Health: Cancer
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Earl Howe
Yes, my Lords. Radiotherapy, particularly of this kind, is highly cost effective when it is clinically indicated. In fact, SABR is available in eight radiotherapy centres in England. The number of centres providing this treatment is increasing, with over a quarter having equipment capable of delivering the treatment. Current evidence supports treating only a small number of patients with this treatment: that is, in early-stage lung cancers for patients who are unsuitable for surgery. That is about only 1,000 patients a year.
Lord Hunt of Kings Heath (Lab)
My Lords, the noble Earl will be aware of a pledge made by the Prime Minister last October that this kind of treatment would be available to cancer patients who needed it. He will also be aware of a statement by Mr Lawrence Dallaglio, who was asked by the Government to help in this. He described it as a “national disgrace” that NHS England reneged on a deal to fund these cancer treatments. Is the noble Earl absolutely certain that the reason the number of treatments has fallen is due entirely to clinical reasons?
Earl Howe
Yes, my Lords: that is the advice I received. It goes hand in hand with other advice around other forms of radiotherapy treatment that are increasing very dramatically. For example, intensity-modulated radiotherapy is a similar form of radiotherapy for different types of cancer—head and neck cancers, principally. The use of that radiotherapy has grown very considerably, partly as a result of considerable investment by the current Government.
NHS: Rural General Practitioner Dispensing
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Earl Howe
My noble friend makes a good point. That is why the rules contain an exception for those who find it difficult to travel and who may therefore wish to have medicines dispensed from their own dispensing GP practice. Those rules do apply to disabled people and to those whom my noble friend describes.
Lord Hunt of Kings Heath (Lab)
My Lords, does the Minister not regard it as somewhat ironic that yesterday we had the Government trumpeting their Deregulation Bill but today he defends what essentially is an uneasy truce between the BMA and the pharmaceutical interest, in which often the public are the losers? Is it not time for that to be reviewed again?
Health: Polypill
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what action they will take to encourage the use of the polypill by the National Health Service.
Lord Hunt of Kings Heath (Lab)
My Lords, I am very grateful for this opportunity to put some probing questions to the noble Earl, Lord Howe, and perhaps ask for his help with something that I am rather puzzled about. I detect a less than enthusiastic response from the medical and health establishment to the development and potential of what is being called the polypill. Perhaps the noble Earl will share the reasons for it and helpfully suggest a way forward for some more constructive engagement on the issue, if that is at all possible.
As we know, strokes and heart disease remain a major public health problem. Across the population as a whole, the chance of having a heart attack or cerebrovascular accident rises as people get older, and age is the single most important predictor of future cardiovascular disease. But we know now—there is robust evidence—that the consumption of fixed-dose polypills containing effective combinations of low-cost off-patent statins and blood pressure medicines can safely cut the rate of unwanted vascular events by 70% or more in otherwise untreated subjects, whatever the initial combined level of their blood cholesterol and other disease risk factors. The use of such a preventive technology across the general population, with access determined by age alone, would prevent the need for much more costly and inefficient risk-testing, and maximise the health gains. Clearly, it is aimed at people in their 50s and 60s who would not at the moment meet any treatment threshold.
The use of the polypill focuses on primary prevention, whereas the majority of current medical activity is focused on secondary prevention. Of course, if a first heart attack or stroke is prevented, there is no second one to prevent. My understanding is that if people take this daily from the age of 50, one in three people would benefit and would gain an extra eight years of life without heart attack or stroke—similar to the benefit achieved by stopping smoking in middle age.
I suppose that the polypill can be thought of as a form of drug-based vaccination that reduces vascular disease rates. However, unlike the situation with vaccines, there is no threshold level of use needed to ensure herd immunity—the higher proportion of healthy people taking the polypill, the greater the benefits—but no one needs to be encouraged against their personal judgment to take it if they do not wish to do so.
An article in the BMJ in April, which contained research news, said:
“Inconsistencies in the design of studies investigating the potential of polypills to prevent cardiovascular disease make the impact of these pills difficult to prove, a systematic review by the Cochrane Collaboration has found. However, the reviewers are confident that polypills do have a role in protecting large populations against cardiovascular disease”.
One would have thought that there would then be a great rush of enthusiasm by the NHS and indeed the medical and health sector generally to use the polypill. But as far as I can see, we have had mostly silence and in some cases downright hostility. There has clearly been difficulty making a polypill with a licence for the primary presentation of cardiovascular disease, and pharmaceutical companies see little commercial advantage because the components of the polypill are all generic. I understand that they are also put off by the uncertainty and cost of obtaining regulatory approval.
I wonder whether we are seeing here a parallel to the statin debate, which, as a lay person, I have found utterly confusing. I pick up the sense among some sections of the medical profession, particularly the public health profession—and I stand here as president of the Royal Society for Public Health—that pills are not really virtuous. It feels as though there is a puritanical approach which suggests that healthy living is the only appropriate policy to adopt in the prevention of stroke and heart disease. I also suspect that doctors fear the workload implication of this kind of medication when it comes out. Perhaps they also fear losing control. In a sense, the use of polypills could be seen as the public very much taking ownership of their own health.
There is no evidence that the use of polypills would lead to increased vascular disease risk-taking. I understand that the available studies imply that health-promoting behaviours tend to be positively correlated with one another, as might be the case with health-damaging behaviours. As with vaccines, the introduction of a general polypill prevention programme within the NHS would probably require a positive, proactive approach, possibly in the form of some government/private partnership.
I was interested in the Government’s approach to antibiotics last week. Clearly, the current mechanisms—the factors that lead pharmaceutical companies to make major investments—were simply not going to produce the goods and the Government felt that they had to step in. Will the Minister consider whether his department might at least play a somewhat more active role in this debate than it has done hitherto? Would he, at the very least, be prepared either to convene a study or an objective, independent review of the potential of the polypill? Would he, at the very least, be prepared to meet me and colleagues to discuss whether there is a way to take this forward?
