Health: Obesity

Lord Hunt of Kings Heath Excerpts

Monday 12th November 2012 Lords Chamber

[Earl Howe]

My Lords, as my noble friend knows, the Secretary of State will set the strategic objectives and policy priorities of Public Health England. It will have operational autonomy and operate transparently. Rates of obesity remain high across England and continue to have clear links to health inequalities. GPs can play a key role in making every contact count by raising the issue of obesity and providing advice or referral to appropriate services, so I do not necessarily accept the criticism that my noble friend levelled at the current QOF indicators. GPs have every reason to act when they see obesity in front of them. I cannot pre-empt exactly what Public Health England will wish to prioritise in the development of the QOF, but I fully expect that it will want to work with NICE to review the evidence base for building on the current QOF obesity indicator.

[Lord Hunt of Kings Heath]

My Lords, I am sure that the noble Earl will agree that action on obesity is best taken when different government departments play their part. If he accepts that, does he regret the abolition of the Cabinet sub-committee on public health?

[Earl Howe]

My Lords, the role of Public Health England will undoubtedly stretch across government departments, because it should and will involve energising the efforts of not just the Department of Health and at not just national level. However, I agree that there is no single magic bullet to solve the problem of obesity. The call to action on obesity published last year set out a range of actions in which government and individuals, as well as local organisations, need to engage if we are to beat this threat to public health.

NHS: Death at Home

Lord Hunt of Kings Heath Excerpts

Thursday 8th November 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, this has been a fascinating debate with uniformly high-quality contributions. I, too, am very grateful to my noble friend for initiating it and have a great deal of sympathy with the thrust of his argument.

As we have heard, some people die as they would wish but many do not. Some people experience excellent care but, sadly, many do not. We know that many people experience unnecessary pain at the end of their lives. Although we have made progress and although the current Government are carrying on where the previous Government left off in relation to this matter, we know that much more needs to be done. We are faced with the fact that a large majority of deaths, following a period of chronic illness, occur in NHS hospitals yet many people would prefer to die at home.

My noble friend Lord Warner was right to say that an increasing number of people will have more complex medical needs and that that might push them into the hospital system unless we are very careful and are determined to provide the choice and service required if one is to die in the community or in one’s own home. That means responding not just to the requirement to improve health and social care services but also to the points raised by the noble Lord, Lord Howard, and the right reverend Prelate, particularly in relation to support for the hospice movement. This has been a recurring problem. We have to face up to the real issue of the reluctance of NHS bodies properly to fund hospices in the past and, indeed, the reluctance to give them certainty of funding for two or three years ahead as opposed to funding on an annual basis.

I would like to ask the noble Earl, Lord Howe, about the implications of the White Paper and the draft Bill in relation to care and support. My understanding is that it has some words of comfort around certain free end-of-life care services. I should be grateful if the noble Earl could provide some clarification on that.

This is not the time to debate the Liverpool care pathway, but I was moved by what the noble Baroness, Lady Masham, said. However, I did not recognise the issue of the Liverpool care pathway in what she said. I would draw a distinction between the philosophy that the noble Baroness, Lady Finlay, gave about how it should work and what may be the problems in practice in some parts of the country. It is important to distinguish between the pathway as it should be and poor practice, which of course must be rooted out and investigated.

An important point made by my noble friend Lord Dubs and other noble Lords is that in seeking to help people to die at home and to help their relatives, it is important to educate people on the reality of that. People who wish to die at home surrounded by their family have a desirable aim but, as Sue Ryder has pointed out to us, often the family can get very consumed with caring responsibilities and issues can arise that make end-of-life care at home more stressful. We therefore need to understand the implications of choosing to die at home.

We should not forget the contribution of social care. A recent Nuffield Trust survey showed that this is a significant part of the care that needs to be provided for people in the final months of their life. However, there is a great variation in the use of social care from local authority to local authority; it matches the NHS variations in different parts of the country in terms of how many people are able to die at home, as my noble friend mentioned. That is not acceptable and comes back to the Government’s response to this.

I know that the noble Lord, Lord Howard, and other noble Lords have raised the issue of the mandate, and I am aware that there is a consultation on the NHS constitution. It is proposed that the constitution be amended, in relation to patient choice and involvement in healthcare, to state:

“You have the right to be involved fully in all discussions and decisions about your … health and care, including in your end of life care”.

That is welcome. I ask the noble Earl: is that enough, because it does not actually mean that the kind of services that would enable choice to be exercised will be made available?

I also say to him that the consultation document states that the report from the NHS Future Forum made it clear that there is a problem with the constitution in terms of whether the health service is sufficiently cognisant of the constitution and what it means. I know that in the consultation there are proposals to make NHS staff more readily aware of it. The point that I would put to the noble Earl is: if it turns out that that is not sufficient, will he be prepared to consider my noble friend’s suggestion that a legislative solution may be required to ensure that the services provided are sufficient to enable people to exercise real choice and to have the kind of end-of-life care in their home that we would all wish people to have?

Health: Cancer

Lord Hunt of Kings Heath Excerpts

Wednesday 7th November 2012 Lords Chamber

Asked By

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what are their plans for the future funding and number of cancer networks.

[Lord Hunt of Kings Heath]

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

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

My Lords, £42 million has been allocated by the NHS Commissioning Board to support strategic clinical networks in 2013-14. Networks will cover a number of priority conditions and patient groups, including cancer. It is for local health communities and the board to determine the number and size of networks, based on patient flows and clinical relationships, and to deploy their resources appropriately.

[Lord Hunt of Kings Heath]

My Lords, does the noble Earl accept that cancer networks have done an outstanding job in improving the quality of service and outcomes? Does he agree that there is widespread expectation that the number of cancer networks will be reduced, the staff in many places will be made redundant and the new set-up will not be as effective as the current one? Will he respond to that?

[Earl Howe]

My Lords, I agree that clinical networks are a success story in the NHS. They have raised standards, supported easier and faster access to services and encouraged the spread of best practice. We very much want to see that continue. The final number of strategic clinical networks and the number of clinical staff who support them have not been finalised yet. Those numbers will be determined locally so it is too early to speak with any certainty about final staff numbers. We do not anticipate many compulsory redundancies at all. A number of staff have been deployed to other posts already. The aim of all this is to achieve not only a more effective series of networks but a more efficient system as well. We believe that that will be delivered.

