Health and Social Care Bill

Lord Kakkar Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Walton of Detchant]

I support the amendment and will make a point about costs. As I said last week in a debate on education and training, since the health service began, the actual financial consequences of training specialists in all branches of medicine—surgeons, physicians, psychiatrists and all other specialists—have been the responsibility of the National Health Service. Many of us will remember the days of SIFT—the service increment for teaching—a financial increment that was given to hospitals and other organisations that provided postgraduate training at the same time as training undergraduate students. I have, I believe, an assurance from the Minister that that process is going to continue, which is extremely welcome. So I am not speaking primarily about finance.

However, I want to raise a point with the Minister that was touched on only superficially in the very helpful debate we had last week where the Minister tabled a series of very important and constructive government amendments and gave a number of very crucial assurances. I particularly want to raise the interrelationship between the health education authority and the regulatory authorities, which has not yet been clarified. The Explanatory Notes mention the importance of Health Education England working with professional regulators. I shall refer to the General Medical Council as an example because I was its president from 1982 to 1989, and before that, for seven years, chairman of its education committee. The fundamental point is that under the Medical Act, the General Medical Council’s education committee has the responsibility of ensuring,

“high standards of medical education and co-ordinating all stages of medical education”.

It is the regulator. If a new medical school is created, it has the authority to inspect it and consider whether its curriculum is sufficient. It has the authority to inspect the qualifying examinations of the medical schools in order to make certain that they are achieving an appropriate standard.

The fundamental point is that the GMC and the other regulators are not just stakeholder groups. Their statutory powers,

“provide independent assurance to patients, the professions and the service that national standards apply across the UK both in terms of the quality of medical training and the outcomes it produces”.

Of course, the important difference here is that Health Education England applies only to England, whereas the GMC and the other regulators are responsible for the oversight of education across the entire United Kingdom. What I seek from the Minister—formally, if I may—is an assurance that the activities of Health Education England will not usurp or attempt to usurp any of the statutory responsibilities of the regulatory authorities, which are already enshrined in law.

[Lord Kakkar]

My Lords, I support Amendment 13 in the name of my noble friend Lord Patel and Amendment 16, which again is in the name of my noble friend and to which I have added my name. This is the first time that I have spoken at the Report stage of the Bill and I remind noble Lords of my entry in the register of interests as professor of surgery at University College London, consultant surgeon to University College London Hospitals NHS Foundation Trust and fellow of the Royal College of Surgeons of England, which is one of the royal colleges that has decided critically to engage with Her Majesty’s Government with regard to the further passage of this Bill through its parliamentary stages.

The reason why there is such anxiety among so many bodies associated with the practice of medicine in our country as regards education and training is in no small part due to the fact that there was terrible trouble and a very unfortunate turn of events associated with the medical training application system—MTAS—some years ago. As a result of that, all those who have some responsibility for education and training are obliged to pay particular attention and scrutiny to any provision concerning the future of education and training for all healthcare professionals in our country.

Amendment 13 in the name of the noble Lord, Lord Patel, is very important. It brings together all those with responsibility for the commissioning and provision of healthcare under a single obligation to respond to the responsibilities of the Secretary of State for Health with regard to the specific question of education and training. There can be no doubt that all those who wish to engage in the provision of a national health service must be alive to their responsibilities in this regard. To have that commitment in the Bill would provide a very important opportunity to allay the considerable anxiety that might exist among the regulatory bodies, such as the General Medical Council, which the noble Lord, Lord Walton, mentioned, and the medical royal colleges to ensure that they have done their duty in terms of protecting a structured process for the delivery of education and training for the entire healthcare workforce.

Amendment 16 is very important because it deals with the establishment of Health Education England. At this stage, it is important to recognise the very proper and constructive way in which the Department of Health, the Secretary of State for Health and the Minister have engaged with the professional bodies with regard to education and training. It has been a remarkable process of discussion, which resulted in the important government-sponsored amendments that we were able to debate last week on the first day of Report and the important recognition that in creating Health Education England there is an obligation to bring together all the resources available for undergraduate training in the healthcare system and for postgraduate education and training.

Is it absolutely the intention that all three funding streams—SIFT, MADEL and MPET—will come together as a single budget for Health Education England at the time of its creation and that that budget will be spent by HEE through local education and training boards to engage a variety of providers at a local level in discharge of responsibilities for education and training in a postgraduate sense and to maintain the additional resources available in clinical environments—primary, secondary and tertiary care—for the continued undergraduate education of our medical and dental students and other healthcare professionals?

It is also important for your Lordships to understand how Health Education England will be composed. What will be the process for appointment to HEE once it is established, potentially first as a Special Health Authority later this year? Will the composition and membership of HEE include representatives from medical royal colleges and other organisations, such as the regulators and so on? Will HEE be responsible for the appointment of the chairs of the local education and training boards? There is particular concern with regard to the need to have independent chairs of local education and training boards. It is vital not only that at the local level these boards have appropriate provider, employer, patient and trainee representation, but also that their deliberations are conducted in a transparent fashion. This can be done only if the chairs are indeed independent of all the interested parties.

There is a further question with regard to the relationship between local education and training boards and the proposed academic health science networks. Do Her Majesty’s Government have a view about that? It is particularly important because a process is ongoing at the moment for the designation of 12 or so additional academic health science networks in the country. Those broad networks will have an opportunity to have substantial employer and provider representation, encompassing universities and NHS providers. It would be useful to understand their potential relationship with local education and training boards. Then there is the question of the future of postgraduate deans. Again, this is a matter of detail, but it is important in understanding how the structure of independent deaneries will work in a future system and, in particular, what relationships the universities will have at the level of provision of local training and education.

I think it is well recognised in your Lordships’ House that the Government have come a very long way on the question of education and training, which is much appreciated, but some further detail is important to allay anxieties and to ensure that the best possible advice, expertise and knowledge can be brought to bear in creating a new system for education and training for the future that does not result in unintended consequences and some of the disastrous outcomes associated with the previous MTAS scheme.

Health and Social Care Bill

Lord Kakkar Excerpts

Wednesday 21st December 2011 Lords Chamber

Moved by

[Lord Kakkar]

354: After Clause 301, insert the following new Clause—
“Review of the operation of the Act
(1) Annually, the Secretary of State shall review the operation of this Act, publish a report on the review and lay the report before Parliament.
(2) If required by a Committee of either House, the Secretary of State must make available to both Houses of Parliament information necessary for the operation of this Act to be scrutinised.”

[Lord Kakkar]

My Lords, I rise to move the amendment in my name and that of my noble friend Lord Patel, who sends his apologies to the Committee. He is strongly enthusiastic about the amendment but regrettably cannot be here. The amendment would introduce a new clause to provide for a review and scrutiny of the operation of the Act.

The noble Earl, in responding to the Second Reading debate, was kind enough to deal with the matter I had raised regarding post-legislative scrutiny. Your Lordships’ House has determined that careful post-legislative scrutiny should be considered because it is of value and importance for all complex Bills. The detailed Committee stage which has attended the passage of this Bill in your Lordships’ House has clearly shown that there has been considerable anxiety about the potential implications and operation of what will eventually be the Health and Social Care Act. It is only right that a Bill of this complexity should be subjected to post-legislative scrutiny. This can be undertaken only if appropriate information is made available to both Houses of Parliament.

The purpose of exploring the opportunity for the Government to consider the issue at this stage is to determine whether the noble Earl—in addition to confirming the Government’s commitment to scrutiny of the Act, if Parliament decides to pass it—would consider initiating post-legislative scrutiny earlier than the three years which he kindly indicated when answering the Second Reading debate. A range of between three to five years is the normal period in which scrutiny might be considered for an Act once Royal Assent had been received. However, in view of many of the issues that have been raised, it would seem appropriate to attend to the matter of scrutiny earlier.

