NHS: Specialised Services
Lord Hunt of Kings Heath Excerpts(13 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
My Lords, I congratulate the noble Baroness, Lady Jolly, on giving us this welcome opportunity to discuss national specialised services. The points that she has made are significant both in terms of specialist services and also in terms of some of the vulnerabilities in the new architecture that we see being brought into the NHS.
One of the issues raised by the shifting of responsibility from Ministers to the NHS Commissioning Board is a concern that Parliament and parliamentarians will not have sufficient influence on the way in which specialist services will be developed. I too would like to acknowledge the work of AGNSS and express our wish to see it continued. I thought that my noble friend Lord Turnberg put it very well. It is important that Ministers continue to receive the advice of this body in the new arrangements. It seems to me that the arguments being put forward by every noble Lord on this matter are persuasive.
I also wonder about the advice that the NHS Commissioning Board is to receive. As I see it, there is a two-stage process. First, there has to be a decision on which services are to be so designated, which will be a subject for Ministers and will have to be done through regulations. I am quite clear that AGNSS has a role to play. Secondly, if there are services to be commissioned, how are they to be commissioned and how much is to be commissioned? Again, I wonder whether AGNSS could play a role in advising the national Commissioning Board. I do not know whether the noble Earl would be prepared to comment on that specific point, which is rather separate from that which we have debated so far on advice to Ministers.
Can the Minister also comment on regional specialist services? Again, we have not really discussed that but, in the past, there has been a mechanism for commissioning at the regional level. Can he say how he thinks that that might be done? Of course, it is possible that the local offices of the national Commissioning Board might do it with the advice of some kind of advisory service. I encourage the noble Earl to go down that route. I really hope that the answer is not that clinical commissioning groups will federate together to commission regional specialist services. Frankly, that will not happen. I would have no confidence whatever in clinical commissioning groups collectively seeing the wisdom of commissioning regional services. At the local level, there has to be leadership. I can see it coming only from the office of the national Commissioning Board. I think that with an AGNSS approach at that level, alongside an ability of the commissioning board at what we call the local level, but which with 28 offices really is at a semi-regional level, there will be scope for that to happen.
The noble Lord, Lord Palmer, raised the issue of postcode prescribing. If too much is devolved to clinical commissioning groups in relation to specialist services, that is almost inevitable. From the action taken recently by a number of primary care trusts, we have seen that they are only too willing to restrict services. The North Yorkshire primary care trust seems to be in the spotlight and to be making some bizarre decisions. It has sought to describe treatment, which is well recognised nationally and internationally, as innovative and almost not proven. The noble Lord, Lord Walton, raised this issue yesterday. I would worry if clinical commissioning groups were given too much discretion in this area.
Finally, I turn to budgets and how much money is to be top-sliced. I gently say to the noble Earl, Lord Howe, that Ministers seem to be in denial about the financial pressures facing the health service at the moment. Recently, I had meetings with the Royal College of Nursing and the Royal College of Physicians. They confirmed my view that the NHS is under extreme pressure, the problem being that primary care—the most vulnerable and most patchy bit of the health service—simply is not stepping up to the plate in terms of demand management or developing the services that were meant to keep people out of hospital. Given that, the acute sector is under huge pressure, and my worry is that the national Commissioning Board will be very reluctant to top-slice sufficient resources in relation to specialist services.
In reminding the House of my health interest, as I should have done at the beginning of my speech, I would be very grateful if the noble Earl could say a little about how resources are to be protected for specialised services in a very strained financial position.
NHS: Primary Care Trusts
Lord Hunt of Kings Heath Excerpts(13 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
To ask Her Majesty’s Government what action they will take to prevent primary care trusts inappropriately restricting access to patient treatments.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is inappropriate for a primary care trust to impose blanket bans on treatments, or to restrict access to treatments on the basis of cost alone. The department will ask strategic health authorities to investigate any examples of such behaviour, and appropriate action will be taken.
Lord Hunt of Kings Heath
My Lords, in thanking the noble Earl, I remind the House of my health interests in the register. The noble Earl will be aware that there is now abundant evidence that some primary care trusts are restricting treatments that are deemed appropriate, in some cases against the guidelines issued by NICE. Given that, will he go further and seek to ensure that he and his ministerial colleagues intervene in the NHS where this is happening so that we can be satisfied that the NHS will still provide a comprehensive service?
Earl Howe
My Lords, yes, we will intervene if ever it is demonstrated that primary care trusts are restricting treatments on a blanket basis or on a cost basis unrelated to clinical need. Any arbitrary restriction on access to treatment of that kind is unacceptable. We have made that clear repeatedly, as has Sir Bruce Keogh, the NHS medical director, on a number of occasions. However, that is not the same as saying that the NHS should be unconcerned about value for money. It should be very concerned about it. It should not spend money on treating a patient when that patient is unlikely to derive clinical benefit from the treatment. Therefore, we need to distinguish that kind of case from the kind cited by the noble Lord.