Mental Health (Approval Functions) Bill

Lord Hunt of Kings Heath Excerpts

Wednesday 31st October 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, detaining people under the Mental Health Act raises fundamental questions of individual liberty and public safety requiring the most careful consideration. When that is combined with emergency legislation of a retrospective nature, it is clear that the circumstances in which we find ourselves today are far from ideal. Your Lordships will want to satisfy themselves that the retrospective measures that the Government are asking us to approve are justified. We have to be sure that this is the only real course of action available and that we are not setting a precedent where emergency legislation can be used as a convenient means of correcting administrative failings.

In doing so, we must have at the forefront of our minds the simple fact that the uncertainty that has arisen in the past week affects thousands of highly vulnerable people and their families, as well as holding serious implications for patient and public safety. If we leave that uncertainty hanging, it has the potential to cause real harm to those individuals and damage public trust in our system of individual and public protection. That is why Her Majesty’s Opposition have concluded that the public interest is best served by the Government taking the swift action that they propose today.

In reaching that judgment, we can take comfort from the fact that the main mental health charities, as well as the Royal College of Psychiatrists and the devolved Administrations, are also supporting the Government’s course of action. We are further helped by the fact that the Minister has today set out a cogent case for this exceptional retrospective measure that is before your Lordships.

However, a number of matters of detail and of principle arise from what the Minister said, which I would like to cover today. It would be helpful for the House to know more about the extent of the checks that have been carried out on the 4,000 to 5,000 cases that the Minister mentioned. The fact that we have a very vague figure suggests that there has not yet been a thorough case-by-case review. Would the Minister agree that that has to be done and that we need to know the precise number on the extent of the problem?

I press the Minister again on the question of the people and families affected, who will no doubt be unsettled by the news of what has happened. I noted from yesterday’s proceedings in the other place that strategic health authorities have been charged with putting a proper communication process in place. With all respect, those very SHAs that did not do this properly have been charged with communicating with the patients. I would like to press the Minister on the point that my right honourable friend Mr Andy Burnham made yesterday about the need for his department to be involved in personal communication to the individuals concerned.

Alongside the question of the details, I ask the Minister about the details of individual SHAs and timing in terms of notification of the department. If it had happened in just one SHA, the explanation might be easier to ascertain and understand. But given that it has happened in four SHAs, it seems to point to a more widespread issue of concern. I share the concern of the noble Baroness, Lady Murphy, on that point. Is it symptomatic of problems arising from historical practice among NHS bodies in those regions, or does it indicate that in those regions there may well have been a general problem with schemes of delegation? If the noble Baroness, Lady Murphy, was able to do the job properly, it is very difficult to know why other SHAs were not so able to do the job, given the extensive legal advice available to strategic health authorities.

I would also like to ask the Minister about timing. On Monday, he said that knowledge arose because earlier in the year,

“a doctor challenged a refusal by the Yorkshire and Humber approvals panel to approve him under Section 12. This challenge highlighted the possibility that the Secretary of State's approval function, which had been properly delegated to SHAs, may, in some areas, have been unlawfully further delegated to NHS trusts. Yorkshire and Humber and then the northern SHA cluster took their own legal advice, which confirmed that the trust had been acting ultra vires in issuing the approvals. The northern SHA cluster identified that this applied to the arrangement in North East SHA and alerted the Midlands cluster, where it was possible that the same issue might apply in East Midlands and West Midlands”.

But it was not until 22 October that,

“the northern SHA cluster alerted the Department of Health to the issue surrounding the approval of doctors and the possible knock-on effects that that would have”.—[Official Report, 29/10/12; col. 449.]

If I have read that right, it seems to have taken a matter of six months or even more between the Yorkshire and Humber SHA, which I think has been subsumed into the northern SHA cluster, first knowing and its then not alerting the Department of Health. I am interested to know why it took so long for the department and Ministers to be alerted.

I come to the point raised by the noble Lord, Lord Pannick, and whether the concept of “Any person” in Clause 1(1) of the Bill is too broad. On normal reading, it appears to legalise approvals by anybody. I know that the Minister said something about that in his introductory remarks. However, the intervention of the noble Lord, Lord Pannick, regarding the outcome of the Constitution Committee’s deliberation this morning was helpful. He said that its reading of the draft is that it is not confined to the mischief of the improper use of delegated powers and, on the face of it, appears to give very broad and retrospective approval to actions that have been carried out in relation to the approval functions. This matter was raised in the other place by my right honourable friend Mr Andy Burnham yesterday when he asked for clarification. In response, Mr Norman Lamb said:

“I am grateful to the shadow Secretary of State for that intervention. We have gone through a very careful process and have followed legal advice on what is necessary to regularise the position. This relates specifically to the approval function, which is defined in clause 1(2). As I have said, the legal advice is that this is the best way to regularise the issue that has been uncovered”.—[Official Report, Commons, 30/10/12; col. 205.]

I recognise that kind of response. It is the sort of response that one tries to get away with. Will the noble Earl give us a little more help on this matter? The clause, on the face of it, seems to go much wider than what would be deemed to be required.

We welcome the review. It will need to look at all the technical issues surrounding mental health so that this House and the public can be absolutely certain that there have been no other technical failures or breaches of regulation. We hope that Dr Harris will be able to undertake this review as swiftly as possible because it is important that it informs the current changes taking place in the National Health Service. We also hope that Dr Harris will be helped by independent professional involvement. Informing the new arrangements which will come in from April next year seems to me a very important part of the work of Dr Harris and his review.

As the noble Baroness, Lady Jolly, said, we are not at all sure about how in practice the new arrangements will relate to the authorisation of doctors under the Mental Health Act. On Monday, the noble Earl said that in future those functions will come back to the Department of Health, but how will that be done in practice? I assume that we will continue to have local panels that will interview the doctors concerned and make recommendations on whether they should be authorised or not. But what happens then? Will the matter then go to the Secretary of State? Will he delegate to the NHS Commissioning Board or local NHS trusts? It is important that we know that there is clarity in the system. I certainly hope that Dr Harris’s review will inform that.

Finally, I echo a point raised by the noble Baroness, Lady Murphy, concerning whether this whole sorry episode is symptomatic of a wider cultural problem with regard to mental health in our National Health Service. Was the issue omitted from the lists of the four SHAs we are discussing because mental health is simply not given the priority that it ought to be given?

