NHS: General Practitioners

Lord Hunt of Kings Heath Excerpts

Wednesday 26th February 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they are taking to ensure that patients can get an appointment with their general practitioner.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and refer noble Lords to my health interests in the register.

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

My Lords, the GP patient survey showed that the vast majority of patients are satisfied with their GP and rated their experience of making an appointment as good. To improve access further we have announced a £50 million fund to support GP practices in improving services and access for their patients. We have also reduced the quality and outcomes framework, the QOF, by more than a third. This will free up space for GPs to provide more personalised care. In addition, by March 2015, all practices will have the facilities to offer online appointment booking and repeat prescription services, increasing ease of access to GP services.

[Lord Hunt of Kings Heath]

My Lords, the noble Earl will know that the analysis by the Royal College of General Practitioners at the weekend showed, according to its work, that 10% of patients were finding it difficult to find an appointment with their general practitioner. Can the noble Earl tell the House what the Government are going to do about that? Does he agree that as hospitals are now moving to full seven-day working, the accessibility of primary care must be improved?

[Earl Howe]

I do agree with the noble Lord’s final comment in particular. We know that GPs are hard pressed. GP consultation rates have risen by 40% since 1995. We therefore need to take several steps to address that. One is in the medium to longer term: we need more GPs, and we have tasked Health Education England to ensure that at least 50% of medical students move to the GP specialty. In the immediate term, there are the measures that I mentioned relating to the GP contract and the £50 million fund, both of which are designed to make the use of GPs’ time a lot more productive than it is at present.

Care: Financial Services Industry

Lord Hunt of Kings Heath Excerpts

Wednesday 26th February 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, thank my noble friend Lord Lipsey and the other noble Lords who have spoken in this highly informed debate. It takes us back to our debates on the Care Bill, which is still subject to deliberation in the other place.

My noble friend referred to the statement of intent and to the difficulties that the industry has encountered in producing policies, for the reasons that he set out. We have studied the statement of intent with care. I noted that the introduction refers to the following fact:

“In March 2013 the Department asked the major firms and trade associations in this field to undertake a review of how the market could develop. This reported back in July 2013 and is being published today”.

No one admires more than me the Department of Health but it does seem to have taken rather a long time for this to have been reported. I should have thought that it would have been more helpful to noble Lords if it had been reported when we were considering some aspects of the Care Bill.

The essential point of the review was that,

“there is currently a lack of demand for products and that new products might initially reach only a small market”.

Shock, horror in the Financial Times—but I do not think that my noble friend was surprised. As he said, he does not really hold out much hope that there will be a market in the future in the way that noble Lords have been talking about tonight: first, as he said, because of the difficulty of pricing products due to the uncertainties in the years ahead, and, secondly, because of the reluctance of most of us to buy those products even if the industry were certain of being able to put them on the market. I should be interested to know whether the noble Earl agrees with my noble friend’s analysis or whether he is more optimistic. If he is more optimistic, then why?

However, my noble friend pointed to what he described as two saleable products: first, point of use and, secondly, enhanced annuities. He felt that those were essential to underpin the Dilnot proposals. I do not want to go over old ground but I agree with my noble friend and other noble Lords that the real problem for us is that, while we obviously welcome the foundations laid in the Care Bill, the fact is that it does not really produce what we originally thought it would—a clear cap that people can understand. We have the £72,000 cap but, in reality, we know that it is much higher. There is the £12,000 per annum living cost and there is also the fact that the £72,000 cap is related to what the local authority will pay. We know that private funders pay more than that, and there are many suggestions that private funders are subsidising people funded by the local authority. Whether that will survive the transparency that will come in a few years’ time, I very much doubt. We argued and debated this when we discussed the Care Bill.

I know the nursing home that my noble friend referred to because my mother has instructed me that, if she has to go into a nursing home, that will be the one to which she goes. She sized it up and everyone in Oxford knows that it is a very good nursing home. However, £50,000 a year—£1,000 a week—is much higher than the local authority will be paying for the people for whom it will be responsible. Therefore, in essence, the cap will be much higher than £72,000. I agree with my noble friend that the Government need to come clean on this. We will not get the certainty that is required or achieve the required literacy among ourselves and other people unless it is clear what the likely liability is going to be for many of us and our relatives.

My noble friend raised two further points. The first concerned regulation. He is not convinced that the standards required of independent financial advisers are sufficient. This is worrying. Noble Lords will have received very interesting briefings for this debate from the Equity Release Council and the Just Retirement organisation. The Just Retirement briefing refers to polling that it commissioned, conducted by YouGov. It found that when individuals were asked where they would go for information or advice on how best to pay if they needed to organise professional care, one in five chose their local council, a similar number chose a CAB and almost a fifth said that they would go to the National Health Service—I am not sure whether that is advised, but there we go.

