Tobacco: Packaging

Lord Hunt of Kings Heath Excerpts

Thursday 28th November 2013 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my health interests in the register. I am very grateful to the noble Earl for coming to the House and I am pleased that the Government have changed their position. We have seen plenty of U-turns in the past three years and this is a major one, undoubtedly caused by the Government’s fear of defeat in your Lordships’ House.

However, why another review? Why must we wait until 2015 before implementation? I have enormous respect for Sir Cyril, but the Government have already had a review. The evidence in that review was clear for all to see. Does the noble Earl agree that it found that standardised packaging would make cigarettes less attractive to young people? Did it not find that such packaging made health warnings more effective? And did it not refute the utter falsehood that some brands are safer than others?

Does the noble Earl accept that all royal colleges and health experts are united behind the case for standardised packaging? Is it not the case that if the Transparency of Lobbying, Non-Party Campaigning and Trade Union Administration Bill goes through in its current form, it would prevent charities such as Cancer Research UK ever raising issues like this in an election year?

Finally, the noble Earl will be aware of an amendment laid by my noble friends Lady Smith, Lord Rosser and Lord Beecham to ban proxy purchasing of tobacco products on behalf of children which will be debated in your Lordships’ House on Monday. Will the Government accept that amendment?

NHS: Clinical Commissioning Groups

Lord Hunt of Kings Heath Excerpts

Wednesday 27th November 2013 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what discussions they have had with NHS England regarding proposals to change the funding allocation formula to Clinical Commissioning Groups.

[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 Government have been discussing health funding, including progress on the fundamental review of allocations, at regular accountability meetings with NHS England. This NHS England-led review began in December 2012. The independent Advisory Committee on Resource Allocation, ACRA, is providing advice on changes to the formula. NHS England will consider ACRA’s recommendations. Initial views should be available to inform 2014-15 allocations.

[Lord Hunt of Kings Heath]

My Lords, my understanding of the formula is that it would move resources from areas where people have worse health outcomes to areas where they have better health outcomes. The noble Earl has said that he and his ministerial colleagues are in discussion with NHS England. Can he confirm that this is a decision for NHS England? If that is so, what is the nature of the discussion that has taken place between Ministers and NHS England? Is it being left to NHS England to decide?

[Earl Howe]

My Lords, very definitely yes. It is precisely to avoid any perception of political interference that we made NHS England responsible for the allocation of resources to clinical commissioning groups. However, we were very specific in the mandate, as the noble Lord will recall, that the principle on which NHS England has to operate is equal access for equal need, with particular attention being paid to health inequalities while not destabilising the NHS. Those are the things we discuss in our regular meetings with NHS England but the actual nature of the formula that it will decide in its board meeting next month is entirely up to it.

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[Earl Howe]

My Lords, ACRA has recommended that CCG mental health services allocations should be set using the same overall approach as that for other hospital and community health services. That means that a large part of the allocation is linked to the diagnoses reported for people registered with each GP. That makes the formula very sensitive to need. It has the potential to improve the way we allocate resources for mental health services, in particular.

[Lord Hunt of Kings Heath]

My Lords, will the noble Earl arrange for NHS England to meet interested parliamentarians before it takes its decision at the meeting next month?

[Earl Howe]

My Lords, I will certainly feed that request back to NHS England.

NHS: Accident and Emergency Units

Lord Hunt of Kings Heath Excerpts

Tuesday 26th November 2013 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I first declare an interest as chair of a foundation trust, president of GS1 and consultant and trainer with Cumberlege Connections.

I too am grateful to my noble friend for raising such an important issue. The case she put for her local hospital, St Helier, was put with great force. The issues she raises are symptomatic of a whole range of issues around emergency care. They are well known, and they are symptomatic of a near collapse of the system in many parts of the country. My noble friends have already referred to the inexplicable closure of walk-in centres, and I ask the Minister why NHS England has pressurised clinical commissioning groups to close those centres. That has exacerbated poor access in primary care, and people are often left with no choice but to turn to A&E, with hospitals becoming very full as a result.

As my noble friend Lord Dubs said, the discharge of patients is becoming ever harder because the severe cutbacks in social services have impacted on councils’ ability to provide community support. The result of this cumulative failure is that more and more old people are left without the care and support needed to let them stay at home.

I want to reinforce a question asked by the noble Lord, Lord Kakkar. What are clinical commissioning groups doing about this? They are, as it were, the treasure of the Government—the people who are supposed to be able to sort the situation out. I see no sign whatever of their getting to grips with the issues. I echo the noble Baroness, Lady Manzoor, in asking; why on earth were they given the money to spend in relation to A&E? Why not give it to the hospitals to spend where it would have an impact on the system?