It might be argued that having scrutiny one or two years after enactment would be a little too early, but many of the new mechanisms and arm’s-length bodies being established to deliver the purpose of the Bill are already available in shadow form. For example, the chief executive-designate of the NHS Commissioning Board has already been appointed. The chairman has been appointed and the board is starting to make other important appointments and to deal with its structure so that when the Act comes into operation the board will be in a position to start its work. It means that, after a year, we should all be able to perform reasonable scrutiny.

With regard to clinical commissioning groups, pathfinder commissioning groups have already been established. They are starting to develop the alliances and relationships in their areas and localities that will allow them to become fully operational at the time that the Bill proposes. Therefore, the period of finding their feet has already been established.

A commitment to both rigorous scrutiny after enactment and early, formal post-legislative scrutiny will allay a lot of anxieties and provide your Lordships and the other place with reassurance that if there were to be unintended consequences associated with the Bill, they may be identified earlier. If other elements of legislation were required to ensure that the Bill’s objectives could be fully achieved, given that the Government are considering a further Bill to deal with matters such as education, research and social care in the next Session, scrutiny of the Bill could inform what legislation might be added to that Bill. I beg to move.

[Lord Hunt of Kings Heath]

I rise to support the noble Lord. Earlier today, he made a very pertinent point on Lords reform, and this one seems equally pertinent. Before I do so, perhaps I may take this opportunity to say that my noble friend Lady Gould has just vacated the Deputy Speaker’s seat. That was her last session, and I wanted to say to her—I am sure on behalf of the whole House—what a wonderful job she has done. She has accompanied us through many pieces of legislation, often very late at night, always with tolerance and very efficiently, as befitting a former fearsome organiser of the Labour Party, if I may say so.

--- Later in debate ---

I hope that the spirit of the noble Lord’s proposal is one that the Government have addressed and indeed met, and that I have provided at least some reassurance to him to enable him to withdraw his amendment.

[Lord Kakkar]

My Lords, I thank the noble Earl for his response, which I think recognises the fact that there will be a need continually to provide reassurance that the purpose of the Bill is not attended by unintended consequences, and an important part of that will be thorough post-legislative scrutiny. However, on the basis of the Minister’s response, I beg leave to withdraw the amendment.

Amendment 354 withdrawn.

Health and Social Care Bill

Lord Kakkar Excerpts

Monday 28th November 2011 Lords Chamber

[Lord Harris of Haringey]

My Lords, this is an extremely important group of amendments, but I hope it is, by and large, an uncontroversial one. The Government say they are committed to patient involvement and patient choice. They say they want to see all decisions being taken with the patient rather than simply by professionals. These amendments all contribute to achieving those objectives. It is worth distinguishing between a number of different elements in terms of patient involvement. There is the involvement of the individual; there is the involvement of the specialist group of patients; and there is the collective involvement of patients. I hope that these amendments provide a means of addressing all three groups.

The involvement of the individual patient—specifically included in Amendment 121 and in Amendment 124, to which the noble Lord, Lord Patel, has just spoken, on access to medical records—is an example of where it is vital to write this into the Bill if you are serious about the Government’s mantra of, “No decision about me without me”. The experience is that, where patients are involved in all decisions about their medical care, better decisions are made and compliance with them by patients is far fuller than would otherwise be the case. Therefore, requiring patients to be involved in every decision affecting them is part of delivering a good and effective health system. My experience mirrors that of the noble Lord, Lord Patel, because the experience of patients’ organisations is that, where patients are given charge of their medical records, they look after them extremely carefully—often much more carefully than under the old system of trolley-loads of not dog-eaten but dog-eared files in hospitals—and are much more likely to be protected by the individuals concerned.

I have put my name to Amendments 123, 192 and 205, which talk about the involvement of healthwatch organisations. Amendment 123 places a duty on the board to promote the involvement of local healthwatch, and it is important that the board sets the tone for the NHS in the way in which healthwatch organisations are expected to be involved at every level. It needs to come from that level. Amendments 192 and 205 relate to the duties of clinical commissioning groups. There is a gap in the Bill, because it seems to be implied that commissioning groups will involve patients and healthwatch organisations, but I am not sure that that is stated explicitly, which is why those amendments are so important.

However, the reason why it is helpful to engage healthwatch at every level within the NHS is the support function that local healthwatch organisations and HealthWatch England will provide to the three levels of patient involvement that, as I have stated, are so important. That is because, as local healthwatch organisations and HealthWatch England, they will have an understanding of the way in which the health service is functioning. They will have an understanding of the pressures on the health service, commissioning groups and local providers and they can therefore support specialist groups of patients with a particular knowledge of their condition in how to exercise their influence most effectively within the organisation. It is those specialist groups of patients who will be tremendously valuable in improving the quality of service. They will often have far more knowledge about the way in which their condition operates than even the clinicians who support them—maybe not the specialists but general practitioners and so on—because they have that detailed knowledge and experience, day in and day out, particularly when they have a chronic condition that may continue over many years. That involvement is crucial in terms of the quality of decision-making, but it is important that they are supported by organisations such as healthwatch, which will then be able to put a context to the way that the local NHS is functioning.

Finally, there is the critical issue of the collective involvement of patients in decisions about the disposition and organisation of health services at a local level. That will be best articulated through local healthwatch organisations. This will be about what best serves the local community and what meets the differing needs within a community. The only simple mechanism by which that can be achieved is through something such as local healthwatch organisations. That is why such involvement must be built into the commissioning process, and the board must lay down how crucial this issue is crucial to the determination of services.

[Lord Kakkar]

I shall speak to Amendment 198 in my name and that of my noble friend Lord Patel. It would impose a duty on clinical commissioning groups to consult relevant academic bodies in their area, including potential future academic health partnerships. I remind noble Lords of the entry in the Register of Lords’ Interests on my involvement in University College London Partners—one of the five academic health science systems currently designated by the Department of Health.

Academic health science partnerships can take a variety of forms but are all based upon a simple principle: the delivery of healthcare should be combined with high-quality teaching, training and research to drive the highest possible clinical standards achievable. Indeed, throughout healthcare systems in the world it is well recognised that alliances between the academic and service-delivery elements of healthcare help us to achieve the best possible clinical outcomes. That view has been recognised by the Department of Health in the designation of the five current academic health science centres in our country.

A number of other initiatives are moving forward at the same time as this Bill and are considering a broader role for academic health service partnerships. These include the ongoing review, conducted under the auspices of the chief executive of the National Health Service, which is looking at innovation in the NHS and how that might best be promoted as we move forward. It is possible that that innovation review could propose a broadening of the current five academic health science centres to a larger number of academic health partnerships that would have responsibility for the promotion of innovation, and would ensure that the results of research and other innovative ways of delivering care are more broadly and rapidly disseminated across the NHS. That dissemination of best practice and innovation could also be used to create an environment in which to stimulate economic growth. That is an important additional opportunity that the NHS and academic medicine have for our country.

There is also the detailed discussion that has taken place in Committee, outside the Chamber, and in the work of the NHS Future Forum with regard to future arrangements for education and training. In those discussions, there is a recognition that academic health partnerships should play an important role, not only in the configuration of Health Education England but in local arrangements, potentially with academic health science partnerships playing an important role in defining the structure and core of local education and training boards.

