up—were told that this will not do any more. I am not at all clear who told them, but it has been made absolutely clear that there now has to be a new CCG covering the five districts, an area of 450,000 people. It is a very significantly different proposition, however you define significant, from groups of local practices, where the whole thing started off.

Blackburn and Darwen, because it is a unitary authority, is insisting that as far it is concerned, it will have its own CCG, which will be coterminous with the relatively small unitary authority, which has a population of around 140,000.

[Lord Hunt of Kings Heath]

Has that potential CCG been told that it will not get authorised? I would think that that is the way in which the system will force it into a larger merger.

[Lord Greaves]

I assume so, but I have no personal knowledge of the processes that are leading to these outcomes. All I hear about—from talking to people who are professionals and politicians involved in these systems and through the normal bush telegraph—is the outcome. The outcome is that there is almost certainly going to be a CCG 450,000 bigger, as I understand it, than any of the doctors involved would really like, and there have to be far fewer doctors involved from each of the districts. In my own district, it was going to be a Pendle-wide organisation where all the doctors involved would be known to a lot of people in Pendle, but now there will be just a small number from Pendle and some from Rossendale and some from far-flung parts of the Ribble valley. Meanwhile in west Lancashire, along the Fylde coast, where there is a string of small holiday towns with Blackpool in the middle and then a large area of countryside, are the two districts of Fylde and Wyre while Blackpool itself, the main town of the Fylde coast, is a unitary authority. What we understand is going to happen there—I have no direct evidence of this, it has come through the bush telegraph—is a CCG of Fylde and Wyre, a relatively smaller one, with Blackpool on its own. Of course all the hospital services and everything else are mainly in Blackpool. There does not seem to be any logic about what is going on, even though it is being defined by local authority boundaries.

I ask the Government to provide some clarity over what is happening in two ways. First it would be very helpful to have clarity on what is actually happening in each area, and for this whole process to be taking place in a much more public way. But it is not. It is all taking place out of the public gaze, and unless there are local journalists who are particularly interested in it and try to research it, nobody has the slightest idea what is going on, whether or not it is being decided locally.

More importantly, I accept what the noble Baroness, Lady Murphy, says, but I think that we need an understanding of the sort of pattern which is going to result from this Bill once it is enacted and the CCGs are set up. We want a clarity of vision from the Government. What sort of number are they talking about? What range of size will be thought to be permissible? If they are saying that it could stretch from areas of 15,000 right up to a major city of half a million or so, and that sort of thing will be left to some sort of diffuse local decision-making, then that is okay, but we need to understand that. If, on the other hand the Government are saying that a lot of the groups that have been looking at this are far too small and they have to be much larger, then they are really moving towards what I might call the Lord Warner position, and again we need to understand that. We have a right to know what the outcomes of this legislation are likely to be before we allow it to go forward.

[Baroness Wall of New Barnet]

My Lords, the noble Baroness, Lady Jolly, has made a very strong argument for what might happen in her part of the world. However for London it is very different, and I want to remind noble Lords that this is about health and social care, and relate what happened in my area.

My trust is part of north central London and that cluster is now going to be merged with north east London. The cluster has been a great improvement on the separate PCTs, not just because of the way they do things, but in the whole vision they have of the health economy. One of the things that we suffered from in Barnet and Chase Farm and North Middlesex was that we were all separate, independently operating providers. We just took notice of what we were providing and what was happening around us. The BEH—Barnet, Enfield and Haringey strategy—made us look beyond that at the whole health economy. The evidence is that we have been failing in not providing social care or community care because each individual provider was looking at what was happening for them and its importance to them.

I can only share the experience that is happening in London. My view is, and our experience as a trust is, that the bigger the cluster has been and the bigger the cluster will become, the more opportunity there is to ensure that the whole health economy of the people that we serve is going to be taken into account, rather than that minuscule Barnet PCT, Enfield PCT or Haringey PCT. I know that they are much closer than Lancashire, and I come from Lancashire, so I recognise some of those areas. People are questioning what is happening in London, and it is very different. The smaller the groups, the worse it is, in my experience, because we are not addressing the whole economy.