However, interestingly, the poll also revealed that when people were informed that they would face a large care bill before reaching the cap, almost two-thirds recognised the need for professional financial advice. That is encouraging as long as we can be sure that the independent professional advice is of a high order. I share my noble friend’s concerns that this is very variable, and I am not sure that the regulatory context in which those providing the advice operate will deliver the goods.

The second point that my noble friend raised comes back to being clear about what people are liable for. There are continuing concerns about the role of local authorities in this and their capacity to deliver. I am still concerned about their ability to undertake assessments when the new clock starts, and I have not been convinced that local authorities really do have the capacity to do the job effectively. However, that then raises the question of the nature of the very welcome campaign that the Government, as a result of our debates, have agreed to.

A national public awareness campaign is very important, but it has to be done with effectiveness and vigour. I wonder whether the noble Earl will be able to say a little more about how the campaign is going to be organised, what the budget will be, when it will be launched, how long it will run for and what partner organisations his department will work with. I refer him again to a poll by Just Retirement, which found that nearly one-third of those aged 55 and over believe that councils pay most of the cost, with individuals topping up the rest, while 40% believe that individuals pay most, with councils topping up the remainder. Many, many people do not understand the liabilities that they will face. We need to do everything that we can to ensure that people understand and can get proper advice, and we need to ensure that where the insurance market has a role to play, that role will be as effective as possible. This debate, although very short, is very important if we are to go forward with confidence in terms of Dilnot and the many liabilities that people are going to have to face in the future.

NHS: Patient Data

Lord Hunt of Kings Heath Excerpts

Tuesday 25th February 2014 Lords Chamber

[Earl Howe]

My Lords, I am aware of concerns around the leaflet. Many people have said that they have not received it, which is clearly a concern. NHS England, which is leading on the development of the programme, will consider how to ensure that it engages fully with stakeholders and the public over the coming weeks and months and respond to the concerns that have been raised. The Government will also be engaging with stakeholders to see what we can do from a broader perspective.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my health interests. Is not one of the problems that if a patient wants to opt out of the system they have to go to or communicate with their general practitioner? I am sure the noble Earl will have seen the report at the weekend from the Royal College of General Practitioners that GPs are sometimes rather difficult to find. Would it not give the public more confidence if they could opt out in a straightforward way rather than have to go to see their GP and then depend on the GP to enact that in practice?

[Earl Howe]

My Lords, I cannot agree with that. The GP surgery is where the records are kept and would seem to be the natural place for patients to go. They do not have to make an appointment to do that. If they are concerned, they can write a letter or send an e-mail to the GP practice and then have a conversation later if they would like to. I do not think this is a difficult process.

Drug Companies: Medical Trials

Lord Hunt of Kings Heath Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My Lords, I readily acknowledge the work done by the previous Government, which makes this country probably the best prepared in the world for a flu pandemic.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I come back to the question raised by the noble Baroness, Lady Brinton. Once a medicine goes off patent it can, through generic production, remain available to members of the public for many years. The evidence seems to be that trials that give a favourable verdict are twice as likely to be published as trials giving unfavourable results. Could the noble Earl focus a little more on whether the industry can be encouraged to produce evidence around those trials in relation to current medicines as well as future ones? I also refer noble Lords to my health interest in the register.

[Earl Howe]

My Lords, it is important to point out that the MHRA does not have evidence that there is systematic or large-scale withholding of data. However, it has investigated cases in the past where clinical trials and safety data were not properly reported. The Government believe that the proposals included in the new EU clinical trials regulation will, as I said, contribute to greater transparency in the area of clinical trials. It must be remembered that any company infringing even the current rules can lay itself open to some very severe penalties.

Health: Folic Acid

Lord Hunt of Kings Heath Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My Lords, I recognise that this is an extremely important decision for the Government to make, affecting many people’s lives. I do not accept the implication behind the noble Lord’s question that the numbers involved in the analysis were somehow statistically invalid. I am assured that they represent a valid statistical base. We welcome all robust new evidence around the issue of fortification, such as the study published last week by the Wolfson Institute, and I can assure the noble Lord that we will take a decision on this matter as soon as possible.

[Lord Hunt of Kings Heath (Lab)]

My Lords, could the noble Earl give a little more precision as to what “as soon as possible” actually means? He referred to the study produced by the Wolfson Institute last week. Is he aware of the comments of Sir Nicholas Wald of the Wolfson Institute that it will be a public health tragedy if this country does not follow the example of the many other countries that have introduced this in a mandatory way? Is it not time that the Government simply made a decision? Indeed, they are clearly briefing to the media that they are going to make a positive decision. Why do not they just come clean and say, “We’re going to do it”, and say which date it will start from?