At a time when the NHS should be focusing all its energies on getting the system to work properly, as my noble friend Lord Kennedy says, the Government have forced it to spend the past three years implementing a costly and completely unnecessary structural change. Remarkably, during that time, rather than increasing staff we have seen a loss of more than 6,600 nurses.

There is a pressing need to integrate health and social care, provide whole person care and prevent avoidable admissions to hospital. That would also embrace the comments of my noble friend Lord McKenzie about accident prevention. Urgent emergency care has a similar need of change. Of course, the recent review by Sir Bruce Keogh argues for a “fundamental shift” in the provision of urgent care and for introducing two types of hospital emergency department with current working titles of emergency centres and major emergency centres. I am not opposed to reform of emergency care, but it is essential, before there is a stampede of closures of current A&E departments, that decisions are based on robust clinical evidence. Any signs of closure for financial reasons must be resisted. I agree with my noble friends Lord Dubs and Lady McDonagh about the domino effect of A&E closures on the services in those hospitals.

I finish by reminding the Minister that what happened in the case of Lewisham hospital was quite disgraceful. A good hospital suddenly found itself having its A&E proposed for closure to shore up problems in neighbouring hospitals. It is shameful that the Government forced through an amendment in the Care Bill to make this kind of thing much easier to force through in future. The Government’s disastrous reforms and failure to manage the system are putting the NHS under ever more pressure. It is time that they got a grip.

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

My Lords, I join other noble Lords in thanking the noble Baroness, Lady McDonagh, for raising this important issue, in which I know that she has a significant interest. I thank other noble Lords who have contributed to this very interesting debate.

I would like to respond initially by explaining the Government’s policy with regard to service change in general, before moving on to the provision of care in A&E specifically. I find it difficult to say much about the noble Baroness’s speech beyond observing that there is such a gulf separating us in our respective understanding of the facts and what is actually happening in the NHS that I shall have to write to her—and I shall do so.

The Government are absolutely clear that the design of front-line health services, including accident and emergency units, is a matter for the local NHS. It is the policy of this Government that services should be tailored to meet the needs of the local population. Reconfiguration is about modernising the delivery of care and facilities to improve patient outcomes, develop services closer to home and, most importantly, to save lives. Therefore, all service changes should be led by clinicians, and be in the best interests of patients, not driven from the top down. That is why we are putting patients, carers and local communities at the heart of the NHS, shifting decision-making as close as possible to individual patients, by devolving power to professionals and providers, and liberating them from top-down control.

[Lord Hunt of Kings Heath]

My Lords, if that is so, why has NHS England put so much pressure on clinical commissioning groups to close walk-in centres? It is simply not happening that clinicians are deciding. The fact is that NHS England is carrying on a micro- management of what is happening; it is simply not playing out in the way that the noble Earl describes.

[Earl Howe]

I would be grateful if the noble Lord could supply me with the relevant facts to back up his statement about pressure from NHS England to close walk-in centres.

Health: Tuberculosis

Lord Hunt of Kings Heath Excerpts

Thursday 21st November 2013 Lords Chamber

[Earl Howe]

My Lords, there are regulations covering ports and airports which provide a contingency for when a passenger on a ship or a plane enters the UK, is suspected of having a notifiable disease and perhaps refuses to seek medical attention. The regulations include provisions for notification of such a case to the destination port health authority and for the detention of that person for the purposes of a medical examination. There are also quite flexible powers for local authorities to deal with incidents or emergencies where infection or contamination presents or could present a significant risk to public health.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer noble Lords to my health interests. The Minister referred to a number of strategies in London, Manchester and Birmingham. Will he confirm that the implementation, particularly of some preventive strategies, will depend on the work of TB specialist nurses? Is he aware that some budgets are under pressure and there is a risk that we will not have enough nurses to do the job? Will he guarantee that we will see an increase in the number of TB nurses?

[Earl Howe]

My Lords, as the noble Lord is aware, NHS England allocates funding to clinical commissioning groups which commission health services on behalf of their local populations. It is for CCGs to decide how best to use the funding that is allocated to them, underpinned by clinical insight and knowledge of local healthcare needs. We expect health and well-being boards to have a major say in those areas where TB is commonplace.

