General Dental Council (Fitness to Practise etc.) Order 2015

Lord Hunt of Kings Heath Excerpts

Monday 18th January 2016 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, thank the Minister for his careful explanation of the order. I welcome the opportunity to debate it as well as the performance of the General Dental Council.

This is one of a number of Section 60 orders that the Minister has brought before your Lordships’ House in the absence of a Bill following up the Law Commission’s work. Will the Minister be able to update the Committee on exactly where we stand with the Government’s intention with regard to whether they see that any part of the Law Commission’s work will lead to legislation in the future? On the order itself, its terms seem unexceptional, although I would like to raise a few points with the noble Lord. The real question before us is whether the General Dental Council is a fit and proper organisation, capable of implementing the changes.

I shall start, however, with the order and will come on to the issues with the GDC and the various reports that have been published about its poor performance over the past four years. On the order, first, I refer to paragraph 8.4 of the Explanatory Memorandum, which refers to a number of organisations which have commented. The British Dental Association is not listed there. I have received a briefing from the British Dental Association, and I wondered whether it had submitted a response to the department. If it has, I am surprised that it is not listed in paragraph 8.4.

The other point I want to make about the order concerns the question raised by the noble Lord, Lord Colwyn, which is about the performance of the GDC. The BDA briefing that I have received states that while the GDC is,

“Britain’s most expensive healthcare regulator”,

it,

“is also the least efficient, most troubled and enjoys little confidence among”,

either dentists or the Professional Standards Authority. It states that the GDC failed to meet eight out of 24 of the PSA standards of good regulation in its 2014-15 performance review and, crucially, fully met only one of the 10 standards relating to fitness-to-practise processes, representing what the PSA describes as,

“a significant decline in its performance compared to the assessment of the year before”.

The BDA points out that, in comparison, last year, the GMC met every one of the 24 standards while charging its members less than half of the annual retention fee that the GDC charges.

I also pick up the point raised by the noble Lord, Lord Colwyn, about the importance of the independence of case examiners. This is a point that we have raised before on some of these Section 60 orders. It is crucial because of the problems that have arisen from the way the GDC has conducted cases in the past, as identified by the various inquiries. I very much support the noble Lord in emphasising that case examiners must be, and be seen to be, independent.

We then come to the real issue for me, which is GDC governance. The Minister will be aware that in February 2013, the Professional Standards Authority published a report following the resignation of the GDC’s chair, Alison Lockyer, in May 2011. The Department of Health had asked the PSA to investigate several concerns which the then chairman had raised in a letter she had written to the Secretary of State on her resignation.

The PSA’s findings were complex. It did not find that the GDC was failing, but it identified some general learning which could be gained from the experiences of the GDC. Following the PSA’s report into the allegations made by Lockyer, it wrote that new evidence had come to light about poor practice in the support and operation of the GDC’s investigation committee. In July 2013, a member of the investigation committee raised concerns under the GDC’s whistleblower policy that certain processes were compromising the independence of the investigating committee’s decision-making. The GDC also commissioned an independent review into the concerns of the whistleblower, which was published in 2014, but in April 2014 the PSA started its own investigation. This was published on 21 December 2015.

The PSA came to a number of conclusions and found several areas of improvement for the GDC. I will come to the main recommendation but I read this report with considerable disquiet. I do not think I have ever seen a report relating to a statutory regulator quite like it. It was published only a few weeks ago, before Christmas. Paragraph 2.1 of the summary states:

“The approach taken by the GDC to recruiting, training and supervising the Investigating Committee Secretaries is likely to have contributed to the development/continuance of objectionable practices”.

These are objectionable practices by the statutory professional body concerned with dentistry. It is a very long report of more than 300 pages but, to get the flavour of it, here are some of the objectionable practices listed that the PSA looked into. First, there are:

“Discussions about cases between Investigating Committee Secretaries and Investigating Committee Chairs prior to Investigating Committee meetings”.

Then, quite remarkably, there is,

“advance drafting of Investigating Committee decision documents/reasons by Investigating Committee Secretaries”.