NHS: Mental Illness
Lord Hunt of Kings Heath Excerpts(13 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, as regards GPs, the Royal College of General Practitioners has identified improved care for people with mental health problems as a priority within its enhanced GP training programme, which forms part of the college’s proposals for a new evidence-based four-year programme of training.
As regards the workforce issues, I am aware that there is concern about recruitment into psychiatry. My department and the Royal College of Psychiatrists are looking into this matter. The royal college has established a task force to make recommendations to improve recruitment, and it is investigating the factors before medical school, during medical school, during foundation training and in core and higher psychiatric training so as to get to the bottom of the issue as best it can.
Lord Hunt of Kings Heath
My Lords, one of the important recommendations in the LSE Centre for Economic Performance report, which led to this Question, concerns the attitude of other doctors to psychiatrists and the issue that that has in relation to recruitment. The report says that,
“it is routine for”,
surgeons and physicians,
“to make derogatory remarks about psychiatry, which affects not just psychiatrists but also their patients”.
I wonder whether the noble Earl has any answer to that.
NHS: Private Finance Initiative Costs
Lord Hunt of Kings Heath Excerpts(13 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, LIFT is one tool that we have in financing capital schemes in the community, many of which have been successful. Such schemes promote integrated services, which I know my noble friend will welcome. All LIFT schemes have been and will be assessed for affordability and value for money. It is not a universal prescription by any means, but we look constructively at LIFT as one way of delivering capital schemes.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. Will the Minister confirm that, under PFI, more than 100 new hospitals were built by the previous Administration? Will he also confirm that the annual expenditure on those schemes is less than 1%? In fact, does he agree that the real financial problem of the NHS is the £20 billion that his Government are taking out of it in a four-year period?
Earl Howe
We are not taking £20 billion out of the NHS; we are redeploying an increasing budget so that we get better value for money for the taxpayer. I say in answer to the noble Lord’s first point, which I think was more serious than his second, that we have confirmed that we remain committed to public/private partnerships. We think that they can continue to play an important role in delivering the country’s future infrastructure. However, it must be on the right basis, with tighter conditions attached.
NHS: Annual Report and Care Objectives
Lord Hunt of Kings Heath Excerpts(13 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
My Lords, in thanking the noble Earl for repeating the Statement made in the other place, I first refer noble Lords to my health interests in the register, which include being chairman of an NHS foundation trust and being a consultant and trainer in the NHS.
The Secretary of State has today presented his first annual report, which I can describe only as a report on a lost year in the National Health Service. Just when the NHS needed stability to focus all its energy on the financial and service challenges that it faces, which are momentous, the Secretary of State pulled the rug from underneath it with a reorganisation that no one wanted and the Prime Minister had promised would never happen. In fact, we have had not one but two lost years in National Health Service as the Secretary of State has obsessed over structures and inflicted on it an ideological experiment that made sense to him but, sadly, to very few other people.
His decision to dismantle existing structures before new ones were put in place has led to a potential loss of financial grip at local level in the NHS. Two-thirds of NHS acute trusts are reported to have fallen behind on their efficiency targets. I can speak personally here of the issues that that causes. We see temporary ward and A&E closures, panicked plans to close services sprouting up wherever you look, and crude rationing restrictions across the NHS, with 125 separate treatments, including those for cataracts and hip replacements, being restricted or stopped altogether by one primary care trust or another. This is an NHS that is drifting dangerously towards trouble or, in the words of the NHS chief executive, a former senior official in the noble Earl’s department and a distinguished health service manager to boot,
“a supertanker heading for an iceberg”.
Listening to the Secretary of State’s Statement, you could conclude that he is not looking at the same NHS as the head of the NHS Confederation. I wonder which world Mr Lansley lives in; perhaps it is la-la land, as it is sometimes called by well known commentators on the NHS. Perhaps that explains why the year has been hailed as a great success by the Secretary of State when it saw the biggest ever fall in public satisfaction with the NHS, as recorded by the British Social Attitudes Survey. I note that the Statement was rather selective in quoting from surveys of opinion, but this is the question that has been asked consistently since 1983.