[Earl Howe]

My Lords, as I have explained on earlier occasions, it is very important that we use the latest data to reach a robust and defensible view of the risks and benefits on this issue. We will take the new National Diet and Nutrition Survey data on folate status into account when we do reach a decision. As for the position taken in other countries, while a number of countries have introduced mandatory fortification of flour with folic acid, others notably have decided against it, including Ireland and New Zealand.

Health: Meningitis B Vaccine

Lord Hunt of Kings Heath Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

I can tell my noble friend that the JCVI has been considering both those issues: first, the possible need for a population-based evaluation of the MenB vaccine to address uncertainties in its effectiveness; and, secondly, what the possible effect of the MenB vaccine on the carriage of meningitis B bacteria might be. I say again that we need to wait for the JCVI’s final statement of advice to get clarity on either of those issues.

[Lord Hunt of Kings Heath (Lab)]

My Lords, of course I understand that we need to await the outcome of the Joint Committee’s further deliberations. However, following up the Question asked by my noble friend, if the committee sticks to the view that a vaccine would have a huge impact on an estimated 1,000 young people every year but still considers that that is not cost-effective, surely it calls into question the methodology that it is using. Will the noble Earl say a little more about how the Government can ensure that this methodology is put under full scrutiny?

[Earl Howe]

Last October, in recognition of concerns about the methodology currently used for assessing cost-effectiveness of vaccines, the JCVI agreed that a working group should be formed to consider two issues: first, how the impact of vaccination programmes to prevent rare diseases of high severity should be best assessed; and, secondly, whether there were aspects of cost-effectiveness in relation specifically to children that should be addressed. It is a complex issue both economically and, indeed, ethically. We should not expect a report from that group, once it has been established, until next year at the earliest.

NHS: Black and Minority Ethnic Nursing Directors

Lord Hunt of Kings Heath Excerpts

Monday 10th February 2014 Lords Chamber

[Earl Howe]

We have to be a little careful about doing anything that appears to look like positive discrimination or setting quotas, because we stray into areas of dubious legality if we do that. Having said that, as I have indicated, the priority of the Chief Nursing Officer is extremely clear and substantial resources have been put behind this. I pay tribute to the work that the noble Lord, Lord Crisp, did when he was NHS Chief Executive. We have picked up a lot of the ideas that he promoted at that time. I would be very disappointed if there were not progress within a few years but one has to set a realistic time horizon.

[Lord Hunt of Kings Heath]

My Lords, I refer noble Lords to my health interests. One answer to the question raised by the noble Lord, Lord Mawhinney, would be to point out that 18% of the NHS workforce in England is from a BME background and 14% of the population of England is from a BME background. As 2.6% of nursing directors comes from a BME background, that shows that there is a very long way to go. Is the Minister confident that NHS England is acting in accordance with the Equality Act? If he is not confident, what is he going to do about it?

[Earl Howe]

My Lords, just to correct the noble Lord, the latest figure I have from 2012 is that total ethnic minority groups in nursing, midwifery and health visiting comprise 19.7% of the nursing workforce. That underscores the basic point that he made. One cannot aspire to 19.7% of those ethnic nurses becoming nurse leaders because there is only a limited number of leadership posts. However, we are clear that this should be a priority for the NHS.

The answer to the noble Lord’s second question is that the Equality and Diversity Council has published some refreshed guidelines. One of its goals is to have a representative and supportive workforce throughout the NHS. It is putting that in train by asking NHS organisations to monitor their equality performance jointly with their patients, communities and staff.

NHS: Competition

Lord Hunt of Kings Heath Excerpts

Monday 10th February 2014 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare my interests as chairman of an NHS foundation trust, as president of GS1 UK, and as a consultant trainer with Cumberlege Connections Ltd. I, too, welcome my noble friend’s debate and the opportunity to return to the issue of competition. I think that it has to be seen in a wider context. No one can be in any doubt about the pressure that the National Health Service is currently under, often because of conflicting policy objectives that the Government are setting. On the one hand, quality and safety demand more staff, but on the other hand, that must take place at a time when the NHS is in its worst financial position. The health service also has to face up to huge demographic pressures. However, the response so far has been to see a vast number of frail elderly people being admitted to hospital and then staying in too long because of a lack of appropriate community care and support. We have debated the urge for seven-day working in our hospitals, which is to be highly commended, but that is being jeopardised by the failure of primary care and social care to respond in parallel. Instead of leadership, co-ordination and partnership, the Lansley changes have bequeathed a dysfunctional system where essentially the Government have legislated for fragmentation—and fragmentation is certainly what has been delivered.