There are irregularities around the,

“provision of legal advice by Investigating Committee Secretaries to the Investigating Committee during Investigating Committee meetings … Inappropriate interventions/undue influence by Investigating Committee Secretaries during Investigating Committee meetings”,

and,

“amendment of Investigating Committee decision documents after Investigating Committee meetings by Investigating Committee Secretaries without appropriate authorisation”.

There are other identified irregularities but I do not need to go into them; I have made the point. The PSA report goes through this in great detail and its overall recommendation is:

“The GDC’s Council, executive management team and the relevant committees should consider this report in full, both individually and collectively, in order to identify all the lessons that should be learnt in particular in relation to governance, accountability and management oversight, as well as the actions the GDC should take to address our recommendations”.

The point I want to make about this is that these matters now go back some years. It was 2011 when the then chairman first raised those issues. This report was started in 2014 and finished only a few weeks ago. It clearly found continuing improper practices—or at least those that would not accord with good practice. Reading between the lines, I see here a culture of utter complacency within the GDC. It looks as though the GDC has simply not accepted the core conclusions of the various reports written about its conduct and carried on with that complacent culture. It is also clear from reading between the lines of the report and the careful way it has been put together that the PSA lacks confidence in the performance of the GDC. Frankly, I would have expected the entire board of the GDC to resign in the light of that report just before Christmas. I understand that the chief executive has resigned but no one else on the board seems prepared to take responsibility for a culture that has clearly lasted over a good many years. That is not acceptable. Can there be any confidence that this organisation is fit for purpose?

I now understand the concerns that the profession has about the GDC. I had not realised until I went through this information just why there was so much angst within the profession. It is absolutely justified. I would be doubtful of putting any order through in relation to the GDC unless we were absolutely certain that it is able to carry out its job properly.

[Lord Prior of Brampton]

My Lords, a number of points have been raised. I will start with those raised by my noble friend Lord Colwyn. He said that independence is critical for the case examiners; I will address that issue first. It is important to remember that case examiners will not be making findings of fact in respect of whether a registrant’s fitness to practise is impaired. They will make the decision about whether a case needs to proceed to the adjudication stage and be considered by a practice committee.

Additionally, in its rules and guidance, the GDC will provide that the case examiners must make decisions based on documentary evidence, which will be supplied to them in the same manner as is currently the case for the investigating committee. The case examiners will not be involved in evidence-gathering. There will be one lay and one registrant case examiner considering an allegation. I accept, however, that they will be employees of the GDC. Nevertheless, our feeling is that sufficient safeguards are built into the way that case examiners will work.

The issue raised by my noble friend and expanded on by the noble Lord, Lord Hunt, is fundamental. If the GDC is not a fit organisation—if its governance and performance are not right—that is a much more profound worry than the details of the order before us today. Before I address this, I will deal with one other point that the noble Lord raised. He asked whether the BDA had submitted anything. It has; it was omitted in error and is now being attached.

Clearly, we are concerned about the performance of the GDC. The report from the PSA is indeed extremely worrying. As the noble Lord said, this has not happened just recently; it goes back many years. It is very important that the council takes responsibility for the proper running of its organisation. My colleague Ben Gummer is the Minister with direct responsibility for the GDC and he has a meeting coming up in the very near future to discuss the GDC’s performance in the light of the PSA report. It is not all bad news in that report. There are some signs that the GDC is working hard to improve. Nevertheless, as my noble friend and the noble Lord have both said, there is a lack of confidence in the GDC among the profession and that confidence must be rebuilt.

Perhaps I might bring to Ben Gummer’s attention the comments that have been made by my noble friend and the noble Lord and ask him to draw them to the attention of the GDC when he meets it in the near future. Clearly, he will wish to keep a very close eye on the performance of the GDC as we go forward. I do not think I can say much more today about that. I do not have the information with which to comprehensively address the issues that the noble Lord has raised. Is he content on that basis? If he would like to meet my honourable friend Ben Gummer, I can arrange for him to do that.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful. One of the problems is that this was scheduled very late and therefore I was able to look at the information only over the weekend. I suspect that I would have put a Motion down for a debate in the Chamber if I had had time to do that.

Secondly, I realise that this is quite a difficult situation. Clearly, the independence of the regulators of the health profession is very important and I have always been keen to protect it. The PSA has a crucial role and I think it does a great job. I pay tribute to the chairmanship of my noble friend Lady Pitkeathley, and Mr Harry Cayton, the chief executive. I think they have done a fantastic job, but it seems to me that there is a gap.