Life on the ground is very tough in the health service, even for foundation trusts such as mine, which have consistently broken even. Acute trusts are in the dock. We are told that we take in too many patients. At times, Ministers say that we take too long to discharge those patients. At others, if media stories go in the other direction, we are told that we discharge patients too quickly. Rather than these knee-jerk reactions, we need an integrated approach. The problem is that the Government’s changes are working in the opposite direction. On the one hand, acute trusts face major squeezes on finances and therefore have to reduce capacity because the only way to make the big efficiencies needed is to close wards and reduce staffing levels. On the other, acute trusts are the most accessible part of the system, 24 hours a day, seven days a week, 365 days of the year. They have a much better offering than most GP deputising services.
Therefore, I ask the noble Earl whether primary care is stepping up to the plate and increasing its own accessibility. I will be very interested in his comments. I certainly find it bizarre that walk-in centres are being closed up and down the country. Can we look forward to primary care surgeries extending their hours to make up for that? Will primary care contribute to demand-management plans? I refer the noble Earl to Mr Lansley’s original speeches, in which he said that the reason for these changes was to put GPs in charge of the budget because, without that, doctors behave irresponsibly. Clearly, the intention was that GPs should ration services and manage the demands made on the rest of the system.
I do not see much sign of effective demand-management, although we certainly see rationing. Primary care trusts are dying but clinical commissioning groups are not focused on the big issues because, at the moment, they must seek authorisation, get themselves up and get the infrastructure ready. Therefore, at local level there is a great hiatus in ensuring that there is a system-wide response to these great challenges.
Paragraph 5.16 of the mandate comments that the NHS Commissioning Board,
“will be responsible for around £20 billion of direct commissioning, including primary care”.
Will the noble Earl tell me how the board will ensure that primary care is commissioned effectively? In paragraph 3.6, there is a very appropriate reference to the need for patient choice and primary care is mentioned. How will the public be given choice in primary care? The issue has bedevilled the health service for many years. We should like to hear how the Commissioning Board will ensure that there is genuine choice so that people can choose which GP’s surgery to belong to.
In paragraph 5.6 of the mandate, we come to this wonderful phrase:
“The Government’s aim is to move away from the top-down management of the NHS to a system where fully authorised CCGs will have, as the Future Forum put it, ‘assumed liberty’”.
The idea that the Government are currently engaged in letting go is a fantasy. The system is being tightly controlled from the centre. Clinical commissioning groups are being told what to do and there is very little sign of any autonomy whatever. I have to tell the noble Earl that nobody in the health service believes a word of what is contained in paragraph 5.6.
I come now to the intention, expressed in the mandate, that judgments will be placed on each part of the provider side of the NHS, in particular by asking patients whether they would recommend a hospital to a family member or friend,
“as a high quality place to receive treatment”.
I very much applaud the intention behind this; it is called the net recommender index. It has been taken from the private sector—the retail trade, I think. However, there is of course a difference. In the private sector, one can take it that most people want to shop, whereas most people do not want to be in hospital. On a scale of nought to 10, anything up to seven is regarded as not being a recommended value. The Picker Institute and CQC have both said that they have real concerns about the methodology. Before the Government simply go in for a simplistic league table, I urge the noble Earl to talk to the health service, let it have an input and come up with a system that actually will be seen as credible and owned. If the department insists on a very crude approach on this issue, I very much fear that it will give very false impressions of the quality of care in individual hospitals.
I welcome in paragraph 4.9 the commitment to promoting innovation and research. The noble Earl himself has a major part to play in this, and it is very welcome.
Alongside the mandate, the Statement is silent on the severe funding problems of local authorities that impact on their ability to provide support either to help to prevent patients having to go into hospital in the first place or to allow for their successful discharge as early as possible. Indeed, the Secretary of State was silent on the unfolding crises in adult social care. We have been promised a White Paper on service change, but the Government are silent on funding. It is widely believed that they have given up on the Dilnot proposals. Can the noble Earl reassure me on that matter?
I also want to ask the noble Earl about ministerial statements that there will be no rationing by cost in the health service. He will know that the recent survey undertaken by the Labour Party showed that rationing is happening on Ministers’ watch right across the system with a whole host of restrictions, not just on unnecessary treatments but important ones—a postcode lottery running riot. Have Ministers issued instructions to the health service to stop this?
I turn to bureaucracy and targets. The Government said when they first came in that they would scrap the four-hour A&E and 18-week targets; they have brought them back. Now they have gone further and adopted Labour’s guarantees. Today they have added on top of that a whole new, complex web of outcomes and performance indicators. The NHS needs simplicity and clarity; what it has got is a dense document with a complex web of 60 outcome indicators grouped within five domains. The House is entitled to an explanation of the difference between an outcome indicator and a target; but there is no difference. In fact, at the time of the greatest financial squeeze the health service has ever had to face, the Government are loading new targets on to the NHS, which is struggling to cope with the challenges that it is facing.
