Health and Care Bill

Debate between Lord Kakkar and Earl Howe

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Earl Howe (Con)]

My Lords, in moving Amendment 3 I will speak also to the other government amendments in this group, in the name of my noble friend Lord Kamall. Of the many critical topics we discussed in Committee, our debate on health inequalities stands out as one that prompted unanimous and emphatic agreement from all Benches on the need for us to recognise in the Bill the centrality of the inequalities issue. My noble friend Lord Kamall and I took it as our mission to respond to the compelling points raised by noble Lords by bringing forward government amendments on Report, which I now do. These are issues and points of principle about which the Government—not least my noble friend the Minister—feel very strongly.

As the House will know, we think it important to empower local health and care leaders to pursue new and innovative ways to tackle disparities in the most appropriate way for their area. However, we should not miss the opportunity to ensure that this Bill reinforces those intentions in other ways. The amendments are designed to ensure that the Bill fully reflects the strength of the Government’s ambition to address disparities by levelling up every area of the country.

First, we will put beyond doubt that tackling disparities should be an integral factor when making decisions across the NHS. This was something that NHS England’s four purposes for ICSs made clear. The triple aim duty was always intended to support achieving those purposes, and these amendments strengthen the duty on NHS England, NHS trusts and ICBs so that, when decisions are made by NHS bodies, consideration will always be given to the effect of those decisions on disparities. What does that mean? It means that NHS bodies should consider the wider effects of their decisions on the inequalities that exist between the people of England with respect to their health and well-being and the quality of the services that they receive.

We are also going further by strengthening the more specific duties that complement the triple aim. Disparities are not limited just to health outcomes or access; they relate also to the experience of the care that is received. For example, the independent Commission on Race and Ethnic Disparities reported that Asian patients are more likely to report being less satisfied with GP services than their white, black African and black Caribbean counterparts. These amendments seek to strengthen existing duties as to reducing health inequalities on NHS England and ICBs by explicitly including patients’ experience of care, the safety of services and the effectiveness of services to create a more holistic duty that addresses how disparities manifest themselves in health and care.

When it comes to inequalities in access to health services, we can go further. The duties currently focus only on people who are already using or accessing health services. This fails to address those who do not or cannot access health services—and, as we powerfully heard in Committee, these include many socially excluded and marginalised persons, who are more likely to have preventable health conditions. The point is fully taken, and we have therefore tabled an amendment to ensure that the duties placed on NHS England and integrated care boards as regards reducing health inequalities require the consideration of inequalities in access for “persons”, rather than simply “patients”. The intention here is to improve outreach, as well as access by socially excluded and marginalised groups.

Lastly, we recognise the crucial importance of information on which to base targeted action. The Covid vaccination campaign was unprecedented in the way that it focused activity on every community across the nation, especially where there were disparities in the uptake of the vaccine. Fundamental to that success was the ability to collect and analyse data from across the system so as to target resources in the most effective way.

Our amendment will require NHS England to publish a statement describing certain NHS bodies’ powers to collect, analyse and publish information relating to disparities in health, together with NHS England’s view on how these powers should be exercised. Those bodies will be required annually to review and publish the extent of their compliance with that view. We hope and believe that this will power the evidence-based drive to reduce disparities in health across the country.

I hope that, together, these amendments provide the reassurances that noble Lords sought from their various amendments tabled in Committee. In conjunction, these changes will strengthen the ability and the resolve of the health and care system to take meaningful and impactful action. I commend them to the House and beg to move.

[Lord Kakkar (CB)]

My Lords, in thanking the Minister for having introduced so thoughtfully and elegantly this important suite of government amendments that address the question of inequalities, I would like to pass to the Minister and the Front-Bench team the thanks of my noble friend Lord Patel, who regrettably is unwell, recovering from Covid-19, but who of course spoke with great insight and passion in Committee on this matter, and indeed has engaged actively with the Front-Bench team subsequently in ongoing discussions.

The noble Earl has done something quite remarkable and absolutely essential. There is no need to rehearse the very strong arguments that were made in Committee around the necessity at this particular time to ensure that every element of the National Health Service is able not only to focus its resource and thought quite clearly at the elements of the triple aim but to ensure that, in a tension with those important pan-NHS objectives, the system is never allowed to forget the importance of addressing the inequalities and disparities that regrettably continue to be an abject failure of the delivery of the healthcare system.

Her Majesty’s Government, in proposing these amendments, deal not only with questions of access and outcomes but ensure that data is appropriately collected and all NHS organisations are obliged to pay attention to those data and to act accordingly; that is a very powerful statement and a powerful act of leadership. But beyond that, in ensuring that the patient’s voice and the public’s voice is heard in these matters, this will set a new tone and new direction for the delivery of healthcare in our country, and Her Majesty’s Government are to be strongly congratulated.

Alcohol-related Disease

Debate between Lord Kakkar and Earl Howe

Wednesday 17th December 2014 Lords Chamber

[Earl Howe]

My Lords, I am sure the noble Lord would not expect me to agree with him on the position of Mr Crosby in relation to the drinks industry. We feel it right to engage with the industry because it is in a position of influence over consumers, and we have seen, through the responsibility deals, some real progress, which it has instigated at our prompting. I recognise the issue that the noble Lord raises on price. That, of course, is only one aspect of the issue of alcohol consumption and its prevention.