It is patently obvious when you look at it from the outside that the board should have read those reports, accepted its ultimate responsibility and stood down. I accept the invitation; I would be very glad to meet Mr Gummer. Of course, this will be debated tomorrow in the other place, and other Members may come back on that. This message clearly needs to go to the GDC council: that it is not good enough and the members should consider their position. I wonder whether it is right that the board carries on willy-nilly simply because the chief executive has stood down.

I am not someone who rushes to say that this, that or the other board should resign because something has gone wrong, but this has been a continuing problem. I accept that improvements have been made, but only a few weeks ago the PSA had to publish a report that continues to draw attention to what is, essentially, the culture of the organisation. Therefore, I very much hope that Ministers will take the appropriate action; that is all that they can do. Ultimately, I am surprised that the board of the GDC feels that it is able to carry on and I think there needs to be a change.

I am grateful to the Minister for the way that he has responded; clearly, he understands the issues that are being faced.

[Lord Prior of Brampton]

My Lords, perhaps we can leave it on the basis that I will organise for the noble Lord to meet Ben Gummer and perhaps ask Harry Cayton to come along, too, as he fundamentally authored the report, so that the noble Lord can express his concerns directly to them. On that basis, I beg to move.

National Health Service

Lord Hunt of Kings Heath Excerpts

Thursday 14th January 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, if the Minister is going to have any time at all, I should cut my contribution short. First, I declare an interest as president of the Health Care Supply Association and the barcoding association GS1, because I want to comment on the remarks of my noble friend Lord Carter on efficiency.

I very much welcome this debate. I was very taken with my noble friend’s description of the ideal world. I wonder if noble Lords think, as my noble friend Lord Carter does, that elements of that are in existence in the NHS at the moment, and that the issue is how to get that going in every part of the NHS. That is one of the essential conundrums.

I will focus also on the very important contribution of my noble friend Lord Winston, who talked about the risks to our medical research. Our medical research has always been one of the best in the world. On it our whole life science sector has depended. The fact is that we in this country have always had a very strong, innovative pharmaceutical and diagnostic industry. When my noble friend says that all of that is at risk, we need to listen.

There is no doubt—I pick this up consistently—that there is a hostility in the NHS to the kind of time that is needed for doctors to practise in research, and even to take part in Royal College activities. This has really got to stop. Seeing the noble Lord, Lord Lansley, here, I have to say that the introduction of NHS England does not help, because, for all the fine words that are in both the mandate and what NHS England says, I do not see any commitment in NHS England to these kinds of issues.

I will raise one further issue in aid of that. Our record on the introduction of new, innovative medicines in this country is a disgrace. We have some fantastic inventions, but the NHS is pathetically slow in introducing them. The noble Lord probably knows very well that we have an accelerated access review under the chairmanship of Sir Hugh Taylor. The word on the street is that it is simply not going to get anywhere because the NHS is not going to play ball and is not going to insist that NHS bodies invest in these medicines. A whole sector of our economy is at risk because of this. I know that the Minister is as concerned as I am and I hope that he might say something.

I come to the issue of junior doctors—not to talk about the dispute but because both my noble friends Lord Winston and Lord Mitchell raised the issue of why junior doctors are so disengaged. Anyone who has met them will know how angry they feel. It is partly about the Secretary of State’s manipulation of statistics—which, frankly, given the brightness of junior doctors, was always going to be very unwise. It is also about their distrust of management. Part of the problem is that they just do not believe that, locally, NHS employers will do the right thing.

My noble friend is right. Why are junior doctors treated so abominably by NHS employers? Why can they not get access to decent hot food at night? Why are the junior messes not in places where they can go and meet? I do not know what can be done to get this home to the NHS. Anyone who meets our juniors knows that they are the brightest of the bright and are hugely committed—yet, somehow, we seem to have made them wholly disenchanted with the NHS. It is a very serious issue.