I am puzzled that, on the face of it, the polypill could lead to a major reduction in the number of heart attacks and strokes that occur in this country, yet the combined efforts of the medical, health and pharmaceutical establishments seem to want to look the other way. Why?
Lord Turnberg
Those are very good points. The doses used in polypills are very low, in fact—20 milligrams of simvastatin, when the normal dose is 40 to 80 milligrams. The other drugs in the polypill are half doses. The point is that, if you have raised LDL cholesterol or raised blood pressure, you should certainly be on the treatments; they have been shown to be effective. It is people who do not have raised cholesterol or raised blood pressure who we are aiming to treat—or to prevent their diseases—so it is a different situation. The point about safety is important. It is clear that we need and should have proper clinical trials of those doses, but the impact of such doses, from what we know about them in this combination, is that they are likely to be safe in the vast majority of cases. What we do not know is the number who will get side-effects.
Lord Hunt of Kings Heath (Lab)
My noble friend, and other noble Lords, mentioned the importance of clinical trials, which I am sure is absolutely right. Is not the problem here that in fact no pharmaceutical company will conduct a clinical trial because all the drugs used in combination in the polypill are off-patent, so there can be no protection of that research by any company taking it forward? So there is, if you like, a block here, although people can see the potential benefits. Rightly, noble Lords are asking for clinical research, but there is no possibility of that happening unless the Government take a hand themselves, which is why the debate on antibiotics is interesting. They are completely separate subjects, but the Government had to step in there because, at the moment, the market simply cannot respond to the issue.
Lord Turnberg
I agree entirely. I think that it will be difficult for the drug firms themselves to conduct trials because these are generics and they are manufactured by a number of companies. The only way forward, I suspect, if we are to have a clinical trial, is through NHS funding—that sort of trial. My final remark is that I very much look forward to the noble Earl’s response.
NHS: Better Care Fund
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Lord Hunt of Kings Heath (Lab)
My Lords, I am indebted to my noble friend Lord Kennedy for raising some real concerns about the way in which the better care fund will impact on the NHS. I thought that his questions went to the heart of the problem. I am grateful also to my noble friend Lord Turnberg for setting the very challenging context in which the fund is to work.
As we have heard, this is a straight transfer of money from the National Health Service to local government. The theory is that this will lead to more community provision, and therefore fewer people will need to go into hospital and it will be easier to discharge patients who have been admitted. The result will be that we need less acute capacity, and therefore the NHS can live on less money. That is the theory. However, there are five or six problems with the way in which this will work out in practice. The first problem is that local authority social care funds have been slashed so much that it is almost inevitable that a substantial portion of this money will be used to shore up their mainstream services. Only yesterday we had a report from the Association of Directors of Adult Social Services saying that these directors have had to cut their care budgets by 26% in the past four years. The budgets are very, very stretched indeed.
The second problem was identified this morning by the Health Select Committee. It described, in particular, managing the care of people with long-term conditions, who are the people we are largely talking about in this debate. It said that moving care for those with long-term conditions to primary community care and self-management—which I am sure we all support—is,
“intended to reduce unplanned admissions to the acute sector”.
That is absolutely right. However, it says:
“Reducing the activity of acute hospitals … and their income from such activity, is bound to have a consequential impact”,
on NHS hospital acute services.
One has to understand, as my noble friend Lord Turnberg said, that although one can certainly find problems with the way in which the health and social care system works at the moment, those who say that the NHS should become more efficient—and of course there are areas where it needs to become more efficient—also have to come back and respond to the point that this country has the lowest bed numbers and the shortest length of stay of any developed country in the world. That is why I certainly have some concern. Obviously, having just given up chairing the board of an acute trust, I come from that angle. But I am concerned whether this will be able to happen in practice.
One of my concerns is the absence of large NHS providers from these discussions. This is a consistent theme in the way in which local authorities, health and well-being boards and clinical commissioning groups have worked over the past years. I think that the reason for this is that they are scared of the acute trusts. They think that they will not be able to withstand the robust argument put forward, and therefore they prefer to exclude them from many of the discussions.
As the King’s Fund said, that is a big mistake. These decisions impact on providers’ existing activity and funding, and the risks arising from that need to be assessed and managed. We have seen it before. Let us take, for example, the four-hour A&E target. Although CCGs and local authorities make decisions that impact on that target, they do not bear the responsibility for it. That is the big problem with the fund that we are talking about. The local authority and the clinical commissioning groups may well make decisions about the fund that will impact on the ability of NHS acute services to do an effective job, but they do not bear the responsibility for it.
I think that the only way to do this would be to give acute trusts a lock on the plans. Unless there is shared ownership, we will not get uniformity in terms of accepting the risk and making sure that the use of this money will indeed drive down the use of acute hospitals. That is where we run into trouble. I am sure that the noble Earl will have seen the recent Nuffield Trust work by Nigel Edwards, who I think everyone agrees is an expert commentator. He says, and I agree absolutely, that,
“nobody can argue with the … sound principle of bringing health and social care closer together”,
as the Labour Party wants to do in its whole person care. However, he says that there is a fatal flaw in that:
“The Fund assumes that hospitals can quickly achieve a 15 per cent reduction in emergency admissions and that these reductions will result in savings in the same year, at full cost”.
The noble Baroness is absolutely right about the need for some kind of transformation fund. Unless you have some kind of double running, you run the terrible risk of money certainly being spent on community provision but acute hospital admissions not reducing, and then the system falling over. That is why we would be very grateful to hear the noble Earl, Lord Howe, respond not only to the questions put to him by my noble friend but also on how the Government will make sure that this community fund is absolutely spent on measures that will actually reduce acute hospital admissions. I hope that he will say—because I believe that this is right—that they should be signed off by the acute hospital providers. This is not an issue where you can simply say, “The commissioners will decide”, because the commissioners do not bear the responsibility. That is often a fatal flaw in the current arrangements. The Government should take a further look to make sure that this system will work effectively.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I join other noble Lords in thanking the noble Lord, Lord Kennedy of Southwark, for enabling us to consider a topic of considerable significance for patients and service users.