Clinical commissioning groups, often staffed by very good people working with the best will in the world, cover too small a population to be able to give strategic direction across a health economy. The local area teams of NHS England are focused exclusively on micro-management rather than leadership, under the weight of excessive performance management from NHS England headquarters. NHS England was itself promised autonomy, but is getting anything but. Its target-obsessed approach seems strangely at odds with the post-Francis culture that is required. Fragmentation at the local level seems to be matched by confusion that reigns at the national level. The Lansley “hands-off” model has been ripped up by the current Secretary of State, who intervenes at every turn. How else can we explain the weekly meetings that he has with the bosses of NHS England, Monitor and the CQC, all supposedly independent bodies? Independent, my foot.

On top of all this, we have competition, which we have debated many times. Of course, choice and competition have a role to play in the National Health Service—on that, I agree with my noble friends. Indeed, when in government I was involved in involving the private sector to help provide extra capacity, speed up hip replacements and cataract surgery, and reduce waiting times for the NHS. Moreover, I have no doubt whatever that where existing services have consistently underperformed, alternative providers, including the private sector, third sector, mutuals and social enterprises, are important as a way to turn things round. However, to conclude that market principles are a panacea is simply wrong. It is enforced competition and enforced marketisation that we on the opposition Benches are opposed to.

I know what the Minister is going to say. He has consistently told us when we have debated these issues that CCGs were free to commission services and would not have to create markets against the best interest of patients, but I remain of the view that Part 3 of the 2012 Act and the Section 75 regulations mandate the open tendering of services.

I listened with great interest to the noble Baroness, Lady Brinton, and welcome her to our debate. I say to her that while I accept that the Section 75 regulations were withdrawn and rewritten, my reading of them remains as I read them at the time: that, in the end, CCGs will essentially be forced to tender all services. That is certainly what the health service thinks. We can see already the impact of this. FOI requests have unearthed the fact that in the first six months of the new system, clinical commissioning groups had spent at least £5 million on external competition lawyers. We also know that NHS providers have reported a sharp rise in their legal bills as a result.

Both my noble friends have mentioned the intervention of the Office of Fair Trading, which is causing absolute havoc. We have the cases in Dorset and in Bristol. The impact of this has been the putting of a lot of sensible reconfiguration proposals into cold storage but, my goodness me, how much we need bold reconfiguration proposals to be implemented in order to provide high-quality, safe care. What has happened in Greater Manchester, where the move to centralise cancer services into fewer top-performing specialist centres is apparently in jeopardy because it is being claimed that it will be anti-competitive and reduce patient choice? My noble friend mentioned the Blackpool case, and I hope that the Minister will respond to that. My understanding is that the CCGs have had to hire administrative staff to collect thousands of documents, tracking every referral from GPs. What a complete waste of time and effort. I refer the noble Earl to a survey of hospital chiefs conducted by the Health Service Journal last December, in which 88% of them said that securing change to competition and choice rules should be a priority for the incoming chief executive officer of NHS England. What a lot of priorities he will have to face when he starts in April.

All this is well known both to the noble Earl’s department and to NHS England. I do not want to repeat what his honourable friend Norman Lamb said, because my noble friends have already done it, or the evidence that Sir David Nicholson gave to the Health Select Committee last November, when he highlighted the cost and frustration caused by the way in which competition law was being used.

I want to ask the noble Earl about the proposals that NHS England is putting forward to centralise specialist services in a small number of centres—or at least it has been said that that is what it is going to be doing. Can the noble Earl confirm that? Is he confident that such proposals will not lead to Office of Fair Trading interventions if he is reducing the number of specialist centres? In view of what Mr Lamb and Sir David have said, will the Government bring proposals to the House in the next Session to put this right? The Opposition stand ready to help the noble Earl make changes to legislation in this regard.

Clearly, competition has a place—I have no doubt about that. I stand by the work that I did to encourage some private sector involvement in order to get waiting times down. That is a very good example of when it is useful to use the private sector. But competition is not the be-all and end-all; it is not the panacea that some claim. The noble Baroness, Lady Brinton, made a very reasoned argument. My response to her and to the noble Earl is that I know that we are getting guidance and further work is being done in this area, but the fact is that the health service thinks it has to tender almost all services. I am afraid that once you do that, in effect you have a competitive market. That is the problem we face. I hope very much that the noble Earl will tell us that the department and the Government will actually listen to the concerns which have been expressed by a considerable number of people in the NHS, NHS England and his own department.

[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 Turnberg, for tabling this topic for debate. I will begin with three simple statements, to serve as mental marker posts, as it were, before I respond to the questions that have been raised.

First, amid the many changes that we made to NHS commissioning through the Health and Social Care Act, one area of the law that has not changed one iota is the law relating to competitive tendering. That law has been in place for a number of years; it has been governed by a European directive; and, as regards the rules governing NHS procurement, the Section 75 regulations change nothing at all.