The House also needs to ask: to whom is this mandate to be given? What is happening here is the outsourcing of democratic responsibility and accountability to Parliament for the organisation that constituents value most to an unelected and unaccountable board. What assurances can the Secretary of State give to noble Lords that the Commissioning Board will listen to the concerns of parliamentarians?
I want to ask finally about the mandate that the Secretary of State has given to his new board. There is widespread concern in the health service that the mandate given to the Commissioning Board is one for privatisation. It was repeatedly claimed in both Houses during the passage of the dreadful Health and Social Care Bill that has been passed into law that there would be no privatisation, yet it is happening at speed as the NHS is being broken up and clinical commissioning groups are being forced to tender community services and create back-office commissioning clusters. In the mandate there is not one mention, except in the distribution list, of an NHS trust or an NHS foundation trust. It is quite clear what is happening. The department is using the language of providers because it wants, in the end, to float the provider side off from the National Health Service. There is widespread distrust of this Government in the health service and outside, and I am afraid that this Statement does nothing to assuage that view.
NHS: Dental Care
Lord Hunt of Kings Heath Excerpts(13 years, 9 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, I absolutely agree with my noble friend about the importance of transparency of information for NHS patients. NHS Choices, which is the department’s public-facing website, already displays a lot of information about fees, the treatment that should be received and how to make a complaint about NHS dentistry, but more work is being done in this area to improve information on patients’ ratings of different practices, and we are updating the patient leaflet as well. What a dentist should not do is mislead a patient or induce a patient to access the surgery and then not provide the treatment that the patient thought they were going to get. If they cannot provide NHS treatment for whatever reason, they should point the patient in the direction of a practice that can, or else refer him or her to the primary care trust helpline.
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interests in the register. Following on from the noble Baroness’s Question, can the Minister refer specifically to the OFT report, which showed that thousands of patients, after being told by their dentist that they could not have a certain treatment on the NHS, were persuaded to go private? That is and was inaccurate information. Are the Government going to take action in this area?
Earl Howe
My Lords, the OFT report on the dental market was published last month and we very much welcome that study. We note that it found that the vast majority of patients were happy with their dental treatment and that the vast majority of dentists behave ethically. There should be, and are, clear penalties for the small minority who mislead patients, but the noble Lord is right to draw attention to that aspect of the OFT report. It is an area that we are taking extremely seriously and we are looking at what more we can do.
Care Quality Commission (Registration and Membership) (Amendment) Regulations 2012
Lord Hunt of Kings Heath Excerpts(13 years, 9 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
That the Grand Committee takes note of the Care Quality Commission (Registration and Membership) (Amendment) Regulations 2012 (SI 2012/1186).
Lord Hunt of Kings Heath
My Lords, I declare an interest as chair of an NHS foundation trust, a consultant in the health service and a trainer in relation to Cumberlege Connections.
When we debated the Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2012 in Grand Committee on 22 May, we touched on CQC’s governance, the PAC report of 12 March and the department’s capability review. The noble Earl will know that the PAC expressed some serious concerns and that his department’s capability review acknowledged that CQC could have done more to manage operational risk and provide better strategic direction.
The review recognised that the department and CQC had underestimated the scale of the task of combining three regulators into one organisation while developing and implementing a new regulatory model. The review also made recommendations to strengthen the board and the board structures, and to establish a unitary board with a majority of non-executives but with senior executives sitting on the board to enable a tighter accountability relationship between non-executives and senior executives. Let me say at once that the Opposition do not oppose these changes which bring CQC governance more into line with that of the National Health Service. While governance is important, underlining it are probably questions about CQC’s capacity to discharge its wide and important responsibilities.
I have read very carefully CQC’s response to the performance and capability review that has now been published. That fairly sets out the scale of the challenge that it faced. However, the CQC acknowledges that the strategy devised at the outset of the new regulatory body failed to take into account the complexity of the changes in the regulatory review regime and, in particular, the workload implicit in recognising so many providers, merging three organisations into one, while reducing costs and changing the working patterns and skill requirements of many of the staff who were either inherited or taken into the new organisation.
That is a very helpful recognition. Many who have been concerned with the architecture of CQC would have to take some responsibility for that; I do not detract from my own Government’s responsibility. We are trying to learn some of the lessons and hope that they can be embraced within the new strategy that CQC will take forward under its new leadership.
Nor do I ignore the progress that CQC has made. Creating a single regulator of health and adult social care services spanning, as CQC points out, more than 22,000 providers of 40,000 services is no mean challenge. Today’s Written Ministerial Statement in another place by the Minister of State, Mr Paul Burstow, concerning the Winterbourne View private hospital, which draws on the reports of the Care Quality Commission’s inspection of 150 hospices and care homes, also indicates the value of the work that has been undertaken by CQC.