In every area of the country, CCGs and local authorities are now planning together to use the better care fund to transform local health and care, to improve outcomes for people and to secure the best possible value for money by pooling resources. This is one part of a wider picture of change for health and social care. We must move away from traditional models if we are to provide responsive, effective services to a changing population.
Noble Lords will remember that the need for greater integration of health and social care has long been a recognised issue. The NHS and the social care system provide some fantastic care for people when they are already experiencing acute poor health and high care needs. We must, however, get better at providing care for those with long-term, chronic conditions by keeping people as healthy and independent as possible, living in their own homes and communities for longer, and going to hospital only when they really need to for specialist medical treatment. People will be supported to return to their homes, and to independence, as soon as possible.
We are living longer now than ever before, which is obviously good news, but we do not live all our lives in good health. As people live longer, we are seeing a corresponding rise in long-term conditions that require regular treatment. A lot of this treatment currently occurs in hospitals when it does not have to. It happens because the NHS was founded to treat episodic cases of sickness in hospitals, but the needs of the people are changing and we as the Government must work with the health and social care sector to adapt.
The noble Lord, Lord Turnberg, gave us some of the statistics. ONS projections show that between 2010 and 2030 the number of people aged 85 and over will increase by 95%. This increase is equivalent to more than 1.1 million people or a local authority the size of Birmingham. By 2030, there will be more than 3 million more people than today with three or more serious, long-term conditions.
Much long-term care can be undertaken in a way that promotes independence, sometimes with family members and carers, or with the support of professionals in people’s own homes and communities. People have told us this is what they want and, yes, it is a more efficient use of resources. As I said, these truths have been recognised for some time, and this Government are the first to address it head on. There is broad consensus that greater co-ordination of health and social care services to enable this kind of home and community-based care for the majority is the right direction in which to go. The better care fund presents a real opportunity for radical change at scale and pace for people to receive the right care in the right place at the right time. Local authorities and CCGs are working together to plan and deliver this shift to a more integrated system, with resources used to best effect where they are needed most. As the noble Lord, Lord Hunt, pointed out, acute trusts should indeed be part of that work.
As my noble friend Lord Bridgeman mentioned, for the first year of the BCF, it will include £1.9 billion of the real cash increase in the NHS budget. This represents 2% of the 2013-14 NHS budget, and it is being redistributed to help fund care in non-NHS parts of the system, which will in turn help to make acute care more efficient.
The noble Lord, Lord Kennedy, asked about funding for the longer term. I cannot yet commit to a five-year plan because we have said that it is for the incoming Government to look at their priorities next year. The 2013 Autumn Statement, however, made it clear that pooled budgets would be an enduring part of the framework for health and social care past 2015-16. While the structure of the fund and the pay-for-performance elements may change as progress is made, the principle is very much here to stay.
The noble Lord, Lord Turnberg, asked a similar question about funding for health and social care generally. We will set out the funding levels for social care from 2015-16 in the future spending review but the Government have already set out their plans for changes in how social care will be funded in the future through the Dilnot reforms.
On the specific issue of winter funding, which my noble friend Lady Brinton put to me, the Department of Health is constantly looking to the future, as she may well be aware. Possible pressures on the NHS and social care are very much part of that thinking. We have considered what pressures there will be in the coming winter and I can assure her we are planning appropriately.
Leading care professionals—hospital staff, care workers, GPs and researchers—all agree on the need for resource to be put into integrating our health and social care services, so that a better service can be provided at the same cost. This will certainly involve changing the way things are currently done. The NHS model is geared toward treating people as they get ill. We must shift our approach to focus increasingly on keeping people well and providing acute care in hospitals for those who unavoidably get sick. Keeping people well and out of hospital for as long as possible, and reducing their length of stay by co-ordinating with social care, will reduce the strain on NHS acute services. It will also improve people’s experience and improve health and well-being. An integrated service would allow this to happen, and that is what the BCF has been formed to do.
The noble Lord, Lord Kennedy, asked me whether dementia will be prioritised in the BCF. Guidance on the better care fund sets out that dementia services provision can be a part of the better care fund. Many area plans already contain good examples of health and social care working better together to provide dementia services. He also asked me what seven-day social working means. It is imperative to see social care working over seven days. Too often people have to stay in hospital because they are unable to leave at the weekend. Seven-day working, which will see social care operate at the weekend, as it already does in many areas, will see people return home at the earliest opportunity.
The noble Lord, Lord Turnberg suggested that all this was about robbing Peter to pay Paul. With respect, I do not see it like that at all. This is not about taking money from one part of the system and giving it to another. The better care fund will be held jointly by CCGs and local authorities for them to decide between them how best to spend it. They will decide how to make best use of the money available across the whole care system. This provides a real opportunity to join up services and transform people’s lives, particularly vulnerable people.
As I have explained, one of the aims of the BCF is to reduce the burden on acute services caused by avoidable admissions to hospitals. The way that funding for acute services works means that hospitals receive a marginal level of funding for unplanned admissions. Using the available budget to fund better-integrated, more proactive services will help hospitals to balance their budgets by reducing the operational and financial burden created by avoidable admissions. I am sure the noble Lord will be familiar with the 30% tariff for emergency admissions above a certain threshold. All this will allow hospitals to focus on providing specialist and trauma services, for which they receive full funding so it will make them more financially viable than they would be if the current system was retained. I say to the noble Lord, Lord Hunt, that evidence suggests around a fifth of all emergency admissions are avoidable in some way. If we get it right, transforming hospital care could therefore prevent these unnecessary admissions, which can be distressing for patients, quite obviously, and are costly to the NHS.