Therefore, at least two initiatives, in addition to the mechanisms and structures proposed in the Bill, will turn to partnerships between the NHS, academic institutions and other academic elements in the delivery of healthcare in our country. The purpose of my amendment is probing in order to try to understand what view Her Majesty's Government take of the potential future role of academic health partnerships and what relationship the Government foresee with regard to clinical commissioning groups working at a more local level with potential academic bodies and partnerships in their vicinity. This is particularly important because we heard today in Committee about the vital importance of clinical commissioning groups being appropriately informed. One of the important roles that academic health partnerships may play in the future is providing that kind of information to better inform the decisions that local clinical commissioning groups take. With the vast amount of evidence that academic health partnerships will have in their structures, bearing in mind that these partnerships are broad and include not only academic institutions but a variety of different service providers brought together with a common purpose, it would be peculiar if clinical commissioning groups did not at least make themselves informed of their information and expertise. It would also be peculiar if, in creating a framework and structure for education and training based around a partnership between academic elements and service and provider elements at local level in local education and training boards, clinical commissioning groups did not avail themselves of the opportunities from that.

Previously in Committee, I proposed to the Minister that clinical senates may be constituted around these broad partnerships of academic health service alliances. There was some concern that this might represent a conflict of interest. However, the very broad nature of these partnerships, with multiples of potential providers as seen in the current five academic health science systems, potentially overcomes the risk of conflict of interest. They provide a natural structure and environment to serve the function of clinical senates, to serve the function of the core of local education and training boards, to provide a useful source of information to clinical commissioning groups with regard to understanding the best pathways of care available in their regions and to promote clinical outcomes, patient safety and patient experience. They also provide a very important basis to serve the objectives of the current innovation review to promote not only best practice but the benefits of economic growth associated with innovation and implementation with regard to healthcare.

I would like to ask the Minister about Her Majesty’s Government’s view of the future role of academic health partnerships, with specific reference to clinical commissioning groups, to understand whether there is an intention that the current five academic health science centres are more broadly expanded into health academic health partnerships. If they are, how will arrangements be made in future to ensure that clinical commissioning groups avail themselves of the great expertise and knowledge that will be available in such partnerships?

Health and Social Care Bill

Lord Kakkar Excerpts

Monday 28th November 2011 Lords Chamber

[Baroness Emerton]

I rise without notes, which is very unusual for me, to thank the Minister very much indeed. There is anxiety about education among nurses, midwives and particularly community nurses—they are getting very agitated. Therefore, I am absolutely delighted that we shall see something soon.

[Lord Kakkar]

My Lords, I, too, want to congratulate the Minister on his very helpful statement on education and training which is warmly welcomed not only in this Chamber but I suspect broadly through the medical and healthcare professions. This issue has caused tremendous anxiety. To provide clarity and the opportunity for it to be addressed in a constructive way on Report is genuinely welcome.

[Lord Rooker]

I, too, welcome the Minister’s statement. He will know that I have no qualifications in this but I have raised the issue of nurse training twice in the House this year—in the debate in March and at Question Time in October. I just want a point clarified. The amendment of the noble Lord, Lord Patel, refers to the board promoting but,

“having taken note of the responsibilities of the regulatory authorities”.

Does the Minister include possible changes and recommendations to the regulatory authorities in terms of their aspect of education and training?

Health and Social Care Bill

Lord Kakkar Excerpts

Monday 14th November 2011 Lords Chamber

Moved by

[Lord Kakkar]

47A: After Clause 5, insert the following new Clause—
“Health Education England
(1) The Secretary of State shall establish a body to be known as Health Education England, answerable to the Secretary of State and charged with the responsibility of ensuring and maintaining high standards of education and training of the NHS healthcare workforce.
(2) In pursuit of that responsibilities, Health Education England shall have due regard to—
(a) the responsibilities of the universities and the Royal Colleges and of other bodies involved with education and training;(b) the statutory responsibilities and authority of the regulatory bodies operating in the healthcare field; and(c) the necessity of ensuring that commissioning groups, foundation trusts, general medical practices and other qualified providers offer appropriate facilities for education, training and research.”

[Lord Kakkar]

My Lords, I beg to move Amendment 47A, which stands also in the names of my noble friends Lord Walton of Detchant and Lord Patel, who, regrettably, cannot attend the Committee this afternoon.

In moving this important amendment and speaking to Amendment 133 in this group, I wish to recognise the important statement made by the Minister on the first day in Committee on 25 October, when he made the case for an amendment to place a duty on the Secretary of State to exercise his function so as to secure an effective education and training system. This is an important and much welcomed recognition of the fact that education and training is absolutely critical to the delivery of healthcare.

The Minister will recognise that, without an appropriate system of education and training, whether it be for a surgeon or a physiotherapist, a neurosurgeon or a nurse, a physician or a radiographer, or indeed a psychiatrist or an occupational therapist, patients will be put at risk. The important gains that the Bill proposes in terms of improving clinical outcomes will not be achieved and vital resources will be squandered.

Education is at the heart of delivering effective healthcare. The professions, the public and indeed government have had previous experience of the introduction of changes in education and training with modernising medical careers that cause severe anxiety and disruption and have made all exceedingly sensitive to the importance of ensuring that any change in systems in the future provides the best opportunity for the patients who have to use health services in our country.

It is well recognised that Her Majesty’s Government wish to deal with education and training in a responsible and sensitive way, and it is broadly recognised that the changes proposed by the Bill raise anxieties about how education and training might be discharged in the future. In this regard, the commitment of the Government to seeking further clarification and the views of the NHS Future Forum is an important initiative. However, it would be impossible for the Bill to proceed unless there were absolute clarity with regard to education and training.

The intention is that employers will play a much greater role in the future discharge of education and training functions, and there is no doubt that the education and training system must be sensitive to the needs of the service and, most of all, to the needs of patients. We must also ensure, however, that two vital issues are addressed. The first is the ongoing interaction and engagement with the academic sector, universities and educational expertise. It would not be right for employers alone to determine the nature and content of curricula associated with the training of the healthcare workforce. Secondly, notwithstanding that there will be a second Bill—most likely in the next Session of Parliament—to deal with health workforce education and training, it is critical that enough detail is associated with this Bill to ensure that we can continue with confidence in planning and organising the arrangements for the healthcare workforce to be appropriately trained and educated.

--- Later in debate ---

[Earl Howe]

My Lords, the Government are clear that the education, training and continuing development of the healthcare workforce are fundamental in supporting the delivery of excellent healthcare services across the NHS. I am very pleased that so many noble Lords here today share that view. It is certainly the Government’s view. I very much welcome what have been excellent comments on this subject.

Amendment 47A, tabled by the noble Lord, Lord Kakkar, seeks to insert a new clause placing a duty on the Secretary of State to establish a body called Health Education England. Similarly, Amendment 47B, tabled by the noble Lord, Lord Warner, seeks to place a duty on the Secretary of State to “provide or secure” an education and training system and to establish Health Education England to take responsibility for these education and training functions. Amendment 47B also specifies that the budget for education and training should be calculated on the basis of total health service expenditure and,

“should be no less than the level of expenditure on education and training at the time of Royal Assent”.

The Government recognise the importance of having an effective education and training system for the healthcare workforce. The NHS invests approximately £4.9 billion centrally in the education and training of health professionals. It is vital that there is a robust system in place to manage this investment wisely, with clear lines of accountability to Parliament. I would point out to the most reverend Primate that that is exactly why we tabled Amendment 43 which, as the Committee will recall, we debated in our first session. The Committee has already approved that amendment, which is now in the Bill and which says that there is a duty on the Secretary of State to exercise his,

“functions … so as to secure … an effective”,

education and training system. It is perhaps worth my flagging up that that amendment has received a positive response from the British Medical Association, which, in the current circumstances, is a rather remarkable fact. I reiterate that it is designed to ensure that the healthcare workforce has the right skills, behaviours and training to deliver a world-class health service. But we want to put flesh on the bones here. We recognise the need to do that and I therefore undertake that we will publish detailed proposals for the education and training system ahead of the Bill’s Report stage where we will describe how this duty will be enacted in practice. However, there are parts of our plans that I can set out now.