Children and Families Bill

Lord Hunt of Kings Heath Excerpts

Wednesday 20th November 2013 Grand Committee

[Baroness Tyler of Enfield (LD)]

My Lords, I rise extremely briefly because I had my go on Monday. I want to add just one point to what my noble friend Lord Storey has said. Some people are saying, “Let’s start with an awareness-raising campaign. Let’s see what we can do there. We don’t need to go straight to legislation”. I do not agree with that. The most effective example that I can cite was the introduction of legislation for the wearing of seatbelts. Awareness-raising had been tried, but it achieved only 25% compliance rates, but soon after the legislation was introduced, alongside the awareness-raising effort—you need both; it is not one or the other—91% of adults started to wear seatbelts. As my noble friend said, it is clear that it has saved lives. I think that very few people in this country, and certainly the polls show it, now think that that is an infringement of civil liberties.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I should perhaps declare an interest as chairman of an NHS foundation trust, as a consultant trainer to Cumberlege Connections and as president of GS1. I welcome this debate. I am delighted to see Amendments 263 and 264, and I have put my name, alongside that of my noble friend Lady Hughes, to Amendments 265 and 266, which are essentially amendments to Amendment 264.

As my noble friend Lady Hughes said on Monday, ever since the advertising ban came in, cigarette packaging has been the way in which tobacco companies have sought to market their products. That is why they spend millions on developing their packaging by testing its attractiveness to potential new customers, and that is why standardised packaging is such an important issue. Amendments 265 and 266 build on the excellent Amendment 264. Essentially, we seek to strengthen that amendment by requiring the Secretary of State to make regulations rather than by simply giving him the discretion to do so. It is important that Ministers are left in no doubt that they need to introduce standardised packaging, which is why I hope that those noble Lords who have proposed Amendment 264 and spoken so eloquently to it will accept our amendments to strengthen the provision. What has happened over the past two years or so would suggest that it is better not to give Ministers discretion in this area.

When the noble Earl comes to wind up, it would be helpful if he could explain the Government’s change of view on this matter. He will know that the former health Secretary, Andrew Lansley, said:

“The evidence is clear that packaging helps to recruit smokers, so it makes sense to consider having less attractive packaging”.

It was widely reported in March this year that legislation to enforce plain packaging for cigarettes would be included in the Queen’s Speech. In April, the then public health Minister, Anna Soubry, said that, having seen the evidence, she had been personally persuaded of the case for standardised plain packaging for cigarettes, but in July we heard the announcement that this was going to be postponed because we would wait and see what happened in Australia.

Will the Minister explain to us why the Government changed their mind and does he agree that the systematic review of all the evidence on standardised packaging commissioned by his department and published alongside the Government’s original consultation showed clearly the strong evidence that standardised packaging would help to reduce smoking rates by reducing the attractiveness and appeal of tobacco products and increasing the noticeability and effectiveness of health warnings and messages? Will he also acknowledge that two internal Philip Morris International corporate affairs documents from February and March 2012 showed that the top lobbying message for the world’s largest tobacco company was to use the strapline, “Wait and see what happens in Australia”? Why have the Government fallen for that attempt? Why on earth should we wait to see what happens in Australia? Cricket aside, I have great fondness for Australia and Australians, but why on earth are we waiting to see what happens there?

We have always been a world leader in this area with actions such as introducing smoking bans in pubs and enclosed spaces, ending tobacco companies’ sports sponsorship and billboard advertising, raising the legal age for purchasing cigarettes and the introduction of graphic warnings on cigarette packs. We have been a leader and our actions have had an impact. We have seen a dramatic reduction in the number of young smokers. Why on earth do we not want to continue in that vein? The Government will be in no doubt about the strength of feeling in your Lordships’ House and I have no doubt whatever that it wishes to see action taken on this issue. I hope that the noble Earl will be able to give us some comfort that the Government recognise that we should get on with tackling this issue.

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[Earl Howe]

That indeed is my understanding. Noble Lords have taken the opportunity of this Bill to raise the dangers of smoking, particularly of passive smoking for children, and I have no issue with that. I merely point out that there are problems with the amendment as drafted. I am not saying that it would not be possible to draft another amendment which noble Lords might care to consider between now and Report. Being able to enforce these provisions as drafted is also a significant aspect. For example, it may be hard to judge whether a product could reasonably be expected to attract children, as the amendment would require, or to determine what might be aimed at or would attract 18 year-olds but not, let us say, 17 year-olds or 13 year-olds.

I am grateful to noble Lords for raising this important issue and for keeping this debate at the front of our minds. It is a debate that we need to continue. As I have said, the Government have yet to make a decision on this policy, but if we were to bring in such a measure, we would not want it to be circumscribed in the way that is proposed. We would not want to set up a situation in which both branded and standardised packs could be sold legally depending on where they were sold and what other products were sold alongside them. I therefore urge noble Lords not to press their amendments and respectfully suggest that they consider other avenues for bringing this matter before the House on Report.