The noble Lord, Lord Turnberg, asked me whether the Government have plans to recruit more doctors into general practice. I am sure he will know from statistics that the number of GPs has increased since 2010, but our mandate to Health Education England requires them to increase the proportion of trainee doctors going into general practice from 40% to 50%. We have also set out our ambition to increase the primary care workforce as a whole—not just doctors, but nurses and other primary care professionals—by 10,000 by 2020.
Using resources to keep people out of hospital, by improving other methods of care—social care and home care—will lead to better use of NHS services, ensuring that services are focused on people who cannot be treated at home or in the community.
That brings me to the issue raised by the noble Lord, Lord Turnberg, of the impact of the BCF on acute care. All areas need to show that they have assessed the impact of their BCF plans on the acute sector—that is, hospitals. No plan will be approved without this. They will need to show that they have considered both the operational and financial implications and how these will be—
Lord Hunt of Kings Heath
My Lords, I realise that the noble Earl does not have much time but can he just answer this point? Why not give the acute trusts the ability to sign up to it, or not, to prove that it will reduce capacity?
Earl Howe
My Lords, we are looking at ways to assure these plans, and to assure them in a way that is satisfactory to the acute sector. At the moment, I cannot tell the noble Lord precisely how that mechanism will work but his central point is well made. I hope that in due course we will be able to share some of our thinking with him. However, the key point is that acute providers must have been consulted in this process.
This sort of approach is being pursued around the country. We know that it can work. For example, a network of 14 pioneer areas around the country are currently working with central government and health sector and third sector organisations to demonstrate the logic of integration and to disseminate what they have learnt to the rest of the country. That includes data-sharing—a point raised by the noble Lord, Lord Kennedy. Areas that have made significant progress in that respect are Southend, Leeds and South Tyneside.
There are other examples, too. In Greenwich, more than £1 million has been saved from the social care budget. In addition, 64% of people who went through their new integrated care pathway required no further services upon completion of the pathway. That has helped to lead to a 50% reduction in the number of people entering full social care.
My noble friend Lord Bridgeman asked whether admissions had been taken into account in the pilot scheme. Greenwich is a good case in point. More than 2,000 patient admissions were avoided there due to immediate intervention from the joint emergency team.
In Northamptonshire, £3.5 million has been saved through prevented admissions, exceeding the target by 14%. In Leeds, children and families now experience one service supporting their health, social care and early educational needs, championing the importance of early intervention. Since the service has been in operation, the increase in face-to-face antenatal contacts has risen from 46% to 94%.
Those examples, along with many others, should demonstrate to noble Lords that the integration of our health and social services can, and indeed has been, achieved in several areas. Integration will not only preserve our ability to provide services but improve them. The better care fund exists to enable all the local areas in England to do what the pioneers and others are doing to move towards a more responsive, effective and sustainable system that makes much better use of the resources available.
Health Care and Associated Professions (Indemnity Arrangements) Order 2014
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Baroness Emerton (CB)
My Lords, I have one or two points to make. It is not very often I disagree with the noble Baroness, Lady Cumberlege, but we really have to focus on the safety of mother and child.
I am talking about independent midwives only, not the whole directive, because I support the directive. I think there is a problem in that the midwifery profession generally is the most regulated of the nursing professions. They are required to be relicensed every year. They are under a supervisory midwife. They are, if anything, more supervised than the nursing profession. I chaired the professional conduct committee of the previous regulatory body and the midwifery cases that came forward were, in the main, where things went wrong with independent midwives. Mistakes are made—I am sure we all accept that—but the problem is that very often they lack support out in the community.
In a situation where things go badly wrong, there is the issue of who is going to pay the compensation to the mother or baby who has to be cared for for many months or even years. The other noble Baroness—I am afraid I cannot remember her name—said that we ought to be looking at something to help the independent midwives, but how do we help a very small group among a very large number of midwives and try to support them when very often the compensation is enormous?
Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the noble Earl for his introduction to the order, following, as he said, the Finlay Scott review. The Opposition have no argument with the principle of the order, but I want to raise with the Minister some of the practical consequences of its implementation. The Government’s consultation states that about 4,200 self-employed nurses and therapists may be required to obtain indemnity cover. For most concerned, the insurance premium is modest. The Department of Health’s consultation estimate was that for nurses the insurance premium would be £195 per annum, and for therapists between £255 and £256 per annum. There should not be a problem with those practitioners being able to pay that premium, but we run into great difficulty when it comes to independent midwives.
I take the point made by the noble Baroness, Lady Emerton, that of course the safety of the mother and baby is paramount, and her point about the issue of professional support for independent midwives. I am sure that she would recognise that for some women, the support of an independent midwife is very important to them. Sometimes the reason why a woman will turn to an independent midwife is that they find that statutory services are either not prepared to help her to have a baby at home or are less than sympathetic. It would be a great pity if, as a result of the order, that very small group of professionals was unable to practise. The RIA accepts that affordable commercial cover is not available to independent midwives working as individuals. The consultation estimates that there would be an annual cost of indemnity cover of about £15,000 per individual independent midwife. There is no way that an independent midwife is likely to be able to pay that sum.
It is fair to ask the Minister whether he considers that independent midwives will be able to practise in future as a result of the order. I take the point that the noble Baroness, Lady Brinton, made, about the benefit of this EU regulation, but what an irony that the Conservative Party, in particular, with its histrionics about Europe and the extraordinary behaviour of our Prime Minister in the past few days, is now bringing in a European order that will put independent midwives out of business. I wonder whether the Government really recognise that. They may find that independent midwives are in fact no longer able to practise, and the Government may come in for considerable criticism as a result.
I was unimpressed by the response given by Dr Dan Poulter in another place. He has been very unsympathetic to the issue of independent midwives. That is a great pity. When this order was debated in the Commons a few days ago, I thought that the government response was weak, unsympathetic and gave very little comfort indeed. It is all very well talking about social enterprises in the Wirral as if that is an answer. Clearly, that will not be an answer for many independent midwives. The impact of agreeing to the order is that independent practitioners will not be able to practise any more. Either they will be forced to come into the NHS or they will simply not be available to women in future. I would like the Minister to give his assessment of what he thinks the impact of the order will be on those independent midwives.