I believe, as the noble Lord, Lord Warner, has said, that we need a much broader and wider experience in the sense of the numbers that we might have. I do not know how big is big or how good is big. What I do know is the difference that it has made, in my experience, across London, that the bigger we have got in the sense of the clusters, the better the service has been and the more able we have been to take our eye away from just acute providers to looking at what is going on in the community. We have failed to do that, and all the debates that we have been hearing in the House during the passage of the Bill have identified how much we have been failing. Most of the social care issues that we have discussed are about how we failed. In my view, as a chair of an acute trust, it is about us being focused on patients coming in to hospital rather than patients being able to have their provision elsewhere. From my experience in London, we need less of them, so that we get a complete health economy view.

[Lord Greaves]

What the noble Baroness, Lady Wall, says is very interesting. Does she understand what the future pattern of CCGs in that area is going to be in relation to the borough PCTs and the clusters that she is talking about?

[Baroness Wall of New Barnet]

In my experience, the PCTs, in a sense, do not exist any more, in my part of London; I am not sure about elsewhere. Contrary to what the noble Lord, Lord Newton, suggested, it has not happened in London. All the PCTs have not been absorbed into the cluster. The chair of each of the PCTs that were in place before the cluster and the growth of the cluster has been seconded as chair of their particular PCT. For me, the important thing is who is making the decisions about the commissioning and what view they have. What is the panorama that they are looking at, rather than the closeness of the individual boundaries? Certainly from the PCTs in London, the clusters are taking over the way that is going more and more; and their relationship with the GP commissioners is much closer than it ever was in separate PCTs, and that has been part of the issue.

[Lord Greaves]

I am really impressed by the enthusiasm shown by the noble Baroness. I understand exactly what she said. The way in which the clusters have been put together is exactly the same, as I understand it, as in Lancashire. What I am trying to get her to tell us, if she knows, is how many CCGs there will be in the area of her cluster once the clusters have disappeared.

[Baroness Wall of New Barnet]

I cannot answer for the whole of London. I really do not know. What I do know is that the more the clusters emerge, obviously the more those PCTs will be absorbed into them. My noble friend will be much more able to give you more detail about that.

What is happening in real life in north central London is that the PCTs are being absorbed into the cluster. Contrary to the experience of the noble Lord, Lord Newton, the clusters have not just taken over the whole PCTs, including staff and everything else; they have not. In fact, the chief executive of the cluster in north central London did not come from north London at all. So that is very different, I think, from some of the experiences that other people have. However, I cannot give you the view of the whole of London because I really do not have that knowledge.

--- Later in debate ---

[Lord Greaves]

I apologise for intervening, but if that is the case can my noble friend the Minister tell me who told the group of GPs in Pendle, who had been developing proposals for a CCG, that they would have to go in with the other four districts in East Lancashire?

[Earl Howe]

My Lords, in those instances, and they are very few, where a pathfinder CCG is of a manifestly unviable size, then it is right that they should receive advice to that effect at an early juncture. Advice is the word. The initial thinking is simply suggesting that emerging groups should be considering the impact of their proposed configurations on their organisational viability and the degree of sharing roles and functions or the use of commissioning support that they might need.

[Lord Greaves]

Is my noble friend, therefore telling me that a well defined borough with a population of 90,000 is manifestly unviable for this purpose?

[Earl Howe]

No my Lords, I am not aware of the specific circumstances that my noble friend refers to and of course I will find out and give him greater chapter and verse if I can.

--- Later in debate ---

[Earl Howe]

Yes, the noble Lord, Lord Hunt, suggested earlier that there was a process of shoe-horning CCGs into certain shapes and sizes, forcing them to take up external support and merge commissioning functions. I emphasise that CCGs will not be forced to take up external support or merge functions. What is happening at the moment is a process of advice and information from the centre. Obviously, the board will not authorise the establishment of any CCG which could not satisfy the board of its ability to discharge its functions and be an effective commissioner. We want to ensure that the process is not too bureaucratic or cumbersome. The noble Lord suggested that it was likely to be, but I do not accept that. We are working with stakeholders to ensure that emerging CCGs can articulate their requirements for commissioning support. I do not accept the picture that he has painted.