It is vital that we ensure a carefully managed transition into the new system and protect staff and students currently undertaking training. We are taking a number of actions in developing the new system to achieve this that I would like to highlight. The Future Forum recommended that the establishment of Health Education England should be expedited to provide leadership and stability in the system. We agree and it is heartening to see that many noble Lords support this course of action. We have appointed a senior responsible officer to drive this forward and inject pace into the design and development of Health Education England.

To respond to the noble Lord, Lord Owen, while I do not share in any way his analysis of the future prospects of the next health Bill, he was right on one matter: we plan to establish Health Education England as a special health authority in 2012. This will enable it to take on some of its functions from October 2012 and be ready to be fully operational from April 2013. There is not and there will not be the chasm that the noble Lord referred to. Noble Lords will have a chance to scrutinise the establishment order and regulations to set up Health Education England as a special health authority when they are laid before Parliament in early summer 2012. Lest there is any doubt on the matter, I reassure the Committee that it is our intention that Health Education England should form excellent partnerships with a full range of bodies involved in the planning, commissioning, provision and quality assurance of education and training.

However, I can say in particular to the noble Lords, Lord Warner and Lord Kakkar, that Health Education England will provide national leadership for education and training, overseeing workforce planning and the commissioning and delivery of education and training across the system. We have been clear about its accountability to the Secretary of State to ensure that, at national level, there are sufficient health professionals with the right skills, education and training to meet future healthcare needs. Providers of NHS services will be expected to meet the obligations set out in the NHS constitution, including the right of recipients of NHS healthcare to be treated with a professional standard of care by appropriately qualified and experienced staff. Health Education England will hold responsibility for the management of the NHS multi-professional education and training budget, or MPET. To ensure that this budget is sufficient to support the development of the future NHS workforce, equipped with the right skills, our intention is to base the size of this budget on the needs of the service, supported by robust analysis of local workforce and education and training plans.

The question of postgraduate deaneries was raised in particular by the noble Lord, Lord Turnberg. The SHAs will continue to be accountable for postgraduate deaneries until 31 March 2013. Securing continuity for the work of the deaneries will be a key part of a safe transition. It is expected that deans and many of their staff will continue to take forward the work of deaneries with an emphasis on a new, multi-professional approach in the new system architecture.

To pick up one point made by the noble Lords, Lord Kakkar and Lord Turnberg, we also want to see stronger partnership working between postgraduate deaneries and universities. Further work is under way on the detail of these arrangements, with the right accountabilities for the quality of education and training lying with Health Education England and the professional regulators.

I was asked by the noble Lord, Lord Kakkar, about ring-fenced funding. As he knows, the MPET budget currently funds the education and training of the healthcare workforce and it is the responsibility of SHAs to invest the budget appropriately. We have proposed transparent systems to ensure that organisations receiving MPET funding under the future arrangements are held to account for using it for the education and training of the workforce.

The noble Lord also asked whether there will be a requirement to engage fully with academics. I partly covered that point but I emphasise that the new system presents a golden opportunity to build stronger links between the NHS and the academic health sector and to strengthen the educational foundation for research and innovation. Health Education England will ensure that research capability and capacity is maintained and it will forge strong partnerships with academia. Health Education England will work with the royal colleges, the Academy of Medical Sciences, regulators, universities and service providers to ensure that the needs of healthcare delivery are reflected in developing curricula in the context of the statutory responsibility of regulators.

The noble Lord, Lord Turnberg, asked me about standards. I reassure him that standard-setting will be the role of Health Education England at a national level, and this is in addition to the important role that the professional regulators play in this area.

However, despite the progress that we have made, a lot more work has to be done to get these important arrangements right. In my view, that is why it is important that we do not try to amend the Bill in a way that later turns out not to be appropriate. The Future Forum is now leading a second phase of engagement on education and training, focusing particularly on the need for greater flexibility in training, variation in standards and quality, and the need for stronger partnership working between education, academia and service providers. I take this opportunity to mention that tomorrow I am hosting a seminar with Professor Steve Field, chair of the forum, and I welcome your Lordships’ involvement.

I appreciate that the service is waiting for detailed plans for the education and training system to be finalised and published, and I have two promises that I can make on this. The first is the one to which I have already alluded. Once the Future Forum has concluded its work, and prior to Report, the Government will publish more detail on the changes to the workforce planning, education and training system. That, incidentally, will include more detail on postgraduate deaneries. Secondly, it is likely that primary legislation will be required to support the continuing development of the education and training system, including establishing Health Education England as a non-departmental public body, but we think it is important to spend time to make sure that these arrangements are correct rather than legislate at this stage. However, I can tell the Committee that we intend to publish draft clauses on education and training for pre-legislative scrutiny in the second Session in the same way as on research. This approach will enable us to ensure that the legislation is fit for purpose and that it allows additional opportunities for parliamentary scrutiny of the legislation. I hope that this undertaking will be welcome to noble Lords and will indicate the Government’s strong desire to provide maximum clarity on these matters at an early stage. Therefore, I hope that noble Lords will feel able not to press those particular amendments.

The noble Lord, Lord Kakkar, and the noble Baroness, Lady Finlay, have tabled remarkably similar amendments—Amendments 133 and 199A respectively—also on the subject of education and training. The noble Lord, Lord Kakkar, wishes to impose a duty on the NHS Commissioning Board to,

“promote education and training of the health care workforce”.

The noble Baroness, Lady Finlay, wishes to introduce a similar duty on clinical commissioning groups. As I have indicated, the Government’s intention is to delegate responsibility for education and training to healthcare providers. They are at the front line of service delivery and are best placed to understand how the workforce needs to develop and respond to the needs of patients.

Responsibility for education and training is of great importance to employers and the various professional bodies that the noble Lord, Lord Kakkar, mentions in his amendment, but commissioners will also have a role. I agree entirely that education and training needs to be effectively linked with the wider system. I am aware of concerns voiced by the royal colleges and professional bodies on precisely that matter. I wish to reassure the Committee that I recognise the vital interrelationship between education and training, and commissioning decisions. That is exactly why national and local education and training plans will need to respond to the strategic commissioning intentions set out by the board and clinical commissioning groups.

Similarly, in commissioning decisions there will be a need to consider the implications for education and training—it works both ways. The NHS Commissioning Board has to work closely with Health Education England and it will be a mutually supportive relationship. Indeed, this will be a prime example of the co-operation duties that will apply to the board and to other NHS bodies. Commissioners must also promote and have regard to the NHS constitution, which of course contains the pledges that I have already referred to.

I do not intend to speak for very much longer but there are a couple of points that I ought to cover. A number of noble Lords pointed to the lack of medical school involvement in the set-up of local arrangements. I need to be clear about this: the new arrangements are underpinned by the desire to strengthen both the provider voice at the local level and the role of professionals and education providers. We envisage that one of the functions of local bodies will be to ensure strong partnerships with universities and medical schools. Providers of services will have to work in partnership; they cannot just sit alone and ignore everybody else. The form of the local provider-led arrangements is still being developed. More details will be available prior to Report, but I have stressed the links that we envisage with academic colleges at a local level.

I hope that I have indicated that, contrary to the statement from the noble Lord, Lord Warner, that within the modernisation agenda we somehow forgot about education and training, this is not at all the case. As I mentioned when we debated this before, this has been an active programme of work ever since the general election. It is a complex issue and we want to get it right. My noble friends Lord Ribeiro and Lord Mawhinney were spot on in their judgment on this. We are taking action now. We are not losing time over this.