We are very glad that the Health and Social Care Bill, following its passage through your Lordships’ House, now includes parity of esteem for mental health services. I do not expect the noble Earl to go into the details of how the department is planning to turn that into a reality. However, in taking forward the work that needs to be done in Dr Harris’s review, it would be helpful to ensure that in future the health service as a whole accepts that legislation relating to people with mental health issues needs to be given as much priority and importance as legislation relating to other parts of the National Health Service.

--- Later in debate ---

[Earl Howe]

The main mischief, I respectfully suggest to the noble Lord, is that the panels which approved the clinicians involved did not, strictly speaking, have the direct power to do that. That is the issue that the Bill tries to capture. The Bill deliberately does not include a comprehensive list of which bodies or persons believed in good faith that they were exercising the approvals function in the past. If we limited the Bill in the way that the noble Lord suggests, we would run the risk of failing to cover some of the approvals given by bodies that we may otherwise have failed to list. I ask the noble Lord to accept that the way in which the Bill is drafted is in the form of a blanket, which gives us certainty that we may not inadvertently have left out any bodies prior to 2002 that may have been guilty of a similar lack of authority.

[Lord Hunt of Kings Heath]

I hope that the noble Earl will forgive my intervention because this is an important point. As the noble Lord, Lord Pannick, said, we are not having a Committee stage, and this is the only time when we can raise this matter.

The problem relates to the approval function. The way that I read it, as the noble Baroness, Lady Murphy, put it so eloquently, is that there might be a quack who somehow got through the system because there has not been the sign-off by the strategic health authority, which could check that the panel had done the right thing by actually exercising an approval function in agreeing—as part of a panel—to someone losing their liberty and being sectioned under the Mental Health Act. The issue is whether this rather open-ended, retrospective clause would give the okay to that as well. The noble Earl has essentially suggested that the problem is the vagueness about the organisational arrangements that were in place prior to 2002. I understand that but it seems to read in such an open-ended way that it could give almost a green light to poor practice or practice that should not have taken place within the panel so constituted under the Mental Health Act.

[Earl Howe]

I understand the question but I believe that that concern is misplaced. The panels operating in this area apply agreed national criteria for approval. Those criteria are clear and extremely rigorous, and that is why we are confident that doctors must meet the same high standards across the country irrespective of whether this technical irregularity applies. The technical irregularity was simply that the panel did not refer back to the strategic health authority for ratification the recommendations that it had made. It is my understanding that strategic health authorities, as a matter of course, accept the advice of the specialist panels. Therefore, I do not share the worry that, somehow or other, quacks or inappropriate clinicians have been appointed to these very onerous and responsible roles.

I now turn to the other main concern raised by the noble Lord, Lord Pannick, and the reason why the Bill has been drafted to refer to, “any person”. I see why he believes that the Bill appears to bestow a wide-ranging retrospective validation on any person, but in fact, the Bill is very narrowly targeted. It only validates any approvals given in the past and it relates only to the function of giving approvals to clinicians as having particular skills, for example, as having experience in the diagnosis or treatment of mental disorder. Once approved, the clinicians are then allowed to carry out certain functions under the Mental Health Act, as I said earlier. It is not the case that the Bill validates anyone other than persons who purported to approve clinicians. It is that role, and that role alone, that is referred to in the Bill.

The persons referred to in Clause 1(1) are as I have described. The Bill deliberately avoids going into further detail about which persons it applies to because, as I have said, attempting to include a totally comprehensive list of which bodies or people who believed in good faith that they were carrying out the approvals function would have created an unacceptably high risk of omitting agencies or individuals that should have been included. I hope that that is helpful.

I am advised in a further answer to the noble Lord, Lord Pannick, that if the power had been wrongly exercised by a panel and an inappropriate clinician had been authorised, that could still be challenged. That is to say: the challenge would be on the basis that the power was wrongly exercised but it would not be a challenge to the power to exercise the approval. I hope that that is helpful further clarification.

On the concerns raised by the noble Baroness, Lady Murphy, she asked how on earth strategic health authorities could have believed that they had this power to delegate. I share noble Lords’ dismay that we could have arrived at this situation but, having been advised by my officials, I am now more understanding of how this could have arisen. Strategic health authorities are able to delegate this function to certain bodies and in certain circumstances. However, they are not able to delegate it in the way that has come to light here. That is why we are legislating.

The options open to strategic health authorities for delegating their functions in relation to all issues are set out in regulations issued in 2002. In relation to the approval of clinicians under the Mental Health Act—which may include clinicians such as psychologists—there were also directions issued in 2008. Such approvals may be delegated to PCTs and therefore there is scope for legitimate confusion as to the exact way in which strategic health authorities had the power to delegate in this area.

I do not think there is any evidence for the fear expressed by the noble Lords, Lord Hunt and Lord Pannick, and the noble Baroness, Lady Murphy, that mental health was somehow not being given the priority it should be in those four strategic health authorities. What happened was that rather than carry out the approval process in-house, the four strategic health authorities decided to deliver the function through a contract with a mental health trust, believing that the focus brought about through a specific contract and the expertise and connections of a mental health trust would deliver a more rigorous and effective approvals process. However, the effect of these arrangements was that the approval functions were to be carried out by the trust, and the regulations and directions specifically set out, as I have said, with which bodies the SHAs may make arrangements to exercise the functions. They cannot completely delegate their responsibility in the way that they did, but it can be exercised on their behalf by a committee, a sub-committee or an officer of the authority. In essence, the panels in the trusts should have been regarded as advisory to the SHA, not having the approval functions themselves.

The noble Baroness, Lady Murphy, asked why this was not picked up sooner. The incorrect delegation was within the process between the strategic health authority and the mental health trust. To all appearances, the process of approving doctors and the quality of the doctors in these four SHAs was the same as in the rest of the country. However, this is a matter with which Dr Harris will no doubt wish to concern himself.

The noble Lord, Lord Hunt, asked me whether we could more precisely define the extent of the problem in terms of the number of patients affected. As of today, my advice is that the north and midlands SHA clusters have reported that they have currently identified 4,117 affected patients—1,265 in the north SHA cluster and 2,852 in the midlands.