Baroness Jolly
My Lords, we all want the CQC to be effective and efficient. The noble Lord, Lord Hunt of Kings Heath, has laid out a clear description of its history and where it is now. It has a difficult task: it has to balance registration complexity for those providing both health and social care and ensure safety and quality of services. Of course, since the Act of 2012, all providers in the public, private and voluntary sectors are involved and it has to extend its remit to include dentists and GPs. It has a huge task. There have clearly been failings in the past, but the organisation as a whole has faced up to them and has made many strides forward.
We have this SI as a result of the Health and Social Care Act 2012. It is in two parts—registration, and governance and membership—and it throws up more questions than answers. I was reminded of a long time ago when I was a CHI reviewer. The training was superb; the teams went in and the inspection was intensive and penetrated every corner. Perhaps there would be some mileage in looking back at that model to see whether it could be incorporated into what currently exists.
Lord Hunt of Kings Heath
I was interested in the noble Baroness’s comments about the CHI training process. Does she agree that one of the great advantages of the CHI approach was that, when a team went in, it had respect because the people in the team were the equals, if you like, of the people whom they were inspecting and, although it was an inspection and allowed people to work with an inspection team, it was almost a development opportunity for the organisation as well?
Baroness Jolly
Certainly that was my experience. Although there were instances where we had uncomfortable inspections, afterwards an awful lot of work was put in to try to remedy issues that had been raised. The team went in as a team and worked as a team. Everyone on the team had experience of working within the NHS in one format or another and, although we may not have carried out identical roles to those that we were inspecting, there was a clear awareness that we knew what we were about. I shall not carry on at great length because of the time.
The amendments to the registration are a tidying-up exercise. All that we are doing is replacing the National Patient Safety Agency with the NHS Commissioning Board Authority, so it is a cut-and-paste job, if you like. Will the Minister confirm that in due course this will subsequently transfer to the board when the board becomes the board and not just the authority? Will the Minister clarify the situations where deaths and other incidents in these situations involving service users—vulnerable people—are reported and say why they might be reported to the board and not to the CQC? If we are to learn anything from this information, it is critical that the board commits to publishing it on a regular basis. It also needs to be part of the board’s regular agenda.
On a related issue, will the Minister update the Committee on deaths of service users and untoward incidents, which cause difficulty for carers and, in the case of untoward incidents, the patients themselves? During the consideration of the 2012 Bill, there was much debate about the duty of candour. Will the Minister give us some sort of update on where things are? I remind him of his comment on 27 February:
“I reiterate the commitment that I have given today that the Government intend to use the ‘standing rules’ regulations to specify that the contractual duty of candour must be included in the NHS standard contract”.—[Official Report, 27/2/12; col. 1055.]
That was a welcome move but I would appreciate it if the Minister could update us on where we are. I appreciate that this will not happen overnight; it will require training and a large amount of cultural change.
I move on to the governance and board membership issue. Today we had the interesting interim report on the Winterbourne View Hospital. Bearing that in mind, will the Minister reflect on whether he believes that the new governance arrangements proposed in these regulations will minimise or even avoid a repetition of this level of behaviour or such an appalling lack of dignity for those with learning disabilities? Does he believe that adequate funding is available for the CQC? Again, the noble Lord, Lord Hunt, gave us a long list with numbers relating to its remit—it is really broad and deep. The Committee would probably feel comfortable if it felt that the CQC was being ably supported with adequate resources. It has had a difficult role in changing times and it can use its registration requirements to drive up quality. To that end, the Government must work with it. I think that we would all agree that service users and carers deserve no less.
Lord Hunt of Kings Heath
My Lords, I thank the noble Earl for his comprehensive response and the noble Baronesses, Lady Wall and Lady Jolly, for joining the debate.
The noble Earl can take it that there is general cross-party support for the work of the CQC; we wish it and Mr Behan well. The tasks that it faces are formidable, but I hope that with the resource increase referred to by the noble Earl and the spirit of support and co-operation, it will be able to make progress in the next few years.
I should like to raise two points. First, I did not mention the National Patient Safety Agency in my opening remarks, although I was tempted to do so. I understand the point the noble Earl is making. The main responsibility of the NPSA, of which I was chair a few years ago, was to record these incidents and then send out reports of the trends. The issue was with what happened to put that into practice. The noble Earl’s argument is that by bringing that into the NHS Commissioning Board it will be more in the mainstream of the architecture and more likely that the reports of those trends will be taken account of in the health service. The risk is that the National Reporting and Learning Service will no longer be seen as independent because it is part of the management structure and that, in the future, staff will be more reluctant to report incidents. All I ask of the noble Earl is that his department keeps a close eye on the number of incidents that are reported. If there appears to be a tailing off, the Government might need to revisit the issue of where the NRLS is placed.