To sum up, we have made provision for education and training in the Bill. We will publish our detailed proposals before Report and we will publish draft clauses on education and training for pre-legislative scrutiny in the second Session. With those assurances, I hope that the noble Lord will feel able to withdraw his amendment.

[Lord Kakkar]

My Lords, I thank the Minister for his very detailed and extensive response, which is genuinely welcome. He has dealt with a number of the issues that were covered in this important debate. The confirmation that Health Education England is to be established as a special health authority and that a senior responsible officer has been appointed to drive forward its development at a pace to ensure that it is in a position to fulfil its important obligations and functions is a very welcome announcement. I think it will provide considerable hope that the question of education and training can be fully and appropriately dealt with in such a way that any future legislation can build upon an established structure that has already given confidence to those responsible for education and training that these matters can be properly dealt with.

--- Later in debate ---

[Earl Howe]

Before the noble Lord decides what to do with his amendment, I should say that I did not wish in the least to imply that this debate was inappropriate in any way. If I did, I apologise. If I may correct one thing that he said, the draft clauses for pre-legislative scrutiny will come forward in the next Session of Parliament rather than before Report. However, we will be publishing much more detail before Report about what our plans will look like.

[Lord Kakkar]

I welcome those comments. It was not a criticism made by the noble Earl about this but by other noble Lords; there was a suggestion that it was not appropriate to discuss education and training in any detail at this stage. These were probing amendments, designed to provide Her Majesty’s Government with the opportunity to address issues, to allay concerns and to allow for further appropriate and constructive evaluation of this matter in the Bill in such a way that noble Lords could fulfil their function of scrutiny and revision to ensure that the best possible Act is finally delivered for the people of our country. With those comments, I beg leave to withdraw the amendment.

Amendment 47A withdrawn.

Health and Social Care Bill

Lord Kakkar Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Kakkar]

My Lords, I would like to ask the Minister what the potential relationship is between clinical senates and an expansion of academic health science networks, or academic health partnerships, that may be proposed from the ongoing chief executive of the NHS review of innovation. It is suggested that that review may endorse an expansion of the current academic health sciences network. I must remind noble Lords of my own declaration and involvement in University College London Partners academic health science centre.

As I understand it, the purpose of clinical senates is to provide support in helping clinical commissioning groups to draw on expertise available from a broader group of clinicians and disciplines within their region to help inform ultimate clinical commissioning decisions. However, if the proposal that the current network of five academic health science centres is expanded into a network of broader academic health partnerships, serving a population of about 3 million to 4 million for each partnership, within those partnerships there would be a broad range of academic and other disciplines. They would be represented in a health partnership or network fashioned on the current academic health science centres to be able to deliver expertise and advice on commissioning and provide the opportunity to aid in a transformation of health practice pathways of care, to provide a potential home for the education and training functions that will need to be rolled out at a sub-national level, and also promote interest with regard to research and innovation.

Under the circumstances, if academic health partnerships were to be expanded and promoted as a result of the ongoing innovation review, could not the responsibility suggested for clinical senates be undertaken by the academic health partnerships and current academic health science centres? This would avoid the need for yet another grouping or layer of bureaucracy to be created within the systems responsible for the commissioning and provision of health services.

[Baroness Williams of Crosby]

My Lords, if I may, I will pursue what has been raised by the noble Lord, Lord Kakkar, and also, in some ways, by the point made by the most reverend Primate the Archbishop of York. I could not help thinking that perhaps protesters count among the networks and the people responsible for running St Paul’s count as part of the commissioning group. With that in mind, I will pursue also what was said by the noble Lord, Lord Hunt. If you look at his Amendment 224A(6), he helpfully refers to the clinical senate having,

“the function of establishing and maintaining a system of clinical networks”,

in the area. I think that should be applauded. I am very impressed by the way in which networks at their best not only extend information very widely among patients with a chronic condition but bring the patients into the discussions about what should be done in their situation. It becomes a huge educational and, indeed, morale-boosting process. So on subsection (6) I think that the noble Lord, Lord Hunt, has put his finger on something that could be very important and where the clinical senate would give clinical backbone to the deliberations and thoughts of the clinical network. That is almost, I suppose, what we are all trying to achieve.

I am not so clear about subsection (8) of Amendment 224A, where the noble Lord, Lord Hunt, has effectively given the clinical senate something of a veto over the commissioning group. I am not sure that that is wise, as that plays right into what the noble Lords, Lord Patel and Lord Kakkar, were saying about creating yet another layer of bureaucracy. I think that would be unhelpful and might indeed feed into a certain self-importance on the part of people who call themselves senators, whether clinical or merely political.

I would like to ask the Minister, bouncing off the amendment from the noble Lord, Lord Hunt, whether, looking through that amendment, he does not find parts of it that are helpful, useful and constructive. It would make a clinical senator a significant part of the whole structure of the relationship between patients and clinicians. Whether he needs to press ahead with provisions that would bring in the senate as a requirement of the decision-making process of the commission is much more questionable. I am playing a kind of ping-pong, in which the ping of the noble Lord, Lord Hunt, has to go to the pong of the noble Earl, Lord Howe.

--- Later in debate ---

[Lord Rea]

My Lords, following the noble Baroness, Lady Finlay, I raised this issue briefly on the second day of Committee. I felt, however, that the Minister only gave a partial answer. CCGs must have an “area” as set out in their constitution, but there seems to be nothing in the Bill which defines the limit of this area or its basis other than that CCGs will cover the registered practice population of the GPs sitting on the CCG. This will result in very untidy boundaries which will interdigitate with a variable number of other CCGs.

However, proposed new subsection (1A) in Clause 10(3) says that a clinical commissioning group has responsibility for other people resident in its area but not registered with a GP—homeless people, rough sleepers, asylum seekers, et cetera. A geographical boundary for those people is therefore implied. Can the Minister say how this boundary is to be delineated? Will it coincide, as my noble friend has suggested, with the local authority, or with the former PCT—which in fact in 85 per cent of cases will be the same as the local authority boundary—or will it have some other basis? There is a strong case for—sorry about this word again—coterminosity with local authorities. They provide many of the services on which GPs depend. In fact, they are an integral part of primary care, such as social services and community health services, and public health, including maternal and child welfare services. They are especially important as, under the Bill, local authorities will all have their own director of public health. There are a number of services which were formerly provided by PCTs on a geographical basis: for example, ambulance and emergency services, genito-urinary medicine clinics, and drug and alcohol services. These are by no means all the services which CCGs will have to commission or co-operate with. What arrangements will be made for the area that these services will have to provide for?

[Lord Kakkar]

My Lords, Amendment 60 is in my name and that of the noble Lord, Lord Patel. It proposes to deal with the anxieties over real and perceived conflicts of interest that might exist in the functioning of clinical commissioning groups. The amendment proposes that:

“The Secretary of State must publish, and may from time to time revise, a code of conduct for all clinical commissioning groups … The code must, in particular, incorporate the Nolan principles …‘The Nolan principles’ means the seven general principles of public life set out in the First Report of the Committee on Standards in Public Life”.

It is important to take the opportunity to explore the issues around potential conflicts of interest and the anxieties that these raise. The reason is very simple. Clinical commissioning groups will be new public bodies. They will have by large measure a large number of primary care practitioners as their membership. Primary care practitioners, GPs, will have responsibility for delivering care and have very special and cherished relationships with their patients in terms of promoting and guarding the interests of their patients. Moving forward, they will have new responsibilities for the commissioning of services. A potential anxiety exists under those circumstances.

For many other statutory bodies in the public sector involved in healthcare, we have dealt with the problem of potential conflicts of interest by ensuring that those organisations and those who serve in those organisations are obliged to conduct themselves in a way consistent with the seven principles of the standards in public life: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. Those seven principles are very powerful indeed.