Secondly, the noble Baroness, Lady Thornton, referred to “Mr Lansley’s agenda” on privatisation. There is no government agenda to privatise NHS services—quite the contrary. We made it illegal in the Health and Social Care Act for the Secretary of State, Monitor or NHS England to have a policy deliberately favouring the independent sector.

Thirdly, the noble Lord, Lord Hunt, spoke of a deliberate policy of enforced competition and marketisation. I must correct him. It is NHS commissioners alone who will decide whether, where and how competition in service provision should be introduced. There are no obligations on commissioners to create or promote markets; nor are they required to fragment services against the interests of patients.

Those three points are key to understanding what the Government are doing and what we are not doing. I will now turn to the place and value of competition in the NHS, which has long existed. As the noble Lord, Lord Turnberg, pointed out, patients have long exercised choice over where they receive services from. I was pleased to hear the noble Lord, Lord Hunt, acknowledge that third sector and independent providers play an important part in providing NHS care; for example, in hospice care for terminally ill patients, mental health services and long-term nursing care for the frail elderly.

We have seen over the past decade the independent sector treatment centre programme and the introduction of payment by results in 2003, the advent of patient choice in 2006, and the transforming community services programme of 2008. I must point out to the noble Lord, Lord Turnberg, that it was this changing landscape that introduced greater competition to the NHS; it was not the Health and Social Care Act. There is robust evidence from a variety of sources that quality-based competition can work to the benefit of patients, and I shall come on to cite that evidence in a moment.

The previous Administration put in place a set of rules to manage that competition, known as the Principles and Rules for Co-operation and Competition, and the Government committed in their response to the NHS Future Forum report to maintain these and place them on a statutory footing so that they could continue to apply to commissioners. That is exactly what we have done; there has been absolute continuity in how the rules apply. Clinical commissioning groups work within this framework to secure the best services for patients that they can, from whichever provider best offers that prospect. In essence that is the value of this framework of rules. They will be supported in this activity by guidance from NHS England and Monitor, and through the work of commissioning support units.

The noble Baroness, Lady Thornton, asked me what I would regard as a reasonable proportion of NHS activity to be put out to tender. I have no view on this, and nor should I. The decisions on tendering are entirely up to commissioners and not Ministers. The noble Baroness also indicated that seven out of 10 NHS contracts have gone to the private sector since last April. I point out that that figure is highly misleading. It was quoted in a newspaper article, but the contracts in the sample that was quoted amount to a tiny and unrepresentative sample of the scale of NHS activity. In reality, spending on healthcare from private-sector providers equates only to around 6% of total NHS expenditure. It was roughly 5% at the end of the previous Administration.

My noble friend Lady Brinton asked whether there will be guidance from Monitor to clarify the duties on commissioners, and the noble Lord, Lord Hunt, suggested that commissioners are confused about that. Monitor has now published its guidance to support commissioners in understanding and complying with the Section 75 regulations. Monitor, along with NHS England, will undertake further engagement with commissioners to support them in understanding the requirements. I acknowledge that there is a degree of misunderstanding out there, but not everywhere. NHS England’s forthcoming procurement guidance will provide further guidance on the EU requirements.

The noble Lord, Lord Hunt, raised concerns about fragmentation and barriers to integration. To the extent that fragmentation exists, I say to him that it existed as greatly under his Government. I am proud to say that this Government are taking practical steps to make integration more commonplace throughout the country. We are supporting a number of integration pioneer sites, which will trailblaze new ideas to bring care closer together. They will be leaders of change—a change we have to see in the system if we want to offer the best-quality care.

We are also supporting the system through the £3.8 billion Better Care Fund, which will encourage organisations to act earlier to prevent people reaching crisis point, to offer seven-day services, and to deliver care that is centred on people’s needs. That idea and that fund have been widely welcomed. Therefore, our focus is for commissioners to innovate and to work with partners in the sector to design integrated care pathways for patients that allow for a seamless experience of care. I assure the Committee that the competition rules do not stand in the way of that. In fact, the Section 75 regulations explicitly allow for it.

Under the regulations, the objective of a commissioner must always be to secure the needs of patients, including through services being integrated. For example, in Milton Keynes, substance misuse services used to be delivered by several providers, resulting in fragmented care. Users found services difficult to navigate, which impacted on treatment entry and retention rates. In response to this, NHS Milton Keynes CCG and Milton Keynes Council developed an outcomes-based approach to commissioning. Existing services were brought together into one fully integrated, recovery-focused service, delivered by a third sector organisation, which enabled more effective delivery of care and efficiency savings of 15% to 20%. That is a clear example of good commissioning delivering improved services for patients.