Secondly, on the approach and methodology of the CQC, I fully accept that life has moved on since the CHI model. The CHI model was certainly not perfect but, as the noble Baroness, Lady Jolly, suggested, it benefited from high-quality inspection teams. I am glad that the noble Earl listened carefully to what I had to say on that matter and I hope that this can be the start of a more general engagement on the work of CQC and its methodology. It enjoys support for what it does and we want it to do well in the future, but we would also like to take part in these important discussions.
Having said that, I thank all noble Lords who have taken part in the debate.
NHS: Liverpool Care Pathway
Lord Hunt of Kings Heath Excerpts(13 years, 9 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, I recognise that some people who have been on the Liverpool care pathway have received poor care. The pathway is not of itself a guarantor of best-quality care. It has been consistently made clear in the guidance for the implementation of the Liverpool care pathway that it is in no way a replacement for clinical judgment and should not be treated as a simple tick-box exercise. Rather, it should be seen as a useful framework to guide the delivery of care in a way that complements the skill and expertise of the practitioner using it.
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interests in the register. Does the noble Earl agree that the noble Baroness, Lady Knight, has done sterling work in bringing to the attention of Parliament issues to do with the appropriate feeding and nutrition of patients in hospitals, but that on this issue she is wrong? Will he confirm that the national care of the dying audit shows that in fact the vast majority of patients on the care pathway in the last 24 hours of their life were reported to be comfortable and receiving good clinical care, and that his department will continue to recommend the care pathway as good practice?
Earl Howe
My Lords, we will continue to do so. The Liverpool care pathway has sometimes been accused of being a way of withholding treatment, including hydration and nutrition. That is not the case. It is used to prevent dying patients from having the distress of receiving treatment or tests that are not beneficial and that may in fact cause harm rather than good. The noble Lord was right that the recent national care of the dying audit of hospitals, run by Marie Curie in collaboration with the Royal College of Physicians, notes that in 94% of documented cases discussions explaining the use of the LCP were held with relatives or carers. That audit process gives clinicians an opportunity to feed in their views about how well, or not so well, the pathway is working in practice.
Tobacco: Control
Lord Hunt of Kings Heath Excerpts(13 years, 9 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interests in the register, in particular as president of the Royal Society for Public Health. I ask the noble Earl to continue his efforts to keep those companies at some distance from him and the Department of Health. Will he confirm that it is the view of the Government, as it was of the previous Government, that the tobacco industry promotes a product that has been described by the WHO as being proven scientifically to be addictive and to cause disease and death, and that we should have very little to do with those companies?
Earl Howe
My Lords, I can only agree with the noble Lord, Lord Hunt, that tobacco is extremely damaging to public health. There is no safe level of smoking, and as a party to the Framework Convention on Tobacco Control, the UK has an obligation to take its undertakings very seriously—which means to develop public health policy free from influence from the vested commercial interests of a very powerful industry. However, that does not mean that we close our ears to what the tobacco industry may have to say: we are very happy to hear from it in writing. That promotes transparency, which I think assists everybody in a freedom of information context.
Health Research Authority (Amendment) Regulations 2012
Lord Hunt of Kings Heath Excerpts(13 years, 9 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
That the Grand Committee takes note of the Health Research Authority (Amendment) Regulations 2012 (SI 2012/1108).
Lord Hunt of Kings Heath
My Lords, I should start by declaring interests as the chair of a foundation trust, as a consultant in the health service and as a trainer with Cumberlege Connections Ltd.
As well as moving this Motion, I shall also speak to my second Motion, which also relates to the Health Research Authority.
On the face of it, the regulations and order are unexceptionable and they passed through the Secondary Legislation Scrutiny Committee without comment. They provide for the board to be reconstituted with independent non-executives and an independent chair.
The responsibility that falls to the members of the authority is indeed weighty. The noble Earl, Lord Howe, has a long-standing record of commitment to health research, which is considerably reassuring to all those with an interest in this area. I have no doubt at all that health research is as important to the economy of this country as it is to the quality of patient experience and outcome. Indeed, embraced with the high quality of life sciences in the UK, it is crucial that we prioritise health research to the fullest extent possible. Certainly my experience in chairing the Pharmaceutical Industry Competitiveness Task Force some years ago convinced me of the essential link between the health of the person, the health of the NHS and the health of the economy, and that is why I think it is so important for the National Health Service to support health research. Our debates during the passage of the Health and Social Care Bill indicated the strength of support for research and for the Secretary of State’s responsibility for it to Parliament.