I turn now to the questions posed by my noble friend Lady Jolly. She asked me whether the intention of Clause 1 is to give power not only retrospectively but also with effect from today. I hope I have made it clear that that is not the case. It takes effect from today retrospectively as soon as it receives Royal Assent, but it has no effect in relation to future approvals because all people involved in this process have now been properly approved. She asked me to confirm that the people who think they are approved actually are and do not need to undergo any validation or further approvals. The answer to that is yes, if she is referring to approved clinicians or Section 12-approved doctors, which I believe she is.

She asked about the lessons to be learnt from 1 April next year once strategic health authorities cease to exist and how the preparations for the transfer of responsibilities are being progressed. From next April, the Department of Health will be responsible for this specific approval process for approved clinicians. The Secretary of State said yesterday that while this will be a departmental process, we do not want the process to be remote from local areas. He also pointed out that we intend to have a structure that draws on local and regional expertise to help us make the right decisions on the suitability of doctors for the role, and we hope that Dr Harris will advise the department on this when he conducts his review.

The noble Baroness asked where the definitive list of SHA roles and responsibilities is and who is its guardian. The guardian is the Department of Health, while the actual list of strategic health authority roles is set out in the 2002 regulations, the National Health Service (Functions of Strategic Health Authorities and Primary Care Trusts and Administration Arrangements) (England) Regulations 2002, and the precise details on approved clinicians are set out in the Mental Health Act 1983 Approved Clinician (General) Directions 2008. That usefully lists the 28 competencies required of an approved clinician. She asked whether we can be confident that there are no other areas where action has not been taken by some or all of the SHAs. We know of no other areas or functions affected, but again Dr Harris’s review will look at the issues of governance and assurance of delegating responsibilities.

I thank the noble Baroness for making a valid point as regards the transition, but as I have alluded, the Harris review will look at issues of the governance and assurance of delegating responsibilities. Moreover, the review will report by the end of the year, so that will be before the completion of the transition process that my noble friend has so rightly brought to the attention of the House. The one remaining question my noble friend asked me concerned communicating with patients and the timescale of that. I shall repeat what I said before: we think that we need to take time to get things absolutely right, which I know she will understand. However, we hope to be able to issue advice within the next few days. I would reiterate that both the advice and the approach to delivering it will be agreed by both clinical experts and representatives of patients and families. I thought that I had covered every point, although I now see that the noble Lord, Lord Hunt, asked me a question about approvals post April 2013. The one thing I should have added was that we do not intend to delegate the function to the NHS Commissioning Board.

I hope that I have now answered satisfactorily the questions that were raised and that I have provided additional reassurances where necessary. Again, I thank noble Lords and others outside the House for their understanding and for the very significant contribution they have made to the debate.

Bill read a second time. Committee negatived. Standing Order 46 having been dispensed with, the Bill was read a third time and passed.

Winterbourne View

Lord Hunt of Kings Heath Excerpts

Tuesday 30th October 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Earl, Lord Howe, for repeating as a Statement the Answer to the Private Notice Question in the other place.

This has been an horrific case, and recent convictions have revealed criminal and inhuman acts which have caused such terrible abuse to vulnerable people who deserved very much better than that. The “Panorama” programme this week has continued to highlight inappropriate and poor-quality care. It is shocking that the first review, mentioned by the noble Earl, revealed that 19 former residents of Winterbourne View were still subject to safeguarding alerts, and at the follow-up review six former residents were still subject to those alerts. Not all those alerts mean that someone has been harmed. None the less, the “Panorama” programme said that there was one instance of assault, and another case has resulted in a criminal investigation. I should like to ask the noble Earl whether the families of all patients with a safeguarding alert have been given full details. What specific action has been taken as a result of those alerts? Can the Minister guarantee to the House that all patients are no longer at risk?

I should also like to ask him about the responsibility of the local commissioners. I believe that a considerable number of commissioners are responsible for the 51 former Winterbourne View residents. Can he say whether the commissioners now have a proper plan in place to ensure that the former residents receive good-quality care? Has the Care Quality Commission recently inspected all the providers that the former Winterbourne View patients were moved to? The “Panorama” programme raised particular concerns about Postern House, which the CQC inspected in January this year and said it met all the essential standards of quality and safety, and that suitable arrangements were in place to ensure that people were safeguarded against the risk of abuse. Yet the programme revealed a number of problems at Postern House over several years, including over a former Winterbourne View patient in June this year. Is the noble Earl, Lord Howe, confident that all the patients currently in Postern House are protected from the risk of abuse?

Of course, the noble Earl is right to say that responsibility lies ultimately with providers, commissioners and the regulators, but it is Ministers who set policy and have responsibility for ensuring that it is implemented. The noble Earl will know that organisations such as Mencap have been concerned that the Government are not moving quickly or strongly enough to end the practice of sending patients with learning disabilities to long-stay institutions, far away from their families and friends. Will the review he mentioned that will be published by the end of November contain a cohesive strategy for people with learning disabilities? Will this practice of placing people with learning disabilities in institutions a long way from families and friends be discontinued? Is the noble Earl satisfied that commissioners understand their responsibilities and that only, as he said, in limited cases should in-patient services be used?

The role of the regulator, the Care Quality Commission, is of course very important. I very much welcome the appointment of David Behan as the new chief executive but I remain concerned that the huge workload being placed on the CQC means that it is not able to devote itself to areas where we need strong regulation. Is the noble Earl confident that the CQC is now able to take on the responsibilities that have been placed upon it, particularly with regard to focusing on the institutions and organisations where the most vulnerable people are placed?

Finally, I agree with and echo the Minister’s point about the ultimate responsibility of providers. However, is he satisfied that the current arrangements ensure that those providers are regulated effectively—that commissioners know what they are commissioning and are able to monitor performance? Does he recognise that there are real concerns about whether the staff in such institutions are given enough support and training? Given that many of the workers in these homes are unregulated care assistants, does he not think that the time has come to reconsider the regulation of health and social care assistants?