This brings me to the issue of leadership, which my noble friend mentioned. In June last year, the noble Lord, Lord Rose, produced an excellent report on how to enhance and improve leadership in the NHS. He asked the Government three questions. How do we get better leadership? How to we recognise it? How do we find and mature the people who are needed to lead the NHS? I am afraid that there has been virtually no response to this from the Government. That is very disappointing. In fact, all that has happened is that the turnover of chief executive officers has continued at an alarming rate. Again, as one of my noble friends said, we have got to get rid of leadership by bullying. There is a bullying culture throughout the system and it is having a corrosive impact on the ability of people locally to lead organisations.

Of course, funding is very important. I do not need to repeat all the arguments that noble Lords have put forward. Essentially, they concern growing population and demographic pressures. We in this country spend less on health than any comparable country. The OECD figures that came out just before Christmas were very convincing on this. The Government’s claims in the Autumn Statement frankly do not ring true. We know that they are front-loading some of the money for the next five years, but the annual increase from here to 2020 will be 0.85%— even less than the average increase from 2010 to 2015.

At the same time, we know that half of that extra money has come from raiding the budgets of Health Education England and Public Health England, from capital funds and from the cost of pension payments. At the same time, what do Ministers do? They pile on more pressure. Not a week goes by without another press release from the Department of Health or an announcement by the Secretary of State that something else has got to be done. No wonder his credibility is shot in the NHS.

Of course, the gap between the money that is going in and the £30 billion per annum that it is generally believed will be required by 2020 is huge. I pay great tribute to my noble friend Lord Carter, because obviously he is helping the NHS to see if it can close part of that gap. I am sure that is right and that, on procurement in particular, a much more cohesive national approach is needed—but at the end of the day, there is still going to be a gap.

Should there be a royal commission? I cannot help repeating Harold Wilson’s famous diktat that royal commissions take minutes and waste years. That is, of course, when they are used simply to postpone a decision. I understand why noble Lords want some kind of neutral and impartial commission to look into those issues. However, we have already had the Barker commission, and I doubt whether anyone is going to improve on that. In the end, it is a matter of political will. I say to the Minister that, at the very least, what we seek is some honesty from the Government: admit that the financial gap is not going to be met and stop piling on the pressure.

[Baroness Williams of Crosby]

I apologise to the noble Lord, but there is a question that is central to this: would he and his party be prepared to take part in an all-party commission, possibly a parliamentary one, in order to get the quickest possible effective answer for the terrible crisis that has been outlined in this debate?

[Lord Hunt of Kings Heath]

My Lords, this is a time-limited debate and I want to leave the Minister a little time to respond. I would certainly be very happy to discuss the issues with noble Lords here—I like the idea of a group of politicians in this House looking at it. On the subject of a royal commission, I do not think I can go as far. In the end, we sometimes have to have the courage of our convictions and come up with proposals to sort this out.

Children: Obesity

Lord Hunt of Kings Heath Excerpts

Tuesday 12th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, we all recognise, as does the Prime Minister, that obesity is a scourge in this country that affects many thousands of young people. Some 2.1 billion people worldwide are overweight or obese, so it is a huge global problem that requires a comprehensive strategic response. I hope that our obesity strategy will be announced in the very near future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in developing this strategy, is his department talking to the Department for Education? He will understand that this is a particular issue at primary school level. There is evidence that the incessant determination of the Government to test primary school children at every age at every moment is squeezing the curriculum of playtime and physical activity. I hope that his department will talk to the Department for Education to turn this around.

[Lord Prior of Brampton]

My Lords, we have got to have a collective response to the obesity problem across many government departments, as the all-party parliamentary group made clear in its paper. Education is a critical part of that. The noble Lord will know that in the spending review the Government committed to continue the PE and sports premium in primary schools because we recognise that physical exercise and playtime at all levels in schools, but particularly in the early years, are vitally important.

Pregnancy: Neural Tube Defects

Lord Hunt of Kings Heath Excerpts

Monday 21st December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, I think they were helpful and wise words from the noble Lord, Lord Blunkett. This is a difficult issue, and it is not as black and white as is sometimes portrayed. As I said, my honourable friend in the other House is taking all these matters into consideration.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I must inform the House that I am president of the Fluoridation Society. Therefore, although I always welcome my noble friend Lord Blunkett’s interventions, perhaps I welcome this one not quite as much as usual. I have great respect for the Minister’s colleague, the Minister for Public Health, and know that she is committed to public health. But she has had the evidence from the research, which caused the Government to delay a decision, for nine months. Is it not a fact that she cannot get agreement inside government, and that the Government have decided not to go ahead? Is not it time for them to be straight on this?