Having read the Commons debate, I am not clear what happens to staff who provide care, sometimes complex care, independently but who are not a member of a regulated body. What about care assistants practising independently? The Minister said that where they are employed they are covered because of the vicarious liability of the employer, but I am not clear about those practitioners in the health and care field who provide services but who are not part of a regulated profession.
As a general principle, the Opposition support the order because it is eminently sensible, but the Government could have found a more sympathetic way to help independent midwives to be able to practise in the future. I for one am fearful that, as a result of the order, they will not be able to do so.
Earl Howe
My Lords, I am grateful to all noble Lords who have spoken. I shall endeavour to answer all questions that have been put to me as fully as I can. To the extent that I cannot, I shall of course write to noble Lords after this debate.
The centre of attention in noble Lords’ contributions has been independent midwives. Independent Midwives UK is the body which has expressed most concern about the regulations. I am the first to say to my noble friend Lady Cumberlege that continuity of care and service in the NHS is important, and that is part of the mandate to NHS England. We fully accept the value of independent midwives. NHS England will refresh the maternity commissioning guidance to CCGs over the summer to support the plurality of providers and to help social enterprises get NHS commissions.
However, as my noble friend is aware, we are dealing here with self-employed, independent midwives. It is therefore important to look at the factors which pertain to that group of people in particular. My noble friend suggested that the order effectively puts certain independent midwives, the self-employed practitioners, out of business. I do not see it in that way at all. We recognise that self-employed independent midwives may be required to change their governance and delivery practices to comply with an indemnity policy, and it is for the individual practitioner to determine a suitable operating model under which they are able to continue to practise. Social enterprises are the obvious route to that.
The suggestion that independent midwives have not received the fullest attention from officials in my department is seriously misplaced.
Legislative Reform (Clinical Commissioning Groups) Order 2014
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Baroness Brinton (LD)
My Lords, the NHS Act 2006 started us down the route of commissioning; obviously, with the updating and creating of clinical commissioning groups under the Health and Social Care Act 2012, we are still moving into fairly new territory. Inevitably, CCGs are feeling their way in the new structures, including joint working. I am pleased that the order will now legislate more formally for CCGs to work closely with each other and with NHS England, and to jointly commission where appropriate.
One of the many reports that come back to your Lordships’ House from CCGs and NHS trusts is the desire to gold-plate any system with legal advice. For example, we know that the Health and Social Care Act enabled tenders to be taken for quality and efficacy, not just on cost, as under the 2006 Act, yet we hear time and again that lawyers tell commissioners that cost is the most important point. I also welcome the issues around CCGs and National Health Service England overlapping. The Minister referred to some of those; it is also important where there is a pathway in rare diseases, where there may also be some linkages with CCGs perhaps implementing at a lower level. That will smooth the way for that to work well.
To this non-lawyer at least it seems extraordinary that CCGs could not form joint committees to commission over boundaries. This draft order now makes it crystal clear that joint commissioning and the arrangements for ratification by the separate CCGs are not just acceptable but welcome. It is encouraging to see in the accompanying notes that the consultees to this order also see it as a cost-efficient measure; I add to that smoother working systems and, most importantly, joined-up services for users of the NHS.
Lord Hunt of Kings Heath (Lab)
My Lords, on the face of it the order is unexceptional, although I agree with the noble Baroness that CCGs have got themselves into a ludicrous state of getting legal advice on almost everything. It is patently obvious that there are ways in which they can come together to make decisions. We also see that as regards tendering, where, despite the commitments the noble Earl made, we see CCGs absolutely panic-stricken about making a decision not to tender out services. If ever one wanted evidence of the foolishness of the arrangements we now have, it would be the kind of reaction we are seeing from CCGs.
I will ask two or three questions on the order. I noted in paragraph 4.6 of the consultation paper that the department points out that there was opposition to the proposal to enable CCGs and NHS England to form joint committees. I understand that while it is mainly about CCGs forming joint committees, they can also form a joint committee with NHS England. The necessary protection is laid out in paragraph 3.6 of the paper we received, which says that:
“The Minister considers that the proposals maintain the necessary protections. CCGs enjoy a degree of autonomy”.
I thought that they were going to be autonomous, but there we go; it has been qualified in that document. The paragraph goes on:
“To this end, NHS England is under a duty … to promote the autonomy of persons exercising functions in relation to the health service. The wording of the proposed amendment to section 14Z9 is designed to ensure that a CCG function can only be jointly exercised with NHS England where both parties are in agreement, thus preserving a CCG’s autonomy”.
I put the point to the noble Earl that if you talk to CCGs, they do not feel autonomous, because they are used to being beaten up by NHS England—receiving incessant phone calls from the local offices of NHS England—and they and the accountable officer find themselves under huge pressure when there are problems with the system. Therefore the idea that there is an equal partnership between NHS England and the CCG as regards a joint committee is simply not believable. Clearly, local area teams will use that mechanism to force CCGs into joint committees and then force decisions through. I would have thought that that is patently obvious from what is happening in the field in the National Health Service. I would be grateful to hear the noble Earl’s comment on that.
Of course, I have no problem about CCGs working together so that we can get rid of some of the current fragmentation. If we take my own patch of Birmingham, where three and a half CCGs cover the city, there is no chance, it seems, of actually having a strategy for the city which can embrace all the trusts and commissioners unless it is done jointly. I would like to hear from the noble Earl how in fact this mechanism is going to be used to encourage CCGs, which are patently too small in many areas, to come together so that we get some decent strategic planning instead of the fragmented and inadequate contracting process that so many CCGs are undertaking at the moment.