Mental Health Act

Lord Hunt of Kings Heath Excerpts

Monday 29th October 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, I thank the noble Earl for repeating the Statement and for giving me earlier briefing today. Detaining people under the Mental Health Act raises the most serious issues of fundamental rights and patient and public safety. Any reported failure will therefore always be a matter of the highest concern. I am sure I speak for the whole House in saying that I have been reassured by the Minister’s comments, in particular on three crucial points: first, that no patient has been wrongly detained or received care that was not clinically appropriate; secondly, that no doctor was unqualified to make decisions; and thirdly, that urgent action is being taken to correct the situation and bring the clarity that is so clearly essential.

I would like to put a number of questions to the noble Earl. Can he say a little more about the events that brought this to light last week? Was it discovered in one SHA, and by what process did the department establish that it extended to three more? Can the noble Earl tell me whether extensive checks have been undertaken in all 10 SHA areas? Is his department confident that no more patients and families are affected than the 4,000 to 5,000 mentioned in the Statement? Has he any plans for direct communications with the patients and families affected? Is it the case that these patients are living not just in the four regions mentioned but in other parts of the country? Will he comment on how many are in high-security hospitals or could potentially pose a risk to the public?

The noble Earl informed the House that, despite the regulations not being followed to the letter in four of the SHAs, the advice from First Treasury Counsel is that the detentions carried out by those panels, even where the relevant doctors were not signed off by the strategic health authority, were none the less lawful. I do not know whether the noble Earl will be able to clarify that or give some more detail of First Treasury Counsel’s advice. The noble Earl confirmed that the Government will be bringing forward emergency legislation to ensure, for the avoidance of any doubt, that the actions of those doctors have legal validity.

The compulsory detention of patients under the Mental Health Act for their own good or for the public good should always be a matter of great public and parliamentary interest and scrutiny. This is doubly so when legislation of an emergency and retrospective nature is contemplated in this area. Emergency legislation should always be used as sparingly as possible, and your Lordships’ House is rightfully nervous of retrospective law. The Official Opposition understand and support the noble Earl’s wish to remove any doubt about the legal status of the patients concerned, but that has to be set against the general undesirability of asking Parliament to legislate hurriedly. Over the next day, will the noble Earl ensure that your Lordships have access to the fullest possible information, including a summary of the legal advice he received? There will also be concerns about the precedent, particularly in the area of people’s rights, and I hope that the noble Earl can reassure me on that point.

The House and the public will, at the end of the day, want to know that this emergency legislation is being used in exceptional circumstances as a last resort, not as a convenient means of correcting administrative failures. In his Statement, the noble Earl mentioned that according to the advice that he had received from his officials none of the alternatives to legislation had proven satisfactory. Will he give a little more detail about what the possible alternatives were? It would be helpful to the House to know that. If he is not able to do that comprehensively tonight, when it comes to Second Reading of the legislation, which I presume we will be debating on Wednesday—I do not know whether that has been agreed yet—it would be helpful to know what the alternatives might have been and why his officials have concluded that they are not sensible ways forward.

Finally, I turn to the investigation. The Opposition support the review under Dr Harris to get to the facts and ensure that lessons are properly learnt. The noble Earl said that he thought the review would be completed by the end of the year. Will the review be made public? While one would not wish to prejudge it, is the noble Earl in a position to say whether it is proceeding on the basis that what has happened is a failure of policy implementation rather than any defect in legislation? This is important because practitioners working in this important field would not want any unnecessary question marks hanging over the mental health legislation in general.

Will the noble Earl clarify what is going to happen post April 2013? This is currently the responsibility of strategic health authorities, which are due to be abolished at the end of March next year. Will the Secretary of State take back this responsibility from April 2013 or will it be delegated to another authority? If it is, to which authority and how it will be ensured that the proper delegations will be carried out in practice? As well as establishing that and the historical facts, will the review consider whether the new arrangements are likely to be well understood post April 2013?

In conclusion, I commend the Minister for the approach that he and his colleagues have taken to this difficult issue. Clearly, the request of this House and the other place is exceptional, but I fully understand that failure to act would potentially cause unnecessary distress and uncertainty to many thousands of vulnerable patients and their families and risk to public safety. While I look forward to a rigorous examination of the emergency legislation, the noble Earl has our support in removing any uncertainty.

NHS: Children’s Congenital Heart Services

Lord Hunt of Kings Heath Excerpts

Thursday 25th October 2012 Lords Chamber

[Earl Howe]

My Lords, I hope that my initial Answer will have made it clear that we expect the Independent Reconfiguration Panel to look at the issue in the round, and that includes the consequences of the JCPCT’s decision, were that to be carried through. I hope that that is sufficiently reassuring. However, what the panel cannot do, in law, is review the decision of the Secretary of State. It can, however, take all the circumstances into account, and I believe that it should do so.

[Lord Hunt of Kings Heath]

My Lords, I remind the House of my health interests in the register. I would like to press the Minister on that point. In the other place on 22 October, the Minister there made it clear that the decision to transfer the ECMO to Birmingham was made as a consequence of the decision of the Joint Committee of Primary Care Trusts. Given that the Independent Reconfiguration Panel is now reviewing the decision of the Joint Committee, are the Government not being unnecessarily legalistic on this point? It would be quite open to the Secretary of State to ask the reconfiguration panel for its advice on the question of the ECMO position. Why on earth does he not do that?

[Earl Howe]

My Lords, I can only repeat what I said in my initial Answer to the right reverend Prelate: my right honourable friend has asked the IRP to review the decision around children’s cardiac services and its consideration of the impact of that, which may include consequences for the ECMO service at Glenfield. I hope that that Answer puts this question into context. While the IRP cannot review the Secretary of State’s actual decision about the ECMO, which, as the noble Lord rightly said, followed on from the original decision of the JCPCT, nevertheless there are interdependencies between the two services that we expect to be taken into account by the panel.

Care Services: Elderly People

Lord Hunt of Kings Heath Excerpts

Wednesday 17th October 2012 Lords Chamber

Asked By

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they propose to take in the light of reports that vulnerable elderly people are obliged to rely on care workers with criminal records.

[Lord Hunt of Kings Heath]

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

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

My Lords, providers of services are responsible for the safety and quality of the care they provide, and the well-being of the people they care for. Providers should undertake a risk assessment as to whether a criminal record check is needed or not, and what action to take as the result of such a check. Providers should keep a record of this process as an audit trail of their decision-making.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Earl, and of course we all welcome the rehabilitation of ex-offenders. However, I refer the noble Earl to reports that recent CQC inspections show that more than 220 care agencies working for older people in England have failed to show that they were employing properly qualified and vetted staff. What action will be taken about this? Further, does this not show that the time is now ripe for the statutory regulation of care-home workers?