[Lord Hunt of Kings Heath]

I always admire the noble Earl’s eloquence when defending the indefensible and he has done that par excellence today, but is not the reality that this is an opportunity for the Committee and the House to express a view in principle on the issue? It would then be up to the Government. As the noble Earl knows, when that happens, the Government simply come back with an amendment at Third Reading to deal with the technical issues. Surely the issue here is whether the House goes forward to a vote in principle, which I hope it might be able to do.

[Earl Howe]

Well, my Lords, if I could repay the compliment to the noble Lord, Lord Hunt, he has very eloquently presented the case for the Government to go away and think further about this, which indeed we will do. I come back to what I said at the beginning of this debate: the message from this Committee has been delivered loudly and clearly. I am grateful to noble Lords for that. I say again that the Government’s mind is not closed on this issue.

NHS: Mid Staffordshire NHS Foundation Trust

Lord Hunt of Kings Heath Excerpts

Tuesday 19th November 2013 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I remind the House of my interests as chairman of an NHS foundation trust, president of GS1 and a consultant and trainer with Cumberlege Connections. I thank the Minister for repeating the Statement. What happened at Mid Staffs was a betrayal of the NHS and its values. The previous Government rightly apologised, but now is the time to back our words with action. That is why, in welcoming much of what has been said, I would like to press the Minister on where we feel we would have gone further and question why, of the 290 recommendations from Francis, 86 are not being implemented in full.

First, I pay tribute to my right honourable friend Ann Clwyd, Professor Patricia Hart, Professor Sir Bruce Keogh, Camilla Cavendish, Professor Don Berwick and of course Sir Robert Francis. Between them they have given us proposals that will help to prevent a repeat and, more importantly, change the whole of the NHS for the better. Both Francis reports found three primary and fundamental causes of what went wrong: a failure to listen to patients; a lack of properly trained staff; and a dysfunctional culture. I shall turn to each of those.

First, I am sure that the Minister will agree with me that patients and their families must always, as Francis recommended, be the first priority for the NHS. Was Francis not right to recommend that the NHS constitution and the ethos that it sets out should be required reading for all NHS staff? I congratulate the Minister on agreeing to implement the Clwyd review in full and change the way that the NHS handles complaints.

Secondly, there is the issue of staffing numbers and training. The first Francis report found that Mid Staffs made dangerous cuts to staffing over a short period. I welcome the Government’s new focus on this issue, but is it not the case that nurse to patient ratios across the NHS have got significantly worse in the past three years, with nearly 6,000 fewer nurses, more older patients in hospital and bed occupancy running at record levels?

It is encouraging that the NHS plans to recruit more nurses and is introducing more monitoring and transparency. The Secretary of State says that things are already changing for the better, but is the Minister aware that Monitor, the economic regulator of the NHS, has warned that trusts are planning major nurse redundancies in the 2014-16 period, far outweighing any increase planned this year? Will the Government intervene to stop that? Further, why have the Government stopped short of requiring safe staffing levels? Is the Minister aware that nurse training places have been severely cut in recent years and that many NHS trusts and foundation trusts are now being forced to recruit from overseas?

Alongside nursing, more action is needed to raise standards across the caring workforce. As Robert Francis has said, it is unacceptable that the security guard at the door of the hospital is more regulated and subject to professional sanctions than the healthcare assistant attending to an elderly patient. The development of the care certificate, as proposed by Camilla Cavendish, is a step forward, but will it not work only alongside a register of those who hold it and with an ability to remove it if they fall short? What happens if a member of staff employed as a care assistant in an NHS hospital has indeed obtained a care certificate but is then found to be wholly unsatisfactory to carry out a care assistant’s work? What happens to the certificate? Surely we need to go back to the Robert Francis recommendation of a system of regulation for healthcare assistants. Will the Government reconsider this decision and at least commit to keeping it under review?

On culture change, Robert Francis’s central proposal is a new duty of candour on organisations and individuals. It is not entirely clear how an organisational duty alone will help individuals challenge an organisation where there is a dysfunctional culture. Is it not the case that an individual duty, as proposed by Francis, is needed? The point comes over very clearly from the evidence given to Francis from a senior, soon to be retired consultant. He said:

“I took the path of least resistance … There were also veiled threats at the time that I shouldn’t rock the boat at my stage in life”.

It is only when an individual is both required to speak out and protected in doing so that the House can say that it has done enough to safeguard patients.

The duty of openness and transparency should apply equally to all organisations providing NHS services, including, as Francis rightly recommended, contractors providing outsourced services. The Government are clearly bringing in more outside providers. Surely patients need reassurance that we do not have an uneven playing field where private providers face less scrutiny. Will the Government extend the duty of candour to all healthcare organisations as Francis proposes? The amendments to the Care Bill do not seem to make that clear. Should not the Minister commit to extending freedom of information law to any provider of NHS services and not allowing them to hide behind commercial confidentiality?