I would also like to ask the noble Earl about consultation when decisions are made by a joint committee. I assume that the consultation rights and responsibilities would apply to a joint committee as much as they do to an individual CCG but, as there is scant evidence of CCGs undertaking proper consultations, I suppose that that is not much comfort. It would be good to hear a little more about how CCGs are going to work this. I must say that after two years of this wonderful new system, I am still waiting for a letter from my CCG saying that it actually feels some form of accountability to me as an individual, but alas that letter has yet to come. From the legal cases which have been brought against some CCGs, it is clear that they do not have any sense of accountability to their local population. That is not surprising because they are membership organisations. They are owned by GP practices, which are the members of the organisation.
This morning I listened to Simon Stevens, appearing before the Public Administration Select Committee, talk about the proposal to hand over some of the contractual responsibilities of NHS England to CCGs. So, in effect, not only are the CCGs membership organisations, they are now going to be given co-power with NHS England to contract with the individual members of the organisations in relation to primary care services. I can well understand why the local area teams do not have the capability to manage the primary care contract. It was patently obvious that they were not going to do so. But what it comes back to is that the governance of CCGs is hopelessly compromised. They ought to be public bodies with much greater lay representation. If they were, we would have much more confidence in the arrangements, but they are not. They are dominated by contractors who have a vested interest in the decisions made by those clinical commissioning groups.
Finally, I turn to page 3 of the impact assessment that provides the evidence base for the supporting paper. It is implied that decisions to deal with specific funding requests might be dealt with by a joint committee. That, of course, is a euphemism for rationing services. Again, we know that some CCGs are making highly dubious decisions about restricting patient services to which NHS patients are entitled. I would like some reassurance that if the joint committee is going to do this, it will be done in public, not behind closed doors, and after full consultation. Recently I have been particularly concerned about evidence which shows that NICE technology appraisals are not being fully implemented in the National Health Service. I remind the noble Earl that it is a legal requirement for a NICE technology appraisal to be fully implemented by the NHS. Again, I would like to hear what the Government are going to do to ensure that CCGs actually play fair by the public and do not unnecessarily restrict treatments.
The order itself is unexceptional and it is supported, but I have to say that the performance of some CCGs leaves a lot to be desired. It is because of the potential of the joint committees to make major decisions that I raise some concerns today.
Earl Howe
My Lords, I am grateful to my noble friend and the noble Lord, Lord Hunt, for their comments and questions. My noble friend was quite right to cite the example of rare diseases and specialised services as one which will be assisted by the order before us, because while we have a mechanism for NHS England and CCGs to get together to discuss these things, we lack the ability for decisions to be taken about the whole patient pathway. This, of course, is vital when we look at the aspiration to join up services for the benefit of patients—not just the specialised care they receive in a centre of excellence, but also the follow-on care that they receive in the community. I therefore share my noble friend’s welcome for this aspect of the order.
I turn to the questions put by the noble Lord, Lord Hunt. A key plank of the Government’s reforms was to increase clinical commissioning. We do not want to depart from that, or from the principle of giving clinical autonomy to those who run clinical commissioning groups. We want to encourage them to enter into arrangements that have the buy-in not just of the local GPs, but of health professionals in their local area and the local authority. We have been clear on the need for a different splitting out of the commissioning functions—for example, to avoid CCGs commissioning individual GP practices and the conflicts of interest that may arise. The arrangements for safeguarding against conflicts of interest are still in place, but what we hear is that as organisations become more established they need a bit more flexibility to work together. In any commissioning structure, there is going to be that need and this order is about allowing those CCGs to work more efficiently. I emphasise that point about allowing them and not requiring them to do so. There is no compulsion about this. The noble Lord indicated that he felt that CCGs do not feel autonomous. I am surprised to hear that, because the arrangements that we have put in place are designed to ensure that local area teams of NHS England are there to support CCGs, not to oppress or breathe down their necks. That is my experience as I go about the health service. This is about joint working and taking decisions together in the best interests of patients.
The noble Lord asked me about transparency. CCGs are under certain duties with respect to patient involvement and transparency when they exercise their functions. Those duties would continue to apply when they exercise their functions jointly with other CCGs. The duty to consult still applies. CCGs will be under the statutory obligations as to patient and public engagements. However, it will be up to committees to agree precisely how they will work in accordance to their obligations. Some consultation responses that we received refer to committees in common that meet in public. Joint working does not have to entail working behind closed doors.
The noble Lord asked about NICE technology appraisals. He is right that some CCGs are slower than they should be under the legal provisions that pertain to adopting and commissioning approved technologies flowing from NICE. To shine a light on that, as he may know, under the Innovation Health and Wealth provisions, we have the NICE implementation collaborative, which is the mechanism designed to measure the extent to which local commissioners adopt approved technologies. The innovation scorecard is also designed to show how innovation in various forms is being rolled out and diffused across the NHS. I believe that mechanisms such as these will be enormously helpful in exposing the laggards in the system.
I hope that I have answered the noble Lord’s questions. I shall write to him if I have failed to cover any substantive point.
Defibrillators
Lord Hunt of Kings Heath Excerpts(9 years, 10 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, I thank the noble Lord, Lord Storey, for starting this debate; I very much agree with his central points. I also pay tribute to the Oliver King Foundation and Oliver’s father, whom I have had the pleasure of meeting on a number of occasions. Indeed, I think that the noble Earl would agree with me that the Liverpool primary schools’ defibrillator programme is a remarkable effort on the part of the foundation, which embraces all primary schools in the city. As part of the project, 12 staff in each school were able to receive training. It is a model for what ought to happen in the rest of the country.