[Earl Howe]

My Lords, it is the responsibility of the employing organisation to carry out appropriate checks on the people they intend to employ. They should take decisions in the context of their responsibility for the well-being of the people who use the service. That position has not changed, and indeed it must be at the core of the safeguarding agenda. Organisations need to risk-assess the suitability of their staff for the role, considering all the information they have on the person, including criminal record checks. If someone has a criminal conviction, the employer should consider how old and relevant that conviction is in the context of the activities that the person would be undertaking and the characteristics of the people they would be looking after. That situation cannot, I think, change substantively.

National Health Service (Clinical Commissioning Groups) Regulations 2012

Lord Hunt of Kings Heath Excerpts

Tuesday 16th October 2012 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House deplores the fact that the National Health Service (Clinical Commissioning Groups) Regulations 2012 (SI 2012/1631) involve the exclusion from membership of a Clinical Commissioning Group of (1) a member of a local authority, and (2) a registered nurse or a secondary care specialist if employed by a body which provides any relevant service to a person for whom the Clinical Commissioning Group has responsibilities.

[Lord Hunt of Kings Heath]

My Lords, I refer noble Lords to the Register of Lords’ Interests and specifically to my chairmanship of the Heart of England NHS Foundation Trust. At the core of the Government’s changes to the National Health Service are the clinical commissioning groups to which a significant part of the NHS budget is to be allocated from the next financial year.

Those clinical commissioning groups face formidable challenges. They need to be authorised and established. They take office at a time when the NHS is attempting to cope with the £20 billion Nicholson challenge. They will face major reconfiguration challenges as the health service seeks to become more efficient in the use of its services. They also will come under great pressure to encourage integration across health and social care but will face also the almost conflicting pressure of increasing the marketisation of the NHS and coping with the bringing in of competition law to a much greater extent. Whatever one’s views about the changes to the National Health Service—I am one who does not take a particularly positive view, as the noble Earl will know—what is not in doubt is that clinical commissioning groups are at the heart of those changes and that the challenge that CCGs face, as we have come to know and love them, is formidable.

These clinical commissioning groups are a curious body. They ostensibly are public bodies to be given £60 billion of public money. They also can be seen as a federation of primary care providers which are given huge financial and commissioning muscle and from which members of the primary care federation can gain considerably. Given that, and given the obvious potential conflict of interest that surrounds clinical commissioning groups, it is clear that they should have the strongest possible corporate governance and effective boards. The regulations before us are therefore of considerable importance.

As the Explanatory Memorandum points out, the regulations set out,

“requirements on CCGs in terms of their establishment and governance”,

requirements in relation to the make-up of the board and requirements in relation to,

“the initial procedure for establishing CCGs and any changes to CCG membership and geographic area thereafter”.

The statutory instrument sets out that membership must include a registered nurse, a secondary care specialist and two lay people.

As I said during our endless debates on the Health and Social Care Bill, I find the very limited lay representation to be very disappointing. It is surely contrary to all good practice in public body appointments that lay people are in such a minority on public bodies to which so much resource has been expended. I doubt that it would pass the Nolan test. I well recall the failures that we have seen in boards over the past two or three decades where it has become clear that the non-executives have failed to discharge their challenge duty. After all, that surely is one of the main lessons of mid-Staffordshire. To have only two lay people who could represent the public interest on those boards seems to me to be a vital error.

I also say to the noble Earl that he failed to respond effectively to our debates on conflict of interest. I am sure that when he seeks to defend the drafting of this statutory instrument, he will talk about conflict of interest. However, the biggest conflict of interest is the fact that GPs will be in a majority on those boards, and GPs can gain financially from the decisions of clinical commissioning groups. That is why this whole structure is flawed.

My concern about the statutory instrument—one of the most peculiarly drafted that I have ever come across—is that people with local expertise are excluded from the clinical commissioning board. Because a registered nurse or a secondary care specialist have intimate local knowledge and provide services to patients in the area of a CCG, they are not to be welcomed; they are to be excluded. That is quite a remarkable decision. For a registered nurse or a secondary care specialist to become a member of a CCG they either have to be retired and therefore completely out of date or they have to live miles away and know nothing of the local area. What a remarkably stupid decision that is. It is compounded by Schedule 4 of the regulations, which excludes a local authority member from being appointed as a lay member of a clinical commissioning group. Why? What on earth is the justification for that?

Given the issue of accountability of clinical commissioning groups, surely having an elected member of a local authority on the board of each CCG would be to the advantage of that CCG. I have yet to hear any convincing explanation as to why they are excluded. Indeed, it is so ridiculous that if you are a GP who happens to be a local councillor, you are excluded from serving on the CCG board. I have had brought to my attention the case of one GP who has been a leading light in the development of his own clinical commissioning group only to be told that he is now ineligible to become a member of the CCG board. Today I met a local authority councillor from east Cheshire who has just been appointed a lay member of a CCG, but she has now been told that because she is a local authority member she can no longer serve on the board.

There are some inconsistencies in the statutory instrument. It looks as though Members of your Lordships’ House can serve on the clinical commissioning group governing bodies, as opposed to MPs and members of local authorities. From my reading it would seem that an elected police commissioner may also serve. That seems to me a trifle inconsistent, and I would be grateful if the noble Earl could clarify that for me.

In the Explanatory Memorandum, when it comes to consultation, we are told that the proposed framework for the established governance and authorisation of clinical commissioning groups was tested with a wide range of stakeholders. Can the noble Earl say a little more about that? Who, in fact, were consulted? I had not realised until I received a briefing that the Foundation Trust Network was not consulted on the details of the regulations. We all read with great interest in Pulse magazine of 24 July that Sir David Nicholson, chief executive of the NHS, said that he was open to relaxing the restrictions that I have mentioned. Was he consulted?