[Lord Prior of Brampton]

My Lords, I do not think that what the noble Lord has said is entirely correct. My honourable friend Jane Ellison received a letter from the SACN, the committee on nutrition, on 20 October that indicated that many more women were below the foliate level than had previously been thought. That evidence is quite new and came in at the end of October. That is what she is now considering.

Southern Health NHS Foundation Trust

Lord Hunt of Kings Heath Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, these are truly shocking revelations and reveal deep failures at the trust. I start by echoing his remarks about the families so grievously affected.

As the Minister said, only 195 of the 1,454 unexpected deaths were actually treated by the trust as serious incidents requiring investigation. Perhaps most worryingly, it appears that the likelihood of an unexpected death being investigated depends hugely on the patient. For those with a learning disability, just 1% of unexpected deaths were investigated. For older people with a mental health problem, just 0.3% of unexpected deaths were investigated.

Obviously, we will expect a full response from the Government when the report is published, but in the mean time, can the Minister say whether he judges services at the trust to be safe? What advice can he give patients currently in the care of this trust, and their families? He explained that NHS England first received the report in September. Can he say why it has not yet been published, and when a final report will be made available?

Finally, I want to raise an issue the Minister himself mentioned. I understand that the trust disputes the analysis by the audit company Mazars, which produced the report. NHS England needs to sort this out. When the report is published, it is clearly vital that there be no question about its methodology or the robustness of its conclusions. Is he absolutely confident that NHS England has got a grip of this?

[Baroness Walmsley (LD)]

My Lords, our hearts go out to the family of Connor Sparrowhawk and all the other families who have struggled so hard to get investigations of the unexpected deaths of their loved ones. On many occasions they have struggled to find the financial support required to make that investigation. That is quite wrong. In this particular hospital’s case, the percentage of unexpected deaths that was investigated is pretty scandalous. In fact, across the board, only 1% of unexpected deaths of those with learning disabilities are investigated.

I very much welcome the Minister’s saying that a light will be shone on this, but will the investigation bear in mind the possibility that it should not be the hospital trust itself that decides which of its unexpected deaths should be investigated? Police forces no longer investigate themselves—that is done by another police force. Should that not be the case with hospitals too? My second question is about timeliness. The report is not the first indication we have had of problems with this trust. The coroners have complained on numerous occasions, and over a long period, about the timeliness and quality of the reports received by them on cases that were investigated. Surely this indicates that there have been problems with the administration, the collection of evidence and the systems of this trust. Why was that not picked up earlier?

Residential Care: Cost Cap

Lord Hunt of Kings Heath Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to wind up for the Opposition and to thank my noble friend. It has been an excellent debate; a number of very challenging questions have been put to the Minister and we look forward to his response. There can be no doubt that the viability of the residential care home sector, the failure to implement Dilnot and the failure to raise the means test are causing great anxiety to thousands of people and their relatives throughout the country. As the noble Baroness, Lady Walmsley, said, the lack of viability of the residential care sector is but one part of what one has to say looks increasingly like a dysfunctional health and social care system.

When the Minister replies—because he has done it recently—he will no doubt talk about the Autumn Statement, ministerial vision and the potential of the new models of health and social care that the Government are putting an awful lot of eggs into, without, I have to say, any evidence that they will be able to enable a response to the challenges. The gap between ministerial rhetoric and reality is striking. There is no problem with a five-year forward view. This vision is described as empowering patients, their families and carers to take more control over their own care and treatment. It is a future that truly integrates health and social care, at last puts mental health on a par with the rest of the system and, crucially, prioritises prevention. That is a fine vision and, in the absence of any vision for social care, I assume it is the Government’s statement of social care policy as well.