I turn to the OFT’s role and the review of mergers. Again, it is important to realise that the NHS has long had arrangements in place to review mergers on competition grounds, and that in considering mergers the competition authorities are acting under their existing powers under the Enterprise Act 2002.

The noble Lord, Lord Turnberg, criticised Part 3 of the Health and Social Care Act. Repealing Part 3 of that Act would not remove the powers of the competition authorities. In fact, the 2012 Act was important in clarifying those powers in order to address the legal uncertainty for NHS bodies as to whether mergers between them would be considered by the OFT or the CCP. Without this clarification, providers would have been at risk of double jeopardy, with both bodies potentially seeking to undertake a review.

The noble Lord, Lord Turnberg, cited several examples of challenges being issued on competition grounds which he attributes to the existence of Part 3 of the Act. I do not want to comment on the detail of those cases—it would be wrong of me to do so—but I would point out that challenges of that kind would have been quite capable of being brought even if the Government had never introduced the Health and Social Care Bill.

[Lord Hunt of Kings Heath]

My Lords, I understand where the noble Earl is coming from in relation to the Enterprise Act. However, is it not a fact that essentially what happened was that the 2012 Act was a signal to the market that a market was being put in place? Why have a 300-page Act and why have the Section 75 competition regulations? In essence, the Government opened the door in this regard and that is why these challenges are now taking place. They did not take place before the 2012 Act.

[Earl Howe]

The market, however, did exist, which was the point that I made. The market was out there well before the 2012 Act and well before this Government came to office. It was incumbent on us to clarify and simplify the rules that the previous Government put in place. We did that through Part 3 of the Act. It was not a signal to anybody to marketise the NHS. Indeed, as I said, we explicitly provided for it to be illegal for Ministers or Monitor to prefer the independent sector over public sector providers. That is explicit in the Act, so the noble Lord cannot accuse the Government of enabling legislation to promote marketisation.

NHS: Seven-day Working

Lord Hunt of Kings Heath Excerpts

Thursday 6th February 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, am grateful to the noble Lord, Lord Ribeiro, for instituting this debate. It is clear that all noble Lords who have spoken are broadly in favour of moving to what we are calling a seven-day week for the NHS. However, there is a range of views about whether it is deliverable. I hope that the noble Earl will be able to address some of the substantive points that have been put to him.

The argument for seven-day working to its full extent is of course persuasive. Noble Lords have talked about the high mortality rate at weekends, the variable staffing levels, the absence of senior decision-makers and a lack of consistent specialist services, such as diagnostics. It is also clear that capital is not used by the NHS to the extent that one would desire if very expensive machines are left idle for quite a part of the week.

However, there are three major questions about whether this is workable which I will put to the noble Earl. First, is the rest of the health and social care system able to match the seven-day working of the health service? It seems that the major pressure problem facing the NHS is frail, older people who probably should not have been admitted, but have been because either nursing homes or social care provision was not sufficient. Once they are admitted to hospital, it often becomes difficult to enable them to be discharged quickly because of an absence of community infrastructure. If we are going to have full seven-day working within acute hospitals, it is essential that GPs and social and community services also embrace seven-day working.

I do not know to what extent the Bruce Keogh work has really reflected that. It will have to be tackled. We cannot carry on any longer with GPs who are inaccessible and unable to do what is necessary to help people who have been discharged into the community. The same goes for social services, which still seem to shut down over bank holidays and the Christmas period. This simply is not going to work unless the whole of the system is working to the same tune.

Secondly, there are mixed views on resources. My noble friend Lord Parekh thought that the cost of this could be contained. I must say that I rather share the view of my noble friend Lord Warner and the noble Lord, Lord Ribeiro, that this is in fact going to be massively expensive. The noble Lord, Lord Ribeiro, talked about the necessary massive expansion of consultants. That must be true because we do not want seven-day working that involves staffing up at the weekends and reducing staffing during the week. I suspect that mortality rates would go up during the week because you would not have the necessary cover. I am afraid that some of the plans of acute hospitals are indeed to squeeze staffing during the week. That is a crazy way to go about it. I am very concerned that, in time, we will see a rise in mortality rates during the week. I do not think that this has been fully considered by those who say that we can do this simply by a better ordering of the way in which things are done. I refer the noble Earl to the Institute of Fiscal Studies report published today, about the resource challenges facing the NHS, and ask him how this is to be afforded.

Finally, does the noble Earl think that, as a result, the noble Lord, Lord Ribeiro, will be even more engaged in dealing with reconfiguration issues? Does the noble Earl agree that the implications of this are that we have to have radical reconfiguration of services? Will Ministers support that? Equally, will they tell Monitor and the competition authorities to back off from instituting competition procedures if this reconfiguration is necessary to make this work?