On openness, Francis made a direct call on the Government to set an example to the rest of the NHS. He said:

“risk assessments should be made public, and debated publically, before a proposal for any major structural change to the healthcare system is accepted”.

Given the Government’s claim to have accepted this recommendation, should they not show what they mean by finally publishing the risk register on the current reorganisation of the NHS?

Finally on openness, the NHS will be more accountable to families with a proper system of death certification. The House will recall that this was a core recommendation of Dame Janet Smith’s inquiry into the Shipman murders. The Francis recommendations on this are not all accepted in full. I hope that the Minister will be able to give me some reassurance on that.

I would also like to ask the Minister about the regulatory structure. I have raised with him before the question raised by Don Berwick in his very interesting report on patient safety, which the Government themselves commissioned. In that report he said:

“The current NHS regulatory system is bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies. It should be simplified”.

He went on to say:

“The regulatory complexity that Robert Francis identified as contributing to the problems at Mid Staffordshire is severe and endures, and the Government should end that complexity”.

Has the Minister picked up on the comment made by the chair of the CQC to the Health Select Committee in October, where he said that responsibility for patient safety in the health service should be transferred back from NHS England to the Care Quality Commission? Will the Minister agree that that is the right thing to do?

Can I also ask about the impact of competition on patient safety? The Minister may well have seen reports at the weekend that there are proposals to centralise cancer services in first-class treatment centres in order to enhance the efficiency, safety and effectiveness of the treatments being offered. Is he as shocked as I am that there has been a challenge to those proposals on the basis that they may run against the competition rules set out in the regulations that the Minister brought to this House in relation to Section 75 of the Health and Social Care Act 2012? Will the Minister look into those circumstances?

Finally, can I ask about the National Patient Safety Agency? In his Statement, the Minister referred to the fact that there will be a duty on staff to report near misses. He will be aware that the previous Government established the National Patient Safety Agency to allow staff to report those near misses. Is he as concerned as I am that the abolition of the NPSA and the transfer of the listening and reporting function to NHS England may, in itself, act as an inhibitor to staff feeling confident in reporting those safety incidents?

Finally, does the Minister believe—

[Noble Lords]

Oh!

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[Lord Hunt of Kings Heath]

My Lords, this does not eat into Back-Bench time. I think I am quite at liberty to ask as many questions as I like. Perhaps the party opposite would do me the courtesy of actually listening to the questions. Let me say finally—

[Noble Lords]

Oh!

[Lord Hunt of Kings Heath]

My Lords, I am very happy to carry on. We have 20 minutes for Front-Bench questions and answers, and I have not yet taken half that time. I am quite happy to go on but, of course, I want to give the Minister time to respond as well. Perhaps some noble Lords will read the Companion to see what the rules are.

Finally, is primary legislation needed to implement any of these recommendations? I say to the Minister that if that is so, we on this side will certainly co-operate on a cross-party basis to enable those recommendations to be implemented in full.

NHS: Urgent and Emergency Care Review

Lord Hunt of Kings Heath Excerpts

Tuesday 12th November 2013 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Lord, Earl Howe, for repeating the Answer. I declare my interests as chair of an NHS foundation trust, president of GS1 and a consultant trainer with Cumberlege Connections.

There is no question that A&E services are under pressure—in crisis, according to the College of Emergency Medicine. Earlier this year, the Health Secretary announced that Professor Sir Bruce Keogh would lead a major review of emergency care in the NHS. It is clearly a significant piece of work, which is why I would have expected the Government to come before your Lordships’ House and the other place to make a Statement. I object very strongly to this being briefed to journalists this morning, yet Ministers were not prepared to come to the House until the Speaker granted an Urgent Question in the other place.

The noble Lord has said, quite remarkably, that because this is to be published by NHS England, it is not appropriate for Ministers to come to Parliament. He says that the NHS is independent. He must be the only person who believes that the NHS is independent. It is a wholly owned subsidiary and quango of the department. Why does a Secretary of State insist on seeing the leader of NHS England on a weekly basis if it is an independent body? I hope that the noble Lord will reflect on that. The Government should have brought this to your Lordships’ House with a proper Statement.

When the Bruce Keogh report was commissioned, the Secretary of State said that it was intended that we would learn lessons for this winter. What are those lessons? What immediate actions are now being taken ahead of winter? Weekend briefings and leaks suggest that Sir Bruce emphasises alternatives to A&E, such as walk-in centres and the 111 service, yet we have had a report from Monitor saying that NHS England has overseen the closure of walk-in centres. He cannot pass that on to clinical commissioning groups as it is well known that NHS England put pressure on clinical commissioning groups to close those walk-in centres. Will that closure programme stop now? Will he put nurses back on the 111 helpline in order to make amends for the debacle of the launch of that inadequate service months ago? What will he do about the recruitment crisis in A&E?