However, it is impossible for me to see how that will happen in the context of a Government determined to bring the share of government spending down from 41% to 37% of GDP. It is always good to wait until a few days after an Autumn Statement to get the real analysis of what is happening in spending. The analysis I have seen from the King’s Fund is that for the next five years the actual growth in the health service will be 0.85% per annum. So we are just continuing the misery of the last five years. We know that the historic growth level in the NHS is 4%, and that is what is needed to meet these challenges. It is striking that, of the much-vaunted extra £8.4 billion, £4.6 billion has come from other parts of Department of Health expenditure, including Health Education England, the nurse bursaries, capital and public health. You also have to add in the £1.1 billion of pension costs due to the changes in the pension rules from next April, for which no additional money has gone into the health service.

The King’s Fund projection shows that in this five-year period social care will be left with an annual cut of 0.3% per annum. Therefore, even though it is back-loaded, it is starting off with a very challenging situation. There is then the cost of the living wage to be added to the negative growth. I cannot possibly see how the health and social care sector can meet the challenges of the demographics that it is facing, with the huge population growth that we have seen in the last 10 years projected to increase by another few million over the next 10 or 15 years, as the noble Lord, Lord Filkin, said.

When it comes to the residential care sector, there is no need for me to repeat the figures that other noble Lords have referred to, but I thought that the ResPublica report got it in a nutshell when it talked about the unsustainable combination of declining real-terms funding, rising demand, increasing financial liabilities, a funding gap of £1 billion by 2021, the potential loss of beds and, of course, the knock-back impact on our National Health Service. I had not seen the advice from Care England. That advice is very sobering indeed when it comes to the whole viability of the residential care home sector.

It seems to me that the result of all this will be that, far from the models being implemented, we will see the perverse incentives mentioned by the noble Baroness, Lady Brinton, getting worse and worse because of the tension between the free-at-the-point-of-use NHS and means-tested social care. That is why integration is so difficult. Until we get to grips with that divide, we will never achieve integration of services. As my noble friend Lord Turnberg said, NHS hospitals are the providers of last resort. If the residential care sector goes down, residents will end up in NHS hospitals. I remember those dreadful long-stay wards that NHS hospitals used to have, and I am afraid that they will be recreated unless we can sort this problem out. Many reports are coming out but one report produced today by the Nuffield Trust shows that 3.6% of patients took over a third of all bed capacity in acute hospitals, and the trust expects the position to worsen in the years ahead. That is the challenge that our system faces.

There are about 10 questions from my noble friends to which the noble Lord, Lord Prior, is being asked to respond. The first, on the positive side, was asked by my noble friends Lady Dean and Lord Lipsey. Can we increase public awareness of the importance and success of many parts of the residential care sector and the good work done by the staff? My noble friend Lady Dean gave a wonderful example of the sector working at its very best.

The second concerns the general view that, essentially, the care cap will never be implemented. Can the Minister say that it actually will be implemented, and when? Thirdly, does he agree with his noble friend Lord Lansley about the sense in going back to Dilnot’s original recommendation about the size of the cap? A number of noble Lords mentioned the £6 billion. Noble Lords look quizzical whenever it is mentioned, but that figure has appeared in government papers and projections. I think we are right to ask what on earth has happened to it.

The noble Lord, Lord Sutherland, asked what analysis the Government have made of the risk of closures. What are their contingency plans? How will we avoid the dreadful situation of very frail older people having to be moved from one home to another, which we know can have appalling effects on life outcomes? When will the means test limit be increased as promised? The Government made a deal. They made a deal with people that the care cap would come in in 2016 and that the means test would be increased. Many people made financial provision on that basis. Surely the Government have a moral responsibility here to deliver what was promised. Does anyone remember the Prime Minister saying no one would have to sell their home? What has happened to that?

There are two final things. First, my noble friend Lord Bhattacharyya asked about incentives to encourage people to build up funds for their care. What has happened to the much-vaunted insurance market? It was supposed to come to the rescue and be complementary, in a sense, to the introduction of the care cap. Finally, and overwhelmingly, my noble friends Lady Pitkeathley and Lord Turnberg and other noble Lords talked about the need for a coherent, long-term strategy. Either we go into absolute crisis in the next year or two, with huge knock-on impacts on the rest of the provision of health and social care, or the Government have to get a grip and actually start going for a long-term strategy. I hope the Minister will announce that tonight.