Noble Lords have given us a lot of information about what is happening and raised some of the concerns. I will refer to the research undertaken in Hampshire which was published earlier in the year, the authors of which included the South Central Ambulance Service NHS Foundation Trust and the University of Southampton. They reviewed all calls to the ambulance service between September 2011 and August 2012 following a heart attack. For all emergency calls made from locations other than a person’s home, the call handler specifically asked whether the caller could access a defibrillator. If so, instructions were given on how to use it. During the course of this study over a number of months, the service received just over 1,000 calls about confirmed cardiac arrests away from hospital, which was the equivalent of one for every 600 members of the public each year. For 44 of those incidents in 34 different locations, the caller was able to access an external defibrillator—that is 4.25%—and it was successfully retrieved and used in less than half the cases, 18 cases, before the arrival of the ambulance.
This gave an overall use rate of just 1.74% of all cardiac arrests recorded, which the authors understandably felt was disappointingly low and was apparently similar to previous figures from the London Ambulance Service. Looking at the Hampshire picture, 673 defibrillators that could be accessed by the public were located in 278 places, including 146 devices in large shopping centres. The research also showed that only just over one in 10 nursing homes, around one in 20 railway stations and a similar number of community centres and village halls had defibrillators. The suspicion is that figures in Hampshire are probably similar to many other parts of the country. This shows the scale of the challenge before us, for which we hope for a government response.
Noble Lords mentioned St John Ambulance, to which I am grateful for the briefing I received. The survey work which it undertook shows that a majority of the public think defibrillators should be compulsory in NHS buildings, care homes, concert halls, sports centres and gyms, workplaces, hotels and supermarkets. This seems persuasive evidence that the public would welcome a more decisive response by the Government.
In relation to schools, where I would have thought there was an overwhelming argument for having a defibrillator and trained staff—and indeed trained students—we are relying on the response which the Government have given. This is simply to say that it is up to each school, then relying on changes to the Children and Families Act in relation to the duties of governing bodies and the common-law duty on staff to act in loco parentis while children are at school. We could expect a little more action now from the Government. Particularly in relation to schools, I want to hear that the Department for Education will reconsider its disappointing response so far.
The noble Baroness, Lady Grey-Thompson, made a good point about the need to help people to use defibrillators and for education programmes. I also take her point about the need to help sports clubs. Does the noble Earl not think it would be good for health and well-being boards to take this on? Because of the potential collaboration between local government, the health service, third-sector and many other organisations within a locality, might they not spearhead an approach to getting many more defibrillators fitted and people trained to use them?
Finally, Public Health England is a wholly owned subsidiary of the Department of Health. Could the noble Earl be tempted to give an instruction to Public Health England to treat this as a priority for the future? The Department of Health has a really positive role to play if, through Public Health England and health and well-being boards, this was seen to be important and I am sure we could make much further progress.
National Health Service
Lord Hunt of Kings Heath Excerpts(9 years, 10 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, it is a great pleasure to wind up on this side and to respond to the noble Lord, Lord Crisp. I am sure that we are all very grateful to him for the work that he has done and the initiative that he has taken today. I very much echo his point that there seems to be a global movement in health where there has been a move from what he described as professional development to patient and citizen development. That is to be warmly welcomed. He also referred—and the noble Baroness, Lady Murphy, backed him up—to the power of technology. None of us has really woken up to the impact that technology will have in the future and its ability to give individuals much more control over their own destinies. We are just on the edge of a revolution that will force the pace of change, even in the most conservative reaches of the health service.
Early this morning, I was at a meeting of regulators to discuss whither the Law Commission Bill. It was interesting that the chief executive of the GDC referred to one of its new roles as being to pick up complaints from patients on Twitter when they had just been to a dental surgery. That was an interesting illustration of how we need to change to adapt to new circumstances.
The noble Lord, Lord Crisp, also made the point that our main clientele for the future will be people with complex conditions, yet we still seem to find it very difficult to organise services around those patients. A recent paper by the NHS Confederation looking at the challenges for 2015 says that,
“the health service largely operates as it did decades ago, when the predominant need/expectation was treating episodic disease and injury rather than providing long-term, often complex, care”.
I have been very interested in the work of the Royal College of Physicians in looking at the new hospitals of the future. Essentially it is saying that we need to build those hospitals around people who have complex conditions and that, instead of the ever increasing drive towards specialisation, we need general physicians to look at the patient in the round. The question I put to the noble Earl, Lord Howe, is: to what extent can the Government encourage the health service rather to re-engineer some of its services so that it is built round the patient, particularly the patient with complex health needs?
My noble friend Lady Pitkeathley referred eloquently to carers and the noble Baroness, Lady Brinton, made very good points about expert patients. My noble friend used the term “patient leaders”; I would love to see more on that idea and I hope that the Government can give some support to it. The noble Baroness, Lady Masham, referred to the very unfortunate events concerning one of my noble friends. The problem with that is that the noble Baroness herself has experienced similar issues, so these are lessons that we have to take to heart.
On the structural issue raised by the noble Baroness, Lady Murphy, I understand the point that she is making about consumers having a stake. She referred to charges and then made the point that not many pay them. This is always going to be one of the issues about charges: their administrative complexity and the fact that the people she is trying to get at are those who will probably not pay because, one way or another, they will be given a dispensation. In any case, I gently remind noble Lords that, whatever the faults of the NHS, in its latest 2014 comparator of all the wealthy healthcare systems in the world the Commonwealth Fund has today moved the NHS up to number one from number two. There are obviously lots of issues relating to the ways in which it makes those comparators but this shows that we have something going for the service. If we could only add more patient involvement, it could be a very fine service indeed.
I ask the noble Earl three things. The noble Lord, Lord Crisp, mentioned the citizen but other noble Lords did not really follow him. However, I wonder whether the noble Earl could, in three ways, encourage more involvement of the citizen in health decisions in the future. First, in relation to Healthwatch, can he say how far it could be encouraged to move beyond the individual patient issue to acting as, perhaps, a representative of the public when it comes to problems with health systems in its patch? This is a real issue in the current, fragmented health service: it is very difficult to find out who is in charge and Healthwatch can play a role.