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

My Lords, I congratulate my noble friend Lord Ribeiro on securing a debate on this important issue. I know that as a former consultant surgeon and former president of the Royal College of Surgeons this is a subject in which he takes a great deal of interest. I also take this opportunity to pay tribute to the work done on seven-day services by NHS England, the NHS Services Seven Days a Week forum, the Academy of Royal Medical Colleges and the Royal College of Surgeons, among others.

The historical five-day service model offered in many NHS hospitals no longer meets justifiable patient and public expectations of a safe, efficient, effective and responsive service. I very much echo the comments of the noble Lord, Lord Parekh, in that context. Over the past 10 years, a growing body of national and international evidence has emerged that links poor outcomes, including a higher risk of death, to patients admitted to hospital at the weekend, around the world. It is impractical and inefficient to continue to operate a five-day approach when our illnesses and conditions do not limit themselves to office hours. Patients are entitled to receive the same standard of care regardless of the day of the week.

As the largest and most comprehensive health service in the world, the NHS is well positioned to solve the issue of poorer outcomes and reduced levels of service provision at the weekend. That is why NHS England has set out a vision for the NHS which is of a service more closely organised around the lives of the public it serves. To develop this vision, NHS England established the NHS Services Seven Days a Week forum in February last year to consider how NHS services can be improved to provide a more responsive and patient-centred service across the seven-day week.

The forum’s work has been met with nothing but positive feedback and support from the public and patients, the Academy of Medical Royal Colleges and the British Medical Association, among other organisations. The immediate focus for improvement activity will be addressing the need for high-quality urgent and emergency care services, seven days a week. NHS England is also looking to make similar improvements across primary and community health services and social care, and the forum will report in autumn this year, setting out proposals for the creation of a fully integrated service. NHS England’s ambition is for seven-day services to be fully implemented in England by the end of 2016-17.

I recognise that we cannot talk about the idea of seven-day services without giving full consideration to questions of staffing and finance; many noble Lords have raised those issues. NHS providers and their commissioners already face difficult choices when deciding where to invest their resources in order to maximise the outcomes for patients and value for taxpayers. Early indications are that seven-day services have the potential to be part of the solution. However, more information is needed. NHS England is therefore conducting research which will provide a helpful indication of the likely costs providers and commissioners face when considering how to redesign their services to provide comprehensive seven-day care. In addition, to answer my noble friend Lady Brinton, NHS England intends to commission financial and system modelling and analysis of the implications of its strategy for achieving seven-day service provision in the NHS.

My noble friend Lord Ribeiro rightly highlighted the workforce implications of having a consistent, high-quality service seven days a week. The department, alongside NHS England, Health Education England, NHS Employers and a number of strategic partners, is considering that very issue. Its analysis is considering issues such as junior doctors feeling unsupported during weekend working and the resulting need to ensure that education contracts include appropriate seven-day senior supervision; and numbers of diagnostic and scientific staff, with NHS England intending to undertake a thorough assessment of the different roles needed in diagnostic and scientific services to support an extended service.

Of course, many commissioners and providers will need support to address the challenges presented by seven-day services. To that end, NHS Improving Quality has just introduced a new, large-scale transformation change programme, set up in collaboration with all healthcare commissioners and providers, to support the spread of seven-day services over a three-year period.

I realise that the move towards seven-day care will not be easy, but there are encouraging examples of pioneering NHS organisations that have moved to make healthcare services more accessible seven days a week to avoid compromising safety and patient experience. For example, Sheffield Teaching Hospitals NHS Foundation Trust has adopted seven-day service provision, improving patient flow of frail and older people through the emergency pathway. Bed occupancy for emergency care for older patients has now reduced by more than 60 beds. Other examples in my brief include Salisbury District Hospital and the Lancashire Intermediate Support Team, both of which have produced impressive results.

We know that across the country, more hospitals, primary and community care organisations and social care services are working together to break the link between poorer outcomes for patients and the reduced level of service provision at the weekend. We also know that patients and the public want us to act now to make seven-day services a reality in all parts of our NHS.

A number of noble Lords, including my noble friend Lord Ribeiro and the noble Lords, Lord Parekh and Lord Hunt of Kings Heath, raised the issue of cost. Interestingly, there is already evidence that seven-day services can be implemented in a way that does not increase the overall cost of healthcare. The average cost of implementation at trusts pioneering the service was 1.5% to 2% of their total income. Costs vary according to local service models, but research shows that they can be reduced by reconfiguring services and by trusts working collaboratively. Seven-day services at the front end—that is to say, A&E departments—could also pay for themselves by reducing admissions and lengths of stay.

Seven-day services would not work under a one size fits all model—a point made by my noble friend Lord Ribeiro. Local solutions need to be found and pioneering NHS providers and commissioners are already working to develop them.