Health: Liver Disease

Lord Hunt of Kings Heath Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the recommendations in the report about a hub-and-spoke approach, to which my noble friend refers, with district general hospitals having some hepatology services but being linked into a specialist centre are absolutely right. It is the right model; I have no doubt about that. We have established 22 operational networks for hepatitis C treatment, which are all linked into specialist treatment centres. We believe that that may be a model for the future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the issue of specialist centres, has the Minister actually read the Lancet report, which points out that the north-west has the highest incidence of liver disease, yet does not have a transplant centre? In view of the very good outcomes from the transplant centres, are the Government making sure that the north-west gets such a centre?

[Lord Prior of Brampton]

I have read the Lancet report and I noted this rather unusual omission in the north-west. I do not understand why the north-west does not have a specialist liver facility. It is something that I will follow up and find out. I will write to the noble Lord if I can.

Health: Adult Pneumococcal Vaccination

Lord Hunt of Kings Heath Excerpts

Tuesday 8th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the report by the JCVI was very clear in its recommendation that the existing vaccination, PPV, was the most appropriate for those aged over 65 and that PCV 13, which is the vaccination used for young children, because it provides herd protection—that is, young people who are treated with it can no longer carry the disease—offered the best long-term protection for the elderly as well.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this year community pharmacists have been given the opportunity to provide NHS vaccinations. Can the Minister say something about how successful that has been? Does he think that there is much greater potential for community pharmacists to do more work for the NHS in this and other areas?

National Health Service (Licensing and Pricing) (Amendment) Regulations 2015

Lord Hunt of Kings Heath Excerpts

Tuesday 1st December 2015 Lords Chamber

This has been a long speech because it is an important issue and one which is somewhat arcane for some noble Lords. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for his detailed and careful explanation of the reason for this statutory instrument. I still regard it as a flawed set of regulations and I am not surprised that your Lordships’ Secondary Legislation Scrutiny Committee has reported it for the specific attention of the House on the grounds that the regulations may imperfectly achieve their policy objective. It is my contention that the regulations undermine a core part of the Health and Social Care Act 2012. They certainly run against the spirit, if not the letter, of what the noble Earl, Lord Howe, told the House during the passage of the Bill. Although the noble Lord has been very careful to differentiate between acute and non-acute trusts, the actual impact of what is being proposed is that NHS trusts and foundation trusts, which provide 96% of the tariff work for the NHS, are effectively disabled from using the tariff objection mechanism because it is mathematically impossible for them to trigger it alone. They would need some of the very small-scale, private providers to join in. The effective silencing of the voice of the NHS front line in the tariff-setting process displays a shocking degree of arrogance on the part of NHS England. It seems to be bent on punishing these providers for having the temerity to object, as they did in the last financial year.

The noble Lord has carefully described the national tariff. I suspect that noble Lords know more about it than they ever thought they wished to. As he says, it is very important in terms of the income going to most NHS providers. The 2012 Act provides for a statutory duty to consult on the proposals that NHS England and Monitor make. There is also a parallel right to object to the tariff proposal if they have insignificant numbers. The current threshold is 51% of commissioners or providers, either individually or based on the proportion of services they provide. This is called the share of supply. I do not think that 51% could be said to be not setting a pretty high threshold. I understand entirely that this mechanism is not meant to be used regularly, but current experience shows that it actually works. It was not used in the first year of its operation, but it was used in the 2014-15 financial year, with 75% of providers by share of supply making an objection. The reason they objected was that the tariff changes made, particularly for specialist services, would have an enormously negative impact on the providers of those services and, by definition, on the specialist services themselves.

--- Later in debate ---

We recognise the degree of consultation, engagement, openness and trust that was not there last year, and we are committed to rebuilding that. We note the comments made by NHS Providers and have taken them on board. I can tell the noble Lord that Simon Stevens, Jim Mackey, the Secretary of State and I are absolutely committed to rebuilding that confidence and to having a much higher degree of engagement and consultation in the tariff-setting process.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to all noble Lords who have taken part in this interesting debate. We perhaps went rather wider than the terms of the regulations. I agree with the Minister that payment by results was brought in essentially to drive through reductions in waiting times by providing the right incentives. By and large that has been very successful, but we are moving, and this is a very good thing, into thinking about systems and how they work. There is a clear need to develop a funding mechanism to ensure that there are proper incentives for system-wide working, and I absolutely agree with that.