Why did the department not listen to the concerns of the Royal College of Physicians, which believes that the CCG boards should always include specialist doctors who work within the area covered by a CCG in order to help the integration of services across primary and secondary care? Indeed, why did it not listen to the BMA, which feels that the regulations are restrictive and are hampering effective secondary care clinician recruitment to CCG boards? Why did it not listen to the Royal College of Nursing, which says that the guidance makes an assumption that GPs from practices in a CCG should be allowed to sit on the CCG governing body, but automatically excludes any nurses employed by any significant local provider or member in general practice? The college says that that will make it difficult to appoint nurses with the necessary skills and expertise who have sufficient knowledge of the local challenges. The Royal College of Surgeons is also concerned.

I have another concern. Again, when I read the regulations, I had not noticed that, as the Foundation Trust Network has pointed out, if you are a member of a foundation trust you are ineligible to serve on the board of a clinical commissioning group. I believe that the total membership of foundation trusts is more than 2 million. My own trust has 100,000 members in its patch, and they are all excluded from serving on the board of a clinical commissioning group. That is a bizarre decision. I really do not understand how the department could have allowed that to creep into this statutory instrument.

I believe that the regulations are badly thought out and badly constructed. Essentially they will ensure that the board of a clinical commissioning group will be bereft of members coming from the local authority, hospitals or the nursing profession who have any intimate knowledge of the patch in which they serve. I urge the noble Earl to reflect on this. It would be much better if these regulations were withdrawn and new ones brought before your Lordships’ House. I beg to move.

[Lord Warner]

My Lords, I begin by congratulating the Minister on surviving the ministerial defenestration at Richmond House over the summer. I recall that some years ago a younger Bruce Willis played the title role in the film “Last Man Standing”. I welcome the Minister to his new role as an action hero. However, today’s regulations do not live up to this star billing.

My noble friend’s Motion of Regret contains many important reservations and I wholly endorse his remarks but there are other concerns as well. I will not repeat my noble friend’s remarks on the inconsistency of the CCG membership provisions but I would like to supplement them briefly. It seems bizarre to me to allow GPs with acknowledged conflicts of interest in a CCG area to serve on the CCG, though with appropriate safeguards and sanctions for failing to acknowledge those conflicts—sanctions which we discussed extensively during the Bill’s passage through this House—but not to allow specialist doctors to do exactly the same. This seems to me not to be in the best interests of patients because it appears to be punishing expertise of a specialist nature in terms of the development of services by commissioners in a particular local area.

My second point, which I want to dwell on a little longer, concerns the issues relating to accountable officers, which to a great extent, to my reasonably tutored eye, look remarkably similar to the roles of chief executives in PCTs. Has the Minister seen the information about CCG accountable officers in the Health Service Journal of 11 October? This reveals that 72% of the emerging 211 CCGs have chosen managers and not GPs as their accountable officers. Only 22% of the accountable officers are GPs—a drop in the 38% expected as recently as March 2012. This is because the job of the accountable officer looks remarkably like the job of a PCT chief executive and simply does not appeal to GPs. As I recall, the Government, when pushing for this legislation and these reforms, made much of the fact that they wanted to see GPs in a leadership role driving clinical commissioning in a reformed NHS. We seem to have ended up with a situation in which GPs as a whole are walking away from a leadership role in commissioning. That leaves the Government’s strategy of increasing clinical involvement in commissioning services, which I wholly support, in a very weakened state. It suggests that after all the upheaval of the poorly constructed Bill, which we spent months discussing, we will end up with more than 200 CCGs replacing 150 PCTs, but still with about 150 PCT chief executive equivalents running the show within CCGs. This is a bizarre outcome from the time we spent on the Bill. Did we really labour through the Bill for many months to achieve that outcome? Can the Minister confirm that the Health Service Journal data are correct? What proportion of the £60 billion a year going to clinical commissioning groups will come under accountable officers who are not GPs or doctors?

I have a few questions about service integration and CCG mergers. The new Health Secretary seems very enthusiastic about integration of health and social care and that is a jolly good thing. Can the Minister explain how excluding local authority personnel—both members and officers, such as a director of adult services—from a CCG board can facilitate joint commissioning of health and social care and the pooling of health and social care budgets, which seems to be attracting increasing support? How will such an arrangement incentivise CCG accountable officers to use resources for adult social care from the national Commissioning Board in such a way as to save the NHS money and provide a better service to patients? Indeed, can the Minister confirm that CCG accountable officers will not be criticised if they use NHS resources wisely to purchase social care that better serves the needs of patients when appropriate?

As the Minister knows, I am deeply sceptical about the need for and viability of having more than 200 CCGs, particularly given the likely service reconfigurations needed over the rest of this decade. I am therefore pleased that there is some provision in the regulations for mergers to take place. However—there is always a “however”—the list of factors to be taken into account before a merger can proceed, in paragraph 2 of Schedule 1, is extraordinarily daunting. There is a page and a bit of factors that have to be taken into account before a CCG—which may find pretty quickly that it is unviable—can move towards merger. They do not encourage CCGs to face up to financial realities and speedily reduce their number when needs must. Should the Government not be cutting this list of factors substantially rather than providing for a slow CCG death, as Schedule 1 seems to do?

I understand that the Minister may not want to answer all these questions tonight but perhaps he could write to me on some of these issues. I certainly support my noble friend’s suggestion that these regulations should be taken back, rethought through and re-presented to Parliament.

--- Later in debate ---

[Earl Howe]

My Lords, it will be up to local CCGs to determine their own constitutions, as I have said. What we are attempting to do in these regulations is simply to set down the bare minima. As we discussed during the passage of the Act—these provisions were well rehearsed—providing there are two lay members, a secondary care clinician, a nurse and an accountable officer, that is the extent of the prescriptiveness that we feel is appropriate from the centre. Otherwise, it looks very much like the Government dictating the governance arrangements. The Future Forum’s recommendations were very clear that we should not go down that path.

It was suggested that CCGs were experiencing difficulties in appointing secondary clinicians or a registered nurse. I understand the concerns that noble Lords have raised on that score but I have recently spoken to the NHS Commissioning Board, which has started the process of considering applications from emerging CCGs. The news I have is that CCGs have so far successfully recruited to these roles. In addition, the medical and nursing royal colleges have offered to help CCGs in sourcing appropriate candidates, which is very welcome.