The HRA has been set up to protect and promote the interests of patients and the public in health research. The aim is to lead to the creation of a unified approval process and to promote consistent and proportionate standards of compliance and inspection. The HRA has a number of functions, including being the appointing authority for research ethics committees in England, and it provides the National Research Ethics Service. Also, by agreement with the devolved Administrations, it supports a UK-wide system for ethical review in the UK. It has an important ongoing programme of work and it also provides the integrated research application system through which applications for regulatory and governance approvals of health research are made in the UK. It also agrees plans to provide a platform for the unified approval process from the IRAS, as it is known.
I turn to the details of the regulations and order. I ask the noble Earl whether it is intended that the non-executives should be a majority on the board. I should also like to ask him about the Government’s intention regarding the publication of draft clauses to establish the HRA as a non-departmental public body. I do not know whether he can give any indication at all about the timing of and commitment to the eventual legislation that has been promised. Will he also comment on the Government’s approach to, and policies for, enhancing health research in the UK?
How are we to ensure that we make the most of the excellence of our life sciences? Can the Minister give some reassurance about the priority to be given to research by the NHS Commissioning Board? Does he believe that academic medicine is given sufficient support by the National Health Service? Is he confident that the HRA has the capacity to streamline research application processes? That point has been made to me by a number of organisations that have been interested in the order and in our debate.
The noble Earl will be aware of the continuous debate over probably the past decade about the bureaucracy involved in the application processes and a feeling that the UK has lost its competitive edge because of that. I know that the previous Government and this one have continued to do work in this area and I wonder whether he can report any further progress. I should like him to comment on whether he believes that the UK will be able to maintain a competitive edge in research in the years to come and whether he believes that the intention is to maximise large-scale patient recruitment.
Alongside that is the importance of site selection and the question of whether it is going to be easier for applicants in the future to conduct multi-centre research. My understanding is that one of the problems is that applications for multi-centre research have to go to the individual institutions concerned, which can sometimes hold up approval. My understanding is that there is going to be a concerted attempt to speed up that process. Again, if the noble Earl could give some comfort there, it would be much appreciated.
It is also important that the National Health Service recognises the importance of its role in supporting, developing and encouraging research. That is partly to do with the appointment of academic clinicians within the National Health Service, partly about a willingness to accept that it is important for clinicians to take part in research and also about the importance of ensuring that individual bodies in the NHS have good processes for offering opportunities for clinical trials. Any positive messages that the noble Earl could give on that would be appreciated.
On the private sector, if the Government are to develop a market in the NHS, what obligation will there be on private companies to maintain and support research if they win contracts to provide services to patients? I attended the launch of the Clinical Practice Research Datalink, at which the noble Earl spoke and which I thought was very impressive. How does he think this will link to the work of the Health Research Authority? I was very taken with the potential to use such a wide database of anonymised information, which the NHS can provide. The issue that arose from that debate and that launch is whether we are really able to make the most of the opportunity that is being given.
My final point brings me to value-based pricing. My understanding is that the Government still intend to introduce value-based pricing. I express again to the noble Earl my reservations about the impact of that on flexibility within the pharmaceutical industry and the pricing structure, which might then have an impact on their willingness to invest in R&D in this country. The Department of Health, I understand, is still a sponsor of the pharmaceutical industry. It is, of course, always torn; there is always a tension between the cost of drugs to the NHS and sponsorship of the industry. I hope that we are not going to see short-term decisions taken in relation to the cost of drugs at the expense of long-term investment in R&D in this country. Value-based pricing is a quite complex and technical subject, but it is important that there is transparency about the decisions that lie behind a move to value-based pricing and its likely impact on the UK as a whole, and not just the cost of drugs to the NHS. I beg to move.
Lord Turnberg
My Lords, the development of the Health Research Authority has been extremely welcome and the research community is very grateful that we have it; it has a number of very important roles in relation to the research ethics committees.
My questions relate to the extension of those functions as it plays out, because, of course, the Academy of Medical Sciences report expected this to apply to rather more than just the ethics committee; they relate to what is planned for it as it moves along. In particular, when is it likely that the ethical approval for the use of patient data—not anonymised data but unanonymised data, if there is such a word—which are currently with the Secretary of State, will come under the jurisdiction of the new authority? My noble friend Lord Hunt referred to the major hurdle that is put in the way of research and which takes time: the problem of getting approval from several health authorities or trusts. At that level, it is unclear whether the Health Research Authority will have any power over that process. I would like to hear more about what is intended for the future, now that we have it set up. I know that there are intentions and I would like to hear more about them.