My noble friend Lord Newton spoke about the clustering of PCTs. Clusters bring together PCTs to prepare for and support the transition to clinical commissioning. Until PCT abolition in April 2013, they continue to exercise their functions and remain statutorily responsible for their functions until abolition. Pathfinders, or emerging CCGs, can act as sub-committees of PCTs until this time. The role of PCT clusters during the transition is to support clinical commissioning groups, not dictate how they operate. For the reasons that I have stated, it is important that CCGs have the freedom to develop their own solutions from the bottom up and that they are fully supported in doing so. The latest operating framework for the NHS emphasises this and we will see that it is acted upon.

My noble friend Lord James queried the legal arrangements. The process of clustering has been open and transparent. If it is acceptable to noble Lords, I can provide a written update on the latest position, giving the numbers, locations and so on, to save time.

[Lord Greaves]

If a CCG pathfinder can operate in the mean time as a committee of the PCT, will it act as a sub-committee of the PCT or of the cluster?

[Earl Howe]

Of the PCT, because the cluster has no legal standing.

Health and Social Care Bill

Lord Greaves Excerpts

Monday 28th November 2011 Lords Chamber

[Earl Howe]

It is highly unlikely that that scenario would arise. What could happen is that the board could identify certain services where it felt that competition would serve the interests of patients. Let us take the example of children’s wheelchair services. If that choice offer were created by the board and Monitor created a tariff for those services, it would be up to local commissioners to decide whether to take advantage of that choice offer. There may be instances where that would be a very good thing to do. On the other hand, in other local areas clinical commissioning groups might find that there was no need to create a local market because the services were already adequate. It might be helpful if I write with some detailed examples of how this is expected to work.

The point that I want to emphasise is that the board’s decisions about who will supply particular services could result in one type of provider having a larger market share. That is fine, as long as the intention is to deliver a service that meets the needs of patients in an area. As I say, what is not acceptable is for a conscious decision to be taken to increase the market share of a particular sector just for the sake of it, unrelated to patient need.

[Lord Greaves]

My Lords, this has been a useful discussion. This clause takes a bit of reading but its meaning is quite clear and it was explained very carefully by the Minister and my noble friend Lady Williams. However, there is one point that I want to raise. I have an old fashioned, perhaps rather simple, view of legislation. When you read it, you should be able to understand what it means. The bit of this clause that is not good in this respect is new paragraph (b). New paragraph (a) very clearly says that the Secretary of State and these bodies cannot discriminate for ideological, dogmatic or general policy reasons in favour of either the public sector or the private sector. That is clearly there because of the concerns that the whole purpose of this legislation is to discriminate in favour of the private sector, as the Minister has explained very carefully.

However, new paragraph (b), which refers to what the Minister described as charities, voluntary organisations and social enterprises, refers to,

“some other aspect of their status”.

That is not clear and understandable legislation. I suggest that the Minister thinks seriously about coming back at a later stage and replacing those words with a clear explanation of what the Bill is referring to, which appears to be charities, voluntary organisations and social enterprises. If nobody else does so, I shall table an amendment on Report to replace the current wording with those words. However, I would prefer the Government to put into legislation words that ordinary people—or even the sort of extraordinary people who might want to read this legislation when it has been passed—can read and understand, rather than vague words such as,

“some other aspect of their status”.

[Baroness Finlay of Llandaff]

The Minister’s comments have been most helpful, so far as they have gone. Taking on board the comments made by the noble Lord, Lord Greaves, it will be helpful, when the Minister writes in response to this evening’s debate, to stipulate how the new arrangements will differ from what is currently available to commissioning by PCTs or by other groups. The voluntary sector works very well, by and large, with the current commissioning bodies and finds that it is viewed as good quality and value for money, by and large, though not all the time. The difference in the arrangements needs to be clarified in that letter so that people can really understand if there is a difference and where it is, and also to allay the fears which are quite widespread in the voluntary sector, as was stated so clearly by the noble Baroness, Lady Armstrong.