Bearing in mind the Birmingham health system, can he assure me that the £250 million allocated to A&E hospitals under the most pressure will be spent to alleviate the pressure on those hospitals and not be filleted away for other purposes?

National Health Service (Approval of Licensing Criteria) Order 2013

Lord Hunt of Kings Heath Excerpts

Tuesday 12th November 2013 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I thank the noble Earl for that very full explanation of this order. In the context of the order, I should declare my chairmanship of an NHS foundation trust, which is subject both to Monitor and the Care Quality Commission.

I thought that the noble Earl’s full explanation of the order really reinforced concerns about the complexity of Monitor’s role and potentially the conflict between its licensing responsibilities, its independent regulation of pricing of NHS services and the general support that it gives for NHS foundation trusts. Now that Monitor has had time to consider these matters, since the passage of the 2012 Act, can he explain how it avoids conflicts of interest between these three separate roles? He will be aware that we discussed that issue when we debated the Bill.

Clearly, a lot of responsibility in Monitor rests on the leadership of Dr David Bennett. The noble Earl will be aware that in the pre-scrutiny hearing in the other place, the Health Select Committee—after examining Dominic Dodd, who had been proposed as chairman of Monitor—said of David Bennett that he,

“was appointed as interim Chief Executive in April 2010, and appointed as substantive Chair in March 2011. Since then he has filled the roles of both Chair and Chief Executive—effectively Executive Chair—and has led Monitor through the whole process of change brought about by the Health and Social Care Act 2012. This has been a period of great uncertainty for Monitor, with the nature of its role in the new system being unclear for most of the 18 months between the introduction of the Bill in January 2011 and its passing in 2012. Dr Bennett has both shaped and interpreted the role that Monitor now plays in the system which makes the transition to another individual taking on the Chair an especially difficult one. We do not think Mr Dodd is the right person to undertake that difficult transition”.

I understand that, following that, Mr Dodd withdrew his nomination, or at least his nomination was withdrawn.

In the context of this order, which sets the framework in which licensing will be undertaken by Monitor in future, can the Minister say a little more about the Government’s intention with regard to leadership, particularly the continuing role of Dr Bennett as both chairman and chief executive? As the Minister will know, in normal corporate governance terms that is not normally encouraged.

My third question relates to the Explanatory Memorandum, rather than the order itself. I was interested to see that, under “Policy Background”, paragraph 7.2 sets out three key functions of Monitor. I have already referred to them as,

“working with NHS England to provide independent regulation of pricing … protecting patient choice and”,

addressing,

“anti-competitive behaviour … and … working with commissioners to secure continuity of services”.

I just wondered where integration had got to. Have the Minister’s officials forgotten that? We debated this at great length and the Bill was amended to ensure the importance of integration. The noble Earl will recall that Monitor was given that express role. I am very disappointed to see that it is not referenced in the policy background but I am not surprised because, frankly, we have seen very little work on integration coming out of the various bodies concerned with the health service.

There has, however, been an awful lot to do with competition. As the noble Earl will know, in evidence to the Health Select Committee—I think it was only two weeks ago—the chief executive of the NHS railed against the way in which competition was being introduced in the health service. He knows, as everyone working in the health service knows, that a huge amount of money is being spent because of the enforced tendering of services that is undoubtedly taking place. It is very important that the Government reconsider the architecture that they have now put in place.

In addition to Monitor, we have the CQC, the NHS Trust Development Authority, the NHS Executive—I am sorry, I meant NHS England; that was a Freudian slip—and Ministers. Compared to the previous Secretary of State, the current Secretary of State takes a very different view of his role, and so we have a very confusing architecture. We also have the Office of Fair Trading making extremely unhelpful and unwelcome interventions, which again seems to act against the appropriate integration of services. It really needs to be sorted out.

I have no doubt that we will talk about this in a few minutes, but after Monitor’s welcome report on walk-in centres—I do not know whether it was as welcome to the noble Earl as it was to me—we have a situation where NHS England has undoubtedly been encouraging clinical commissioning groups to close down walk-in centres to make savings. However, yet another part of the architecture has come out with a report essentially saying that this has been a big mistake and has added to the pressure on A&E departments. One is entitled to ask: who on earth is really driving the policy at the moment?