In answer to the noble Baroness, Lady Masham, on the issue of safety at weekends, we expect all NHS services to be able to meet patients’ needs as they arise. To do this, trusts should adopt the clinical standards developed by the seven-day services forum to drive up clinical outcomes and improve patient experience at weekends.

My noble friend Lady Manzoor referred to the CQC. The CQC and the Chief Inspector of Hospitals are considering how implementation of the clinical standards could best be assessed by the CQC and how this might be reflected in its forthcoming ratings and the judgments it makes when it inspects.

As I said, workforce is a major issue. The noble Baroness, Lady Masham, was right to raise that point. There are over 12,200 more clinical staff in the NHS than there were before the election, thanks to the money we have invested in the service and to the reforms we have carried out. Nevertheless, there is an issue about motivating staff to work at weekends, as the noble Baroness rightly said. We understand that contractual levers and incentives are required to drive change. NHS England and a number of key strategic partners are already looking into this. However, in many cases seven-day services have reportedly already had a positive impact on individuals’ work-life balance, offering greater certainty in planning ahead and flexibility in time off. In addition, the medical royal colleges are all in support of seven-day services. Building seven-day service provision into recruitment, job planning and appraisal processes will help create a sense of common purpose to underpin organisational delivery.

A number of noble Lords, including my noble friends Lord Ribeiro and Lady Barker, referred to the role of GPs. To address that important role in the mix of services the NHS provides, we recently announced the setting up of a £50 million fund to support innovative GP practices in improving services, and in particular access for their patients, including seven-day week access and evening opening hours and the testing of a variety of services including Skype, e-mail and phone consultations.

However, as the noble Lord, Lord Hunt of Kings Heath, emphasised—as did my noble friend Lady Barker—community services and social care are absolutely integral to this as well, particularly when it comes to the care of the frail elderly. Social care and the NHS are priorities for the Government and we know that there is interdependency between the two systems. However, providing more resources is not enough on its own. We have provided more resources from the Department of Health but we need to do more. NHS England is currently working with the Local Government Association to create a health and social care system that is truly seamless so that people receive the right care at the right time and in the right place. The Seven Days a Week forum will report on that work in the autumn, setting out proposals for a fully integrated service.

The Better Care Fund is a key enabler for change, as my noble friend Lady Manzoor pointed out. As part of the process for accessing funding, clinical commissioning groups and local authorities will have to demonstrate, as part of agreed local plans, that they are addressing a number of national conditions, including seven-day services in health and social care.

The noble Lord, Lord Warner, asked whether the Government would expect A&E departments to have weekend consultant cover. We recognise that the consultant contract is a key enabler of seven-day services. In October last year the Government mandated NHS Employers to enter into formal negotiations with the BMA to deliver joint proposals for consultant contract reform, including changes that will support seven-day services.

My noble friend Lord Bridgeman focused on the working time directive. He may know that we asked the president of the Royal College of Surgeons, Professor Norman Williams, to chair an independent task force to look at the implementation of the working time directive, and the impact of the directive on the delivery of patient care and the training of the next generation of doctors. The independent review will provide its report during March 2014. Professor Williams is working with stakeholders from the Royal College of Surgeons, NHS organisations, the BMA, National Voices and others, and we ourselves are working with the task force to ensure that it has appropriate legal and analytical support.

There is a compelling case for healthcare services to be accessible seven days a week. To echo the noble Lord, Lord Parekh, if we were starting the NHS from scratch I very much doubt whether we would design a part-time system. We would surely create a seven-day service to better meet patients’ needs. Seven-day service provision is about equitable access, care and treatment, regardless of the day of the week. It is a cause for some pride that the NHS will be the global pioneer in providing equality of access to consistent, high-quality healthcare seven days a week.

[Lord Hunt of Kings Heath]

My Lords, before the noble Earl sits down, I was remiss in not declaring my interests at the start as chair of a foundation trust, president of GS1 and a consultant trainer with Cumberlege Connections. I know that we all know that, but I have to do it every time.

NHS Property Services Ltd

Lord Hunt of Kings Heath Excerpts

Thursday 30th January 2014 Lords Chamber

[Earl Howe]

My Lords, I am not aware of the detail of that particular case, but I will gladly write to my noble friend about it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my interests in the register; I should have done that yesterday on another health Question, for which I apologise to the House. Can the Minister confirm that the chairman of this organisation resigned early, that capital money was raided to cover a revenue shortfall and that, only months after the organisation formally started, an investigation has been mounted by the National Audit Office? Given that the shares in this company are owned by Ministers, will Ministers take responsibility and can the noble Earl confirm that this was forecast in the NHS risk register, which the Government have not yet published?