The noble Lord, Lord Warner, referred to the HSJ article of 11 October. I will clarify my answer when I write to him, which I will be happy to do. We are very pleased not only that so many clinicians have chosen to apply for leadership roles, which they have, but that so many first-rate clinicians have done so, whether as clinical chairs or clinical officers in CCGs. What is important is that there is a good mix of expertise in the broader leadership team of clinicians and managers, to help the CCG discharge its responsibilities effectively, and that is what we are now seeing.

I have a number of examples of where the drive towards integration is really taking shape on the ground. My noble friend Lady Jolly mentioned South Devon and Torbay; this is a service designed by secondary care doctors and GPs working together in a clinical pathway group for urology, and the whole impetus of the CCG is to improve collaboration and get over the gulf between primary and secondary care. There is another excellent example of integrated services in Wokingham, which again I would be happy to write about.

The noble Lord, Lord Hunt, asked whether police commissioners and Peers could be members of a CCG governing body. Yes, they can. He also asked who was consulted over these regulations. As I have indicated, the proposals were developed in response to the NHS Future Forum, the listening exercise that set out requirements around the secondary care doctor and registered nurse. The proposals were further discussed with emerging CCGs, primary care organisations, the medical royal colleges and, yes, colleagues in the NHS Commissioning Board Authority.

The regulations discussed today provide a fair and transparent rules-based framework to complement the provisions in the Health and Social Care Act around the establishment of CCGs. Creating a responsible and accountable CCG with good governance is essential for good management, good performance, good stewardship of public money, good public engagement and—our ultimate goal—good outcomes for patients. I commend the regulations to the House.

[Lord Hunt of Kings Heath]

My Lords, I shall be brief. I thank the noble Earl, Lord Howe. He started by referring to the importance of clinical leadership and I would not disagree with him, but he has not really answered the point that the biggest potential conflict of interest is if GPs are in a majority on the boards—and I would hazard a guess that, in most places, they will be. They do not commission primary care, but their decisions can shift resources into primary and community care services. That is the essential conflict of interest.

The Government’s legitimisation of what must be some of the worst drafted regulations that I have ever come across would stand up in relation to conflicts of interest in other professions if one had any inkling at all that they recognised that CCGs carry a huge risk in relation to the GPs’ own position. The Minister said that the CCGs are about clinical leadership. As my noble friend Lord Warner pointed out, you are not even getting that, because only 20% or so of the accountable officers of those CCGs are to be GPs. The remainder are to be managers. Let us be clear: the accountable officer will in effect be the chief executive. The noble Baroness, Lady Finlay, said that the exclusion of local consultants and nurses from CCGs would mean that, in large parts of the country, the people appointed would have no local knowledge whatever. I agree that, in London, it may be more practical; in most of the rest of the country, it will not be.

I agree with all the points raised by the noble Baronesses, Lady Jolly and Lady Williams, but it is not sufficient to say that there will be a review in 2014. At this late stage, I invite them to join us in the Lobbies tonight. I could not disagree with anything that either noble Baroness has said. They tore apart the regulations. Will they not join us tonight?

I was amazed by the remarks of the noble Baroness, Lady Cumberlege. She came to the health service, as did I, through local government. Local government is having to take some immensely tough decisions. Having a local authority councillor around the board table of a CCG would help legitimise its decisions and help tie in the local authority with difficult decisions that have to be made. Excluding them is a huge mistake. I do not understand—clearly, the department forgot them—why elected police commissioners are deemed worthy of service on a CCG board when elected MPs and councillors are not. When my noble friend Lord Prescott is duly elected a police commissioner in a few weeks’ time, as one hopes, he will be eligible to serve on the whole clinical commissioning group, but no MP and no councillor. These are some of the most nonsensical regulations that I have ever seen.

The Minister said that we should not worry because local authority councillors, local doctors and local nurses can serve on the committees of a CCG—no conflict of interest there—but they cannot serve on the board. However, the board is the sovereign decision-making body of the CCG. I would have thought that most clinical commissioning groups would have wanted to have local expertise, whether it is local authority representation, a doctor or a nurse.

The Minister then said that these are only minimum requirements. Well, Schedule 4 states:

“Individuals excluded from being lay members of CCG governing bodies … An employee of a local authority in England and Wales or of any equivalent body in Scotland or Northern Ireland … A chairman, director, governor, member or employee of an NHS foundation trust”.

Excluding a chairman, director or governor of a foundation trust is fair enough, but a member? My trust has 100,000 members. Patients are automatically enrolled in membership of my trust unless they decide to opt out. We are talking about 100,000 people living in the catchment area of my hospital who are not allowed to be lay members of a CCG. Surely they are the very people you would want to be lay members of a CCG.

[Earl Howe]

They are not allowed to be the statutory lay member.

[Lord Hunt of Kings Heath]

My Lords, I am most grateful to the noble Earl for that enormously helpful clarification. The point is this: why should they not be statutory lay members of the CCG? There is no guarantee that CCGs will appoint any more lay members. I have yet to hear any rational explanation as to why this statutory instrument has been drafted in this way.

As we know, the noble Earl, Lord Howe, is a very fair man and always engages in debate. He will know that this statutory instrument has been ripped apart tonight. Even at this late hour, I ask him to withdraw the instrument. If he is not prepared to do so, I will test the opinion of the House.

NHS: Evidence-based Medicine

Lord Hunt of Kings Heath Excerpts

Wednesday 10th October 2012 Lords Chamber

[Earl Howe]

My Lords, I would expect that my right honourable friend the Secretary of State is well aware of the public comment on his recent statements, but he is entitled to his personal views. The Government’s position remains that it is the responsibility of local NHS organisations to make decisions on the commissioning and funding of healthcare treatments, such as homeopathy, for NHS patients.

[Lord Hunt of Kings Heath]

My Lords, I refer the House to my interests in the register. Following up that point, does the Minister not think that the Secretary of State should at least show some discretion when he comes to make statements on these issues in the sense that he is also head of the Department of Health and the National Health Service? In relation to his response on NICE and guidance, is he satisfied that the technology appraisals that NICE issues are indeed implemented by the health service?

[Earl Howe]

My Lords, I do not think I can add to what I said previously as regards my right honourable friend. No doubt he will take the noble Lord’s comments into consideration. As regards NICE guidance, as the noble Lord will know, there are concerns that in certain parts of the health service NICE guidance is not followed as we would expect it to be. There are various initiatives in train to correct that, both as regards the NICE technical appraisals and also clinical guidelines.