On 14 April I put a supplementary question to the Minister at Oral Questions about whether clinical commissioning groups would be obliged to follow the Nolan principles. The Minister stated that, since they were going to be public bodies, they would be obliged to do that. As they are new public bodies, many of those that are going to serve in important capacities in clinical commissioning groups will have little experience of public life. Yet they will have very important responsibilities and have to deal with the sensitivities and anxieties of patients, because they will both serve in capacities on clinical commissioning groups and continue to serve as patients’ principal caregivers and primary medical practitioners. We need to find a way of ensuring that those anxieties are overcome.

In many other situations, we have dealt with that through these seven basic principles. Indeed, the Parliamentary Standards Act 2009 was designed to ensure that anxieties over the conduct of Parliament could be dealt with in such a way as to satisfy the public more generally that there was transparency, and that those serving in public life in this Parliament had no doubts about their obligations and responsibilities. The Parliamentary Standards Act 2009 includes a commitment and requirement to adhere to the standards in public life defined in the Nolan principles. I therefore believe it might be an important opportunity to overcome the anxieties that attend the question of potential conflicts of interest in terms of the conduct of clinical commissioning groups for the same approach to be taken with regard to this Bill, and to include a specific reference to the Nolan principles in terms of the conduct of clinical commissioning groups.

Health and Social Care Bill

Lord Kakkar Excerpts

Wednesday 9th November 2011 Lords Chamber

[Baroness Finlay of Llandaff]

In intervening in this interesting debate, I shall be very brief. I simply want the Minister to explain where the levers will be in the commissioning decisions to make sure that the principle of research that is being embedded across all the professions happens, given the multiplicity of providers and, as the noble Lord, Lord Turnberg, clearly outlined, the relative paucity of research in primary care but an increased push for more people to be cared for in the community across all the disciplines involved. A simple example of that is the problem that we now have with antibiotic resistance. There is potential overprescribing, but much of that prescribing is going on in primary care in the management of relatively simple conditions. If those are not researched into, we miss a fantastically important opportunity.

[Lord Kakkar]

My Lords, I support many of the amendments in the group. I do so as a biomedical research and clinical academic, therefore benefiting from many of the opportunities that the current systems for biomedical research in the National Health Service provide.

I start by congratulating Her Majesty's Government on having included for the Secretary of State for the first time in a health Bill responsibilities to promoting research. That is hugely important, because it allows us to secure what has been achieved to date in structures and funding going forward in the National Health Service.

There are, of course, anxieties, which we have heard in this important debate, which need to be addressed. Can the noble Earl provide clarification in three areas, notwithstanding the fact that the Bill already emphasises the responsibilities of the Secretary of State for Health? First, how is it is envisaged that the funding for biomedical research will be protected when that fund moves to the NHS Commissioning Board? Secondly, how will the clinical commissioning groups be responsible for promoting research in future, how will that be supervised by the NHS Commissioning Board, and will any form of instruction or performance measure be included in the supervision that the Commissioning Board provides for clinical commissioning groups?

Finally, how, within the proposed structure of the Commissioning Board, will there be encouragement and support for academic health science centres, as they currently exist, and in the future, potentially, academic health partnerships? They provide the opportunity both to drive forward opportunities for biomedical research to improve healthcare and the health gain for our population, and to drive forward the economic opportunities that attend the biomedical sciences industry in our country. However, they also drive forward opportunities for a broader population health gain through a focus on the tripartite mission of improved clinical care, education, training and research.

[Lord Hunt of Kings Heath]

My Lords, this has been a very interesting debate, and I am very grateful to the noble Lord, Lord Willis, and other noble Lords who have spoken in it very persuasively about the importance of research.

At heart, there are three particular questions that we put to the noble Earl, Lord Howe. First, how is funding for research to be protected? Secondly, how are we to ensure that strong leadership will be given from the centre? The third is the question of levers. What levers are there in this system to ensure that research is given a prominent place?

First, there can be no doubt whatsoever, as the noble Lord, Lord Willis, said, of the direct link between research and the quality of patient care. That must be at the forefront of our consideration. Secondly, he is also right about public health. Research into public health, evidence and epidemiology is vital if we are to improve the overall health of people living in this country. Thirdly, we have the contribution that research makes to UK plc, and specifically the contribution of the pharmaceutical industry.

When I chaired the competitive taskforce with the industry some years ago, we found that out of the 100 most important branded medicines at the time, 30 had been developed in the UK. Although the UK share of global spend on pharmaceuticals was about 2 per cent, our R&D contribution, including that of the industry, was about 10 per cent. I suspect that those figures have slipped a little since that report, but there is no question that the pharmaceutical industry in particular makes a huge contribution to our economy. We cannot be complacent about that in the future.

On the question of leadership, I was fortunate to be present at the recent annual conference of the NHS Confederation. I take the point made by the noble Lord, Lord Mawhinney, that, “They would say that, wouldn’t they”, when it comes to this rather foolish idea that somehow if you just leave it to them everything will be all right, but I recall a speech made by Dame Sally Davies in which she talked about the importance of research. She argued that the NHS itself has to make a greater contribution to research. This was not about funding; this was about NHS organisations recognising that research was important. It was a brilliant speech. It is essential that we continue to have that kind of national leadership in research funding.

There is a big question about what exactly the duty of the Secretary of State will be with regard to research if we end up with a highly devolved structure in which the levers left to the Secretary of State will clearly be limited. It is clear that the day-to-day concerns of most people in the NHS are going to be diverted into a market-orientated culture, where, frankly, the kind of collaboration that research requires across NHS organisations may well be regarded as collusive behaviour by economic regulators and the competition authorities.

I speak with some experience of economic regulation. Ofgem was the last economic regulator with which I had regular dealings as Minister for Energy. What struck me was that regulators’ concerns are much more about day-to-day issues than they are about the long-term viability of a particular industry. We found, with Ofgem, that we had to change the law to make sure that it had some regard to future customers rather than simply being concerned about the actual price of energy to the customers of today. If we have regulators whose main concern is about driving day-to-day competition, I wonder where issues of research come into play.

Health and Social Care Bill

Lord Kakkar Excerpts

Monday 7th November 2011 Lords Chamber

[Baroness Bakewell]

I support Amendment 18B, which is also included under the heading,

“Duty as to improvement in quality of services”,

of the proposed new Section 1A to the 2006 Act.

I speak on behalf of particular interest group: the old. I declare an interest. I was for 18 months the government-appointed Voice of Older People. The interest group for which I speak is large and growing larger. Some 10 million people are now over 65 in the UK. In 2034, 23 per cent of the population will be over 65 of whom 3.5 million will be of the older old—over 85. That age, 85, is significant to the amendment. The amendment is to new Section 1A(3), proposed in Clause 2, dealing with the Secretary of State’s duty to seek continuous improvement in the outcomes, and it lists the relevant outcomes to be measured: effectiveness, safety and quality. We have already heard from the noble Lord, Lord Patel, and others about the important amendments to that.

Amendment 18B seeks to add a fourth consideration—and a rather odd one—which is that,

“These outcomes should not exclude sections of the population due to age”.

That phrase sits uneasily here—it would sit uneasily anywhere—because it is not of a kind like any other. However, it is important for the many people who will be numbered in the data on which outcomes are based—or, rather, not listed in the data.

The NHS Outcomes Framework 2011/12, which sets out outcomes and corresponding indicators, states:

“Where indicators are included which can be compared internationally, levels of ambition will work towards the goal of achieving outcomes which are among the best in the world”—

a laudable aim indeed. However, the document goes on later to state:

“Current data collections are limited in the extent to which this is possible … We recognise that there are certain groups or areas which the framework may not effectively capture at present, simply because the data and data collections available do not allow outcomes for these groups to be identified”.