Although I welcome the Monitor report, I was interested to know why it has produced it. At paragraph 1.2 on page 9 of the report, Monitor says:

“Our decision to review walk-in centre provision is grounded in our main duty as health care sector regulator: to protect and promote the interests of patients by promoting the provision of health care services that is effective, efficient and economic and that maintains and improves the quality of services”.

Well, yes, but is Monitor’s role really to look at this area of service provision? Fine—it is a good and welcome report, but it is confusing as to where one regulator’s role stops and the other starts. I have this great impression of five or six large, powerful bodies, all with well paid executives and strong boards, vying for influence. What that does at a time of huge pressure in the health service is to create uncertainty about who is leading, who is setting the policy and who is responsible for its implementation.

Finally, I come back to the question raised by Don Berwick in his very interesting report on patient safety, which the Government commissioned. In that report, which was published only a few months ago, he said:

“The current NHS regulatory system is bewildering in its complexity and prone to both overlaps of remit and gaps between different agencies. It should be simplified”.

It certainly should be simplified. He went on to say:

“The regulatory complexity that Robert Francis identified as contributing to the problems at Mid Staffordshire is severe and endures, and the Government should end that complexity”.

Does the noble Earl agree that the order he brings before us today is simply a sign of greater complexity? I do not think that we have had a response from the Government on this recommendation. I know that the noble Earl has a regulatory Bill up his sleeve for the next Session. Given what Don Berwick said and the evidence that Sir David Nicholson gave to the Health Select Committee, does he not agree that it might be sensible to go wider and look at this whole business again, to get much greater clarity into what is a complex situation?

[Earl Howe]

My Lords, I am grateful to the noble Lord, Lord Hunt, for his questions. I start with the issue that he raised initially, which was about the role of Monitor and what he perceives as the conflicts within that role. I address that by saying that there is no fundamental conflict, although he is perfectly right to say that Monitor has distinct, separate functions. Different executives within Monitor lead on each of those areas. Monitor has a board, which functions to ensure that David Bennett’s dual role as chair and CEO works effectively. At the same time, the Department of Health, as the steward of the system, keeps Monitor’s performance under review. It does that through quarterly accountability meetings. I suggest that the conflicts that the noble Lord perceives are much more in the perception than the reality. There are mechanisms in place within Monitor to ensure that the functions are kept distinct and that, where appropriate, Chinese walls operate.

The noble Lord referred to the nomination of Dominic Dodd as the chair of Monitor and the Select Committee’s view that he was not the right person to lead the organisation. That was a view which Mr Dodd himself accepted, and he volunteered to step aside. In the light of that, we are currently considering options for a sustainable solution to Monitor’s leadership. We will make an announcement as soon as we can on that, but, meanwhile, I emphasise that we have complete confidence in David Bennett’s leadership of the organisation.

[Lord Hunt of Kings Heath]

I meant no criticism of Dr Bennett in his role. I just point out that if one goes back to Cadbury and all sorts of reports since then, the evidence is clear that it is undesirable to have the same person carrying out both roles.

[Earl Howe]

I completely take the noble Lord’s point. We will of course be looking carefully at how best to proceed. It was, of course, with a view to appointing a separate chair that Mr Dodd’s name was put forward.

The noble Lord referred to the importance of integration. He is of course right that we debated the issue extensively during the passage of the Health and Social Care Act and have done so since. The Health and Social Care Act established Monitor as the sector regulator of healthcare. That involves a duty placed on Monitor to protect and promote patients’ interests by promoting provision of NHS services which is economic, efficient and effective and which maintains or improves the quality of those services. Within those broad headings, integration fits neatly.

The provider licence is a key tool which Monitor will use in carrying out its duties and in influencing and regulating the provision of NHS services. Specifically, the licence enables Monitor not only to set prices for NHS-funded care, which it does in partnership with NHS England, but to enable integrated care. The fact that that is not explicitly referenced in the Explanatory Memorandum is not something to which noble Lords should attach particular significance. Integration is part and parcel of Monitor’s overall duties.

Professional Standards Authority

Lord Hunt of Kings Heath Excerpts

Thursday 7th November 2013 Lords Chamber

[Earl Howe]

My Lords, the Francis recommendations made no reference to voluntary registers for healthcare support workers. The broad position is that the PSA has not received any applications from organisations holding voluntary registers for healthcare support workers, and therefore no voluntary registers for healthcare support workers have been approved. As accredited registers are voluntary, I am afraid that the Government are not in a position to predict how long it will take for all healthcare support workers to be registered.

[Lord Hunt of Kings Heath (Lab)]

My Lords, going back to the question raised by the noble Lord, Lord Taverne, is the Minister confident that every intervention by a doctor is actually based on robust clinical evidence?