Secondly, perhaps I may raise the issue of foundation trust members. I think that well over a million people could, one way or another, count as members of foundation trusts. We have not yet made enough of their own role in holding the people who run foundation trusts to account. For instance, my own former trust had more than 100,000 members and I always thought that was a powerful way of letting patients get through to the heart of decision-making in a trust.
Finally, I come to clinical commissioning groups. I admit that I am waiting for the first letter to be received from my own CCG saying that it is in business and feels somewhat accountable to the public. CCGs may have set up token patient groups but I do not get a sense that they feel accountable to the public. I want to hear more about how we can encourage CCGs to do that.
National Health Service: Nursing Staff
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Earl Howe
I agree with my noble friend. To ensure that nurses have the leadership skills, styles and behaviours that our healthcare system needs, the NHS Leadership Academy has launched the largest and most comprehensive approach to leadership development ever undertaken. More than £46 million has been invested in core programmes that will map to foundation-level, mid-level and executive-level leadership development, with two programmes specifically for nurses and midwives that started in March last year.
Lord Hunt of Kings Heath (Lab)
My Lords, given the answer that the Minister has just given to his noble friend, surely it is ironic that throughout the NHS the number of senior posts is actually being squeezed. Would he not agree that that runs counter to what Francis said post-Mid Staffordshire about the need for highly effective quality supervisory nurses? Is the reason why this is happening not that the NHS cannot afford to increase its nurse staffing levels with the amount of money that it has been given by the Government? Something has gone, and unfortunately it is these crucial posts that seem to be having to give way.
Earl Howe
My Lords, I do not agree with that because nursing numbers are now at a record high, which cannot indicate that hospitals are being starved of resources for their nurses. I do not see it as ironic that some senior posts have been reduced, bearing in mind the effect of Robert Francis’s report which has caused hospitals to increase the number of nurses on the wards. By and large, nurses at grades 7, 8 and 9 are in managerial positions and not in front-line posts.
People with Learning Disabilities
Lord Hunt of Kings Heath Excerpts(9 years, 11 months ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, I, too, welcome the debate and pay tribute to the noble Baroness, Lady Hollins, both for initiating the debate and for being an enthusiastic champion over so many years of people with learning disabilities. I agree with my noble friend Lady Warwick, who repeated those figures from the confidential inquiry about the poor life outcomes for people with learning disabilities. The fact that men with learning disabilities die on average 13 years sooner than men in the general population and women 20 years sooner is really sobering. I also find it sobering that 22% of those with learning disabilities who died under the work of the confidential inquiry were under the age of 50.
As my noble friend Lady Andrews pointed out, 29% of those who died had,
“significant difficulty or delay in diagnosis, further investigation or specialist referral, and for 30% there were problems with their treatment”.
The report states:
“The lack of reasonable adjustments to facilitate healthcare of people with learning disabilities, particularly attendance at clinic appointments and investigations, was a contributory factor in a number of deaths”.
It points out that:
“GP referrals commonly did not mention learning disabilities, and hospital ‘flagging’ systems to identify people with learning disabilities who needed reasonable adjustments”—
which is a legal requirement—
“were limited”.
There are some very key questions to put to the Minister. First, will he respond to the noble Baroness, Lady Hollins, on why the Government have not published a one-year-on report detailing what progress has been made in implementing the recommendations of the confidential inquiry? Secondly, can he explain where responsibility lies for implementing those recommendations? Is it with his department or is it with NHS England? I ask that because we are all aware of concerns expressed by his right honourable friend Norman Lamb on the failure of the NHS and local government to implement the core recommendation following the Winterbourne View scandal so that all those with a learning disability in inappropriate institutional care are offered community support. It is quite an extraordinary thing when a Minister says that the health service and local government have completely failed to meet that target. What I do not understand is who is responsible. It seems to me that Ministers are evading their responsibilities.
The noble Baroness asked the Minister about the central recommendation that a national learning disability mortality review board should be established. We have all had briefing from the BMA that emphasises the importance of such a review. We are told in the debate that this is now to be set up in the first half of 2015. Can the Minister confirm that? Can he also confirm that, once established, it is to be a permanent mechanism?
Another point that the BMA raised was that:
“One of the barriers to providing joined-up care is the way in which services tend to be commissioned separately, to the extent that co-morbidities fail to be recognised in either process”.
It went on to say:
“The planning and commissioning of services for people with intellectual disabilities, mental health problems, and chronic physical conditions must take greater account of the diverse healthcare needs of these groups. To facilitate this, commissioners need to have the knowledge and skills to understand how best to provide services for people with mental health problems and with an intellectual disability”.
Can the Minister respond to that point? Will he also respond to the point raised by my noble friends Lord Patel of Bradford and Lady Andrews and the noble Lord, Lord Adebowale, about the worrying evidence of health and care workers’ ignorance about the Mental Capacity Act, as identified in the excellent Lords Select Committee report?
I would like to pick up a point raised by the right reverend Prelate the Bishop of Carlisle on hospital services. My former trust—Heart of England NHS Foundation Trust—has appointed a team of specialist nurses in learning disabilities to work with local GPs to map patients’ pathways, enhance communication between community and acute hospitals, develop resource packs and training programmes for staff working in the hospitals and make sure that treatment options are available to people with learning disabilities. A number of noble Lords said that too often people with a learning disability and a physical health issue are ignored by health professionals when it comes to treatment options. I worry that lawful consent to treatment is not given in those circumstances: I rather doubt that it is in many cases. Will the noble Earl encourage other trusts to follow the example of Heart of England NHS Foundation Trust?
The noble Baroness, Lady Hollins, referred to data linkage. That is a very important issue. If the Health and Social Care Information Centre is reluctant to make progress on that matter, I hope that the noble Earl will consider her suggestion that Ministers should take steps to issue a direction from the department to tell that centre to get on with it.
Finally, will the noble Earl confirm that parity of esteem applies to services for people with a learning disability? If he can confirm that, will he say how it is being put into action?