In the document’s charts that show the overarching indicators, it is clear that many of the indicators stop at the age of 75. The indicators specify the mortality rates from cardiovascular disease, respiratory disease and liver disease. Thus, the data on deaths from such causes over the age of 75 are not monitored under the outcomes framework, despite the fact that life expectancy is far higher than 75.

It is also clear that many of the data are under development. I understand that, and there is work to be done. As the document states:

“This is the first NHS Outcomes Framework and … it is intended to signal the direction of travel for the NHS”.

The direction of travel for the population of this country is to have a much higher percentage of older old people. We already have more than 12,000 centenarians. Throughout debates on this Bill, I will be pressing for considerations of age to be written specifically into its provisions.

Why do we need to be so explicit? Surely we are all citizens, we are all taxpayers and, in the end, we are all patients. That is of course the reasonable case, but that is not how care is experienced. A recent report commissioned by the Department of Health concluded:

“Evidence of the under-investigation and under-treatment of older people in cancer care, cardiology and stroke is so widespread and strong that, even taking into account confounding factors such as frailty, co-morbidity and polypharmacy we must conclude that ageist attitudes are having an effect on overall investigation and treatment levels”.

That was in a report published for the Department of Health. To give just a simple anecdotal example from broader practice, although the risk of breast cancer increases with age, the general-practice reminders that are sent out to women to invite them to mammograms stop once a woman reaches the age of 70.

My amendment seeks to make clear, and even overemphasise, that all outcomes include all sections of the population. Prevailing attitudes to the old require that to be spelled out in the Bill.

[Lord Kakkar]

My Lords, I support Amendments 15 and 19, in the name of the noble Lord, Lord Patel, to which I have added my name. In so doing, I speak as a practising clinician and I wish to emphasise the wise point made by the noble Lord, Lord Patel, about the need to ensure that the Bill describes important facets of what needs to be achieved to improve culture within the NHS.

At Oral Questions today, we heard a discussion about hydration policy. Clearly, in a healthcare system, it is important that the culture is appropriate. Therefore, an emphasis on specifying “health outcomes” and “clinical quality standards” is also important because that will drive a cultural emphasis on the fact that improvement of health is the purpose of the Bill. The failure specifically to recognise, on page 2 in line 17, the issue of outcomes being specifically those of health, and in line 27 the quality standards to be specifically those of clinical quality, is potentially an important failure that should be recognised. I hope that in responding to this debate the Minister can confirm that with the emphasis on health outcomes and clinical quality standards, the purpose of the Bill will be emphasised in the language used in the Bill.

Health and Social Care Bill

Lord Kakkar Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Phillips of Sudbury]

My Lords, Amendments 24, 30 and 299B are tabled in my name and those of the noble Baroness, Lady Finlay of Llandaff, and the noble Lords, Lord Kakkar and Lord Darzi. I hasten to state the obvious, which is that I am a relative ignoramus as regards the refinements of the delivery of health within a hospital. The other three noble Lords who have added their names to this amendment are by contrast as distinguished a trio of consultants as one could find. I must at once, as requested by the noble Baroness, Lady Finlay, give her apologies to the Committee for her inability to be here. She is well out of London.

Amendments 24 and 30 add to Clause 3 which in turn adds to Section 1 of the National Health Service Act 2006. Clause 3 is headed: “The Secretary of State’s duty as to reducing inequalities” but refers to NHS patients in different parts of England, not to differences between NHS and private patients within a single NHS hospital.

Other parts of the Bill which talk of equality of access and outcomes are similarly limited. Nowhere in this 445-page mammoth is there any clear statement, let alone requirement, as to equality of clinical treatment and healthcare between NHS and private patients within an NHS institution. Amendments 24 and 30 clarify that. Amendment 299B also clarifies that inessential care such as what one might call the hotel services—the quality of the accommodation, drugs prohibited by NICE standards and indeed treatment and care that is not a clinical priority—can still be provided privately on the basis of privilege. Those matters are, as I say, non-essential and we have put in—the four of us whose names are to these two amendments—Amendment 299B to make very clear that we are not seeking to row back on the status quo.

It was Aneurin Bevan during Second Reading on what would become the National Health Service Act 1946 who said:

“If people wish to pay for additional amenities, or something to which they attach value, like privacy in a single ward, we ought to aim at providing such facilities for everyone who wants them”.—[Official Report, Commons, 30/4/1946; col. 57.]

For example the state will provide a certain standard of dentistry free but if a person wants to have his teeth filled with gold the state will not provide that. It is in that vein that Amendment 299B stands in our four names but, and this is a big but, where there are two patients with the same essential clinical health needs—one an NHS patient, another a private patient; one in a public ward, the other in a private ward—the one with the fat wallet can buy priority and buy his way to the top of the queue. That cannot be allowed in our National Health Service. It would be fundamentally against the spirit of the NHS and directly contrary to the ideals on which it was founded.

In a Britain that is becoming more divided in terms of living standards at a rapid rate the maintenance of the ideals of the original NHS for many of us are absolutely integral to our sense of citizenship and sense of comfort in an increasingly differentiated and diverse society. We must not on any account allow under the new regime a—no doubt inadvertent—two-class service to develop in NHS hospitals with regard to essential care. In saying that, I want to make it abundantly clear that neither amendment will touch private institutions that have no NHS connection—they are free to carry on doing what they will, how they will. That is an aspect of freedom in this country on which I would not for a minute seek to trespass.

The dangers are that the privatising and commercialising, as they are fairly called, will, as I say, bring into the NHS a much wider and deeper engagement with the private sector and that could, and I again say inadvertently, develop into a two-class NHS. Let us be clear: the NHS and the private sector march to different drums. The NHS is concerned solely and only with equal free treatment and fair access to any of us who go to its institutions. The private sector, which I do not wish to unduly disparage—which is made up of public companies and many very commercial entities—is none the less first, secondly and thirdly in the business of profit. It is no good saying that doctors and consultants working within the private sector, unless they are sole traders so to speak, will be immune from that commercialisation, the managerialism that goes with it and the pressures that are inevitably engaged when working for a commercial entity.

Amendment 30 strengthens the original ideals of the NHS. Perhaps I may say to my noble friend the Minister what I have said to him previously: I believe that it will cement public support for what is good in this Bill. There is much that is good and I am not for a minute saying that extending the contact with the private sector is wrong. In many respects, it can be good and can bring new resources into the NHS. But that is all at risk unless we put firmly and clearly in the Bill that we will not allow a two-class service of clinical treatment and healthcare within an NHS institution.

I want briefly to refer to the deluge of letters, petitions and the like which everyone in this House has received. In my 14 years here, there have been far more letters on this Bill than any two others put together. My noble friend Lord Razzall mumbles that there were more for hunting. I have to say to him that I do not think there were, but be that as it may. I just mention the Coalition of UK Medical Specialty Societies, which saw the issue that my amendment is designed to address. It wrote:

“Choice must be for patients rather than provider; the provider choosing the simple cases and leaving the unprofitable, more complex cases (elderly, chronic illness, disabled) to fight for remaining funds will disadvantage patients”.

A petition from more than 400 public health doctors and specialists from within the NHS and academe said:

“As public health doctors and specialists”,

we think that the Bill could usher,

“in a significantly heightened degree of commercialisation and marketisation that will … widen health inequalities”.

It is to prevent that widening that this amendment is put down.

Finally, the BMA, which has informally backed this amendment, in one of its key points states:

“Increasing patient choice should not be a higher priority than tackling fair access and health inequalities”.

We all say amen to that. I hope very much that the Government will accept these amendments. It may well be that on Report I will want to bring forward something to make clear that there should be some oversight of the provisions that these amendments seek to entrench, which might be through the monitors. But, for the time being, I hope that the Committee will warm to these amendments and the sentiments behind them. I beg to move.