Earl Howe
The noble Baroness is right to draw attention to that omission in my coverage of these instruments. Of course, she is right that there are many different kinds of research that will involve the HRA in one form or another. I have emphasised only the medical and pharmaceutical elements of the HRA’s remit, because these matters were high up on the agenda of the Academy of Medical Sciences when it produced its report in the context of UK plc.
However, the noble Baroness should bear in mind my remarks about joining up health research and social care research. The HRA will co-operate with various bodies for the purposes of creating a unified approval process, not just for health research but to promote a consistent national system for research governance generally. Where this includes a social care or nursing element, the HRA will work closely with the relevant bodies to promote processes and standards that are consistent with the NHS and social care elements.
Lord Hunt of Kings Heath
My Lords, I thank the Minister for his positive response. I also thank the noble Baroness, Lady Emerton, the noble Lord, Lord Patel, and my noble friend Lord Turnberg for taking part in this interesting debate. I believe that the appointment and development of the HRA is a positive move forward, and of course we support the appointment of a majority of non-execs. The Minister mentioned the appointment of a chair. I do not know whether that is yet in the public domain or whether he has the name to hand, but it would be helpful to know.
I welcome the publication of draft clauses on the establishment of the HRA as a non-departmental public body in due course.
Earl Howe
My Lords, I am happy to inform the Committee, for noble Lords who were unaware of it, that Professor Jonathan Montgomery was appointed chair of the HRA on 11 June, that interviews for non-exec directors will be held on Friday, that interviews for the substantive chief executive were held on 11 June, and that the other executive members will be appointed by the rest of the new board as soon as possible.
Lord Hunt of Kings Heath
My Lords, that is very helpful. On the question of the reduction of the regulatory burden and the Minister’s reference to improving the cost-effectiveness of the whole process of approvals, that of course is welcome so long as patient consent and confidentiality are maintained and research is ethical. There is common agreement on that. I welcome his commitment to streamlining the approach in general for health research. I also welcome the decision by the devolved Administrations to encompass some of the work within the HRA, particularly the work of research ethics committees, which I assume will mean that cross-UK multi-centre trials will be subject to the streamlined process that the Minister has referred to.
On the role of the National Health Service in encouraging research, I take the noble Lord’s point about the NHS Commissioning Board’s statement of intent. I have no doubt that at that level Sir David and his colleagues will wish to support research. I am more concerned about the individual organisations in the NHS. I do not think that all NHS bodies quite realise the importance of research not only to patients but to UK plc. Anything that can be done to encourage the NHS to recognise that importance is vital. Sometimes that might mean the practicalities of recognising that their clinicians need time to take part in research activities. At a time when the NHS is having to find large efficiency savings, that may not always be welcome to chief execs of NHS organisations or to clinical commissioning groups. None the less, it would be disastrous if practising clinicians in particular were dissuaded or prevented from taking part in research activities. Again, messages on that matter from Ministers and the NHS Commissioning Board are vital.
Academic health science networks, particularly those outside London, are an important development. They will, I am sure, enhance research efforts. Again, the more support that can be given to them, the better. However, it is important that those networks focus on research—there has been some indication that almost everything about their intent is being put into the bath. One needs to come back to the fact that they are about enhancing our research capacity in the interests of the quality of patient services.
I agree with the Minister that the CPRD is a major step forward. We are uniquely attractive, but can we translate that into research money coming to the UK for what undoubtedly can be offered?
The Minister knows that I have always been sceptical about value-based pricing. He said that there was much to do. I urge him and his department to take their time on this matter. The PPRS allows industry flexibility to set the price within a profits cap. Although the UK is not a great purchaser of branded pharmaceuticals globally, the fact that it is able to set a price has an influence on price throughout Europe. My concern is that taking that away might have an impact on industry’s willingness to invest in R&D in this country, given that we so are slow to take up innovative new medicines. We developed NICE to encourage the health service to do that, and it is still a struggle because unfortunately the default position of the NHS and of clinicians is to be slow to invest in and agree to innovation.
If value-based pricing can encourage the NHS towards innovation in the way that the Minister suggests, that is of course to be welcomed. However, looking more generally at the impact of research, we do not seem yet to have a philosophy that goes hard on innovation where it can definitely improve the quality and outcome of patient care. That is to do partly with the conservative nature of clinicians in the UK and partly, probably, with the mindset of finance directors in the NHS. I know that the noble Earl is the Minister for Innovation and that he is wrestling with those issues. It is very important when we look at both research and value-based pricing that we encourage the NHS as both commissioner and provider to do everything that it can to take advantage of the huge amount of innovation that takes place in this country on the back of a fantastic resource in life sciences, in our universities and in the medical devices industry. Overall, we have had a very good debate and I am glad to support these statutory instruments.