[Earl Howe]

My Lords, as the noble Lord knows, it is the responsibility of local NHS organisations to make decisions on the commissioning and funding of any healthcare treatments for patients, taking account of issues to do with safety, clinical and cost effectiveness and the availability of appropriate practitioners. However, it is interesting to note that there are a number of complementary and alternative therapies referenced in NICE guidance, and I would expect any self-respecting doctor to take account of those.

NHS: London

Lord Hunt of Kings Heath Excerpts

Wednesday 30th October 2013 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Earl, Lord Howe, for repeating the Statement. I refer noble Lords to my interests, particularly as chair of a foundation trust.

Decisions on hospital reconfiguration should always be made on the basis of the best clinical evidence available. The noble Earl’s announcement today means the closure of a number of accident and emergency departments in London, with the centralisation of A&E services at five, rather than nine, hospitals. That is to happen at the same time as accident and emergency departments are under heavy pressure up and down the country, not least in London. Taking all major A&E units together, London as a whole has missed the Government’s A&E target in 48 out of the past 52 weeks. Is the noble Earl convinced that the system will be able to cope with the reduced number of A&E departments in London?

I note that the chief executives of the three major health regulators have been summoned to meet the Prime Minister to discuss the pressure that services are likely to come under this winter. These meetings are complementary to the weekly meetings that the Secretary of State has with these eminent people. Apparently these discussions are dominated by winter performance planning, particularly relating to accident and emergency departments. What measures are being taken to increase capacity in the community, to enable the flow of patients and their discharge at the right time?

What is being done about the accessibility of general practitioners? We heard much from the Prime Minister about a move to seven-day-a-week access, which the noble Earl will know has provoked a lot of opposition from primary care interests, citing cost at a time when the NHS is cash strapped and when there is a shortage of general practitioners. Does that mean the inevitable merger of smaller GP practices? Can the noble Earl spell out the Government’s intentions? In the Statement, we are told that there is to be seven-day access to GP surgeries throughout north-west London. Can the noble Earl confirm that that means that all surgeries will be open from 8 am to 8 pm, seven days a week? If that is not the case, what happens to patients in practices which are not prepared to open seven days a week?

I now turn to the noble Earl’s announcement about Charing Cross and Ealing hospitals. Very simply: is this a permanent reprieve? The report of the Independent Reconfiguration Panel says that the future of the proposed local hospitals at Ealing and Charing Cross, and the final decision about what might best be provided from each location must be the subject of a specific programme of work which should address the needs for in-patient services for the vulnerable and frail elderly, and that its outcome would determine whether there is a need for further consultation. In his Statement, the noble Earl has said that, whatever the outcome of that further work, Ministers have decided that Ealing and Charing Cross hospitals should continue to offer an A&E service, even if it is a “different shape or size” to that currently offered. Can the noble Earl spell out what, exactly is meant by that? Can he guarantee that both Charing Cross and Ealing hospitals will continue to run full, 24-hour A&E services in the long term?

The Statement is about hospitals in London. I was surprised that the noble Earl made no mention of Lewisham Hospital. The victory won by the people of Lewisham in the Court of Appeal yesterday will give hope to patients everywhere. Back in the summer, the Opposition explicitly warned the Secretary of State to accept the first court ruling. Instead, he ploughed on with a hopeless case, wasting taxpayers’ money in a cavalier fashion. Will the noble Earl confirm that there will be no further appeal to the Supreme Court? Will he give the people of Lewisham and the staff who work in Lewisham Hospital a commitment that their accident and emergency and maternity units will be protected in the long term? Given that the Lewisham clinical commissioning group opposed those changes, what does it say about the assurances that he gave during the passage of the Health and Social Care Act 2012 that the whole purpose of those misguided changes was actually to let local clinicians decide? What happened to that in Lewisham?

The noble Earl tabled an amendment to the Care Bill only a few days ago, which he described as making a small change, so he will of course know that the Government have sought, very rapidly and very quietly, to change the law so that what happened in Lewisham cannot happen again. My interpretation of that amendment is that in the future there is a risk of services being shut down without the agreement of local people, without extensive consultation and without agreement from local commissioners. We, on this side of the House, support reconfiguration of health services when supported by the clinical evidence, but it must be on the basis of a requirement to go through a properly defined and structured reconfiguration process with extensive consultation with the local community.

From all we have learnt, we know that successful reconfigurations need to take the form of open and honest leadership, a patient process of engagement and consultation and proper consideration of the wider impact. The changes that the Government seek to make in legislation will ensure that that does not happen in the future. I hope that the noble Earl will be able to say that, in the light of yesterday’s ruling, the Government are giving second thoughts to their intentions in this regard.