[Lord Kakkar]

My Lords, I support this group of amendments and in so doing remind your Lordships of my interest as consultant surgeon at University College London Hospitals NHS Foundation Trust, an institution with private healthcare facilities that I would be entitled to use if I ever decided to do so. This group of amendments is very important because it deals with an area of anxiety with regard to potential consequences that will follow removal of the private patient cap. Removing that cap may well provide important opportunities for NHS foundation trusts in the future, opportunities that they may well need to exploit. But in so doing, we need to be certain that access to clinical facilities in NHS institutions for either NHS patients or those in private healthcare facilities in NHS institutions is based purely upon clinical need and that no other factor influences access to those facilities.

I believe that in the majority of circumstances that will always be the case, as it has been to date. But with the important changes in this Bill with regard to the role of potential private practice in NHS institutions, we need to be absolutely certain that any anxieties or opportunities for misunderstanding are dealt with at an early stage. So in bringing forward these amendments at this stage, one hopes that there is an opportunity for the Government to explore how they plan to deal with any potential tensions and what security the current Bill as we consider it, and any potential amendments in the future or well established working practices in the NHS to date, would protect against a situation developing where access to facilities was determined by anything other than absolute clinical priority. For this reason I strongly support the amendments being brought forward at this stage in the hope that the noble Earl might be able to provide some clarity on the approach that Her Majesty’s Government might take in regard to these matters.

[Lord Walton of Detchant]

My Lords, 53 years ago, after seven years in full-time clinical research followed by 18 months as a first assistant in a neurological department with an honorary senior registrar contract, at the age of 35 I was appointed as a consultant in the NHS. But since at the time I had not even reached a salary of £2,000 a year, on being appointed as a consultant I chose to take a maximum part-time contract to do limited private practice, if only for financial reasons. In fact, it was a very interesting experience. I did this only for a few years before I became a full-time academic.

At that time every NHS hospital had a private ward or had the opportunity, as was the case in the regional neurological centre in Newcastle Upon Tyne, such that on my ward of 28 beds I was entitled, if I so wished, to use four single rooms for private patients. The advantage of that arrangement, which was widespread throughout the country, was that the consultants working in that kind of hospital had the right to be geographically whole-time at the hospital. They were not being diverted away to distant private hospitals. They could look after their patients, both private and public, on the same ward and give them equal standards of care. The only real advantage for the private patients was that they had single rooms.

Many years later, along came Barbara Castle, who was the Secretary of State for Health and who later became the much respected Lady Castle. By that time I was a full-time academic with no private practice. I took private patients under my care into hospital, as I had to do if they came from overseas. In order to take advantage of the research facilities in my department, they had to be treated as private patients. However, under pressure from the trade unions, the Government worked through a process of gradually removing private patient beds from NHS hospitals so that, in the end, in the three major hospitals in Newcastle Upon Tyne we had one private bed in each hospital. The result was that, as an academic with major research facilities for the investigation of neuromuscular disease, I had to refuse patients referred to me from the United States, Canada, Australia and elsewhere because there were no private hospitals which could provide the facilities needed for the investigation of these patients, and there were no private beds into which they could be admitted. I look back on the period before that, when there were private beds in NHS hospitals, with great interest. I think that it was an excellent arrangement.

This is why I strongly support the proposal that the cap on private patient beds in NHS hospitals, foundation trusts and so on be removed, but I agree that there should be a restriction so that the opportunity for such beds to be established for private patient care must not be excessive. However, the advantage is that the NHS will gain substantially from the income derived from those private beds. The noble Lord, Lord Phillips, has enunciated the principle that the standards of clinical care for public and private patients in those hospitals should be entirely comparable. The only advantage for private patients would be a better standard of accommodation, as Amendment 299B indicates, which is wholly acceptable. The quality of medical care should be identical. For that reason, I support the principle.

On the other hand, the wording of Amendment 30 is not satisfactory. Although I accept the principle of equal standards of clinical care, the amendment would make it impossible to provide the improved standards of accommodation to which Amendment 299B refers. The principle is important and I would support it in general, but the amendment needs a little adjustment.

Health and Social Care Bill

Lord Kakkar Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Lord Kakkar]

My Lords, the noble Earl, in his thoughtful introduction of the Bill on Second Reading, identified the challenges that face all mature healthcare systems such as our own in terms of the changing population demographics, with an older population, more chronic disease and the need to improve clinical outcomes through integration of the new technology innovations and pathways of providing care.

In trying to understand how those important objectives will be achieved by the Bill we need to try to identify potential strategies. One of the most important is to ensure that the health service focuses on integrated care in the future. We know from quite a lot of important experience around the world that integrated care has the opportunity to improve clinical outcomes. We have heard of the patient with diabetes that the noble Lord, Lord Patel, described who ended up with the potentially unnecessary amputation of toes. Integrated care could have improved the clinical outcome in that case by avoiding a deterioration of the patient. Careful supervision in the community and the appropriate integration of different specialties and disciplines could have avoided that outcome. We know that integrated care has the opportunity to drive improved patient experience. We have heard about the potential for integrated care to improve patient safety. The example given by the noble Baroness, Lady Cumberlege, of the remarks made by Martin Marshall with regard to “lost in the system” puts patients at great risk, and the importance of integrated care and enhancing patient safety should not be neglected.

We also know that integrated care can achieve the important objective of taking our system towards a value-based healthcare system where, in addition to improving all the good clinical outcomes and improvement in experience and safety, the healthcare system can also deliver better value and ensure that the vital resources available and devoted by Government to the provision of healthcare can be used most effectively. Therefore, I strongly support the amendments that speak to the need to emphasise in the Bill the importance of integration.

The Bill has the important purpose of ensuring that a legal framework exists for driving forward future provision of the National Health Service, and also provides an important opportunity to set a vision and ensure that those ultimately responsible for implementation have an appropriate focus at the outset and can design the service moving forward in such a way that it achieves the objectives and meets the challenges that the noble Earl set at Second Reading. To ensure that there is a focus on integration is a very important objective. It will help achieve those important challenges. Failure to emphasise integration would run the serious risk of losing the opportunity to drive forward the improvements in healthcare and in the utilisation of resources that the health service desperately needs.

[Baroness Barker]

My Lords, the noble Baroness, Lady Pitkeathley, mentioned that she wrote a book 40 years ago. I wish I had written a book about the experiences of older people in various parts of the healthcare system. Many noble Lords talked about integration at different levels. My view is that integration just within acute hospitals will be ever more complex in future because they will be treating many people with dementia. The treatment of people with dementia in different parts of acute hospitals is a growing scandal. It poses a challenge to health professionals of all kinds, many of whom have never bothered to think about the issue of dementia. They will have to think about it for their own specialisms in future.

I have taken part in this sort of debate many times and come to the conclusion that the debate rests on a single factor: information. It is the sharing and availability of information and data about outcomes. Everything else is secondary. The previous time we had a serious discussion about this was when we discussed the proposals of the noble Lord, Lord Darzi. Some of what he achieved, in particular in improving stroke care in London, rested on the willingness and ability of people just in different parts of the NHS—let us not be too ambitious—to share information. I ask the Minister what the department has learned since the passage of the legislation of the noble Lord, Lord Darzi, about the crucial issue of sharing information about patients and their treatments, and other data on outcomes. Until we address that issue, and until health professionals feel able to maintain client confidentiality while sharing information just with other professionals, everything else will be redundant: we will never crack any of this until we get that right. Therefore, I ask the Minister how the department’s thinking was influenced in the preparation of the Bill by what the noble Lord, Lord Darzi, achieved.