However, I also agree with the noble Lord, Lord Warner, my fellow former Minister. Looking at the Five Year Forward View, it seems to me that essentially we are moving again to a planning model but we are still stuck with the 2012 Act, and the two do not seem to mesh together. The Minister is struggling with these regulations because they are trying to operate a system that is still based on payment by results, when in essence we are trying to incentivise people to work together to produce a much more effective system and that is very difficult. If he were to tell me that the NHS amendment Act was to be brought forward, I think he would find a warm welcome in your Lordships’ House, but perhaps I dream too far.

I say to the noble Lord, Lord Patel, that I do not disagree at all with his idea of an independent commission; the funding challenges facing health and social care warrant that kind of independent consideration. I say to him, though, that all the work done by the King’s Fund and the Nuffield Trust suggests that if you could maintain real-terms growth at 4% a year, which is the historic annual real-terms growth of the NHS, we would get a pretty good system without some of the pressures that we are facing at the moment. It is not a question of having to increase money to the NHS and social care hugely, but it needs some increase or we will be faced with the kind of problems that we have at the moment. The Barker commission, which was sponsored by the King’s Fund, shows some of the thinking that one might ask a royal commission to go into.

My noble friend Lord Turnberg mentioned the particular challenges of highly specialist providers, which of course are very much tied into the area that he knows so well: our whole R&D effort in this country and the link with the life sciences. While I understand the language of domination by specialist providers, we need to recognise that the link that these very same providers have with R&D and the life sciences is crucial to this country and to the lead that we often have in these areas. We have to be very careful not to undermine their financial viability because of the general financial challenge.

I am delighted that the noble Lord, Lord Warner, is working on, chairing or leading this work on specialised services, and I am sure he is right that we need to have much more effective commissioning. I certainly accept that that is likely to lead to a rationalisation of specialised services, which will not be universally popular. However, if we can show that by doing so we get more bang for our buck, getting better specialist services, and that they are a better investment, clearly, that has to be followed through. I hope that we will see the outcome of that work within the next few months.

I have no problem at all with putting more resources into mental health and community services—I entirely understand that. However, the regulations are a pretty poor show, and in effect disfranchising the providers, who get 96% of the tariff income, is not the way to go forward. However, I am very grateful to the noble Lord, Lord Prior, for what he said. I take his commitment to rebuilding the confidence, as he described it, of providers in the system, as a very strong one. He did not quite go as far as I would have wished with regard to endorsing the open book approach. Does that mean that that is still being considered, or has it been rejected? Can I take anything from that?

[Lord Prior of Brampton]

I will have to defer to Jim Mackey, the chief executive of NHS Improvement. It would not be fair for me to answer that question.

[Lord Hunt of Kings Heath]

I am sure of that, my Lords. I will just say to the Minister that I hope the spirit of this debate will be conveyed to him and NHS Improvement. I certainly have been very impressed by the chief executive’s words since his appointment, and of course the chairman, Ed Smith, commands great respect and authority, not least for the work he has done on behalf of Birmingham University, for which those of us in the city are very grateful.

With that, I thank all noble Lords who have spoken. The point has been made, we look forward to a better approach in the future, and I hope that the spirit of the proposal regarding early consultation and an open book process will be acceded to. I beg leave to withdraw my amendment to the Motion.

Amendment to the Motion withdrawn.

Accident and Emergency Departments

Lord Hunt of Kings Heath Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Prior of Brampton]

My noble friend makes a very important point. Many people go to A&E departments who need not go there. The review of Sir Bruce Keogh, the medical director of NHS England, concerning how we structure emergency care in this country will be very important. Clearly, we can make much more of NHS 111.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the point that Minister’s noble friend made was that the Government’s decision to phase out NHS Direct, which used qualified nurses, and replace it with call handlers who simply use algorithms on their screens means that those call handlers are risk-averse, which therefore leads to many more people being sent to A&E. Is it not time to get qualified nurses back behind those screens and talking to patients?

[Lord Prior of Brampton]

The noble Lord makes a good point. If qualified people take the call, the level of risk they are prepared to absorb will be greater, and that applies throughout the whole system.