[Lord Kakkar (CB)]

My Lords, I declare my interest as professor of surgery at University College London. A recent Lancet commission on liver disease in the UK has identified alcoholic liver disease as an increasing cause of mortality in our country. What measures do Her Majesty’s Government propose to take to improve both expertise and facilities for the early detection and treatment of liver disease in primary care?

[Earl Howe]

My Lords, increasingly, GPs are being made aware of the need to upskill in this area. Of course, it is not just GPs but local authorities who have responsibilities in the arena of public health to make sure that excessive drinking is discouraged. I can write to the noble Lord with the precise details of the GP training that I am aware of.

NHS: Five Year Forward View

Debate between Lord Kakkar and Earl Howe

Thursday 23rd October 2014 Lords Chamber

[Earl Howe]

My noble friend is absolutely right in what he says. The report lays great emphasis on the prevention agenda, not only through the work done in the public health arena by Public Health England and local authorities, but also through secondary prevention by the NHS itself: preventing the need for people to enter hospital in the first place. I fully agree with my noble friend about the potential role of pharmacists. Actually, that role has been enlarged over the past few years in an encouraging way with such things as medicines use reviews and the Healthy Living Pharmacy agenda. We want to go further and pharmacists are keen that we should do so.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. This ambitious programme will require very strong leadership. What arrangements are going to be put in place to develop strong clinical leaders across the different sectors and environments of the health delivery system that will be required to ensure that this become reality?

[Earl Howe]

One of the great features of the Government’s reforms is to put clinical leaders in charge of designing the way that care is delivered throughout the country. That point is often overlooked. It is, of course, the quality of that leadership that we should focus on. That quality is variable and why NHS England, Health Education England and partners in the system are looking as carefully as they can at how to improve that quality of leadership. I direct the noble Lord’s attention to certain passages in the Forward View, which talk about the need for all the bodies in the system to work together: NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Health Education England, NICE, Public Health England—all working together to achieve greater alignment and greater common purpose in the way that these proposals are implemented.

Health and Social Care Act 2012: Risk Register

Debate between Lord Kakkar and Earl Howe

Wednesday 9th July 2014 Lords Chamber

[Earl Howe]

My Lords, it is possible to monitor how the Act is working without publishing the risk register. It is quite true that the transition to the new commissioning system is over. However, the risk register related expressly to the implementation of the reforms and the system is still bedding down. Therefore, we are still of the view that it is inappropriate to publish the register.

[Lord Kakkar (CB)]

My Lords, I declare my interest as professor of surgery at University College London and chairman of UCL Partners. At the time of its Second Reading, the Minister was kind enough to indicate that the Health and Social Care Act would enjoy post-legislative scrutiny after three rather than five years. Does that remain the intention?

[Earl Howe]

My Lords, I undertook to publish an assessment of the implementation of the 2012 Act within three years, so the noble Lord is right. News on that front will be forthcoming very shortly.

Health: Secondary Care

Debate between Lord Kakkar and Earl Howe

Thursday 26th June 2014 Lords Chamber

[Earl Howe]

My noble friend is right. This is absolutely central to raising our performance as a country in successfully treating cancer. We are doing several things. We have piloted a tool to help GPs to identify patients whom they might not otherwise refer urgently for suspected cancer. The tool covered lung cancer, as well as others. Across England, 502 GP practices took part in the pilot. Initial indications are that the tool is extremely helpful. There is also an e-learning tool that offers accredited professional development for GPs. The Royal College of General Practitioners has also identified cancer as an enduring priority. It is working with Cancer Research UK and other partners in promoting models of best practice.

[Lord Kakkar (CB)]

My Lords, I declare my interests as professor of surgery at University College, London, and chairman of UCLPartners. Better integrating primary and secondary care is crucial to ensuring patient safety, improved clinical outcomes and the most effective resource utilisation. What progress has been made in defining whole pathway metrics for integrated care to best inform rational commissioning of these services?

[Earl Howe]

Several things are in train. One of those, as the noble Lord will know, was reflected in the legislative reform order that we debated in the Moses Room two days ago. It will cut down the administrative burden of joint commissioning by NHS England and CCGs, as well as the burden currently being experienced by CCGs in joint commissioning between themselves. More importantly, we need to incentivise the system for integrated care, and that is what the better care fund is designed to do. It will ensure that patients receive joined-up care, whether that is in acute settings, in the community or, indeed, from social care.

NHS: NICE-appraised Medicines

Debate between Lord Kakkar and Earl Howe

Thursday 27th February 2014 Lords Chamber

[Earl Howe]

It is important to distinguish between a technology appraisal, where, if favourable, there is a clear funding direction for the NHS—in other words, it must fund the drug if the doctor thinks that it is appropriate for the patient—and a clinical guideline, where NICE issues best practice advice for the NHS. There is no funding direction attached to that. However, clinicians are expected to take account of NICE guidelines in everything that they do.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman-elect of University College London Partners, one of the designated academic health science partnerships. Is the noble Earl content that the funding arrangements to be put in place by NHS England for the 15 designated academic health science networks are appropriate and will ensure that they can discharge their substantial obligations under their licence agreement, including the adoption of NICE guidance among the populations for which they are responsible?

[Earl Howe]

The noble Lord asks a very important question. It is slightly wide of the Question on the Order Paper, which relates to a particular set of statistics. However, I can tell him that I am broadly satisfied with the level of funding for AHSNs, and NHS England has given its commitment to maintain its support for them going forward.

NHS: Patient Data

Debate between Lord Kakkar and Earl Howe

Tuesday 25th February 2014 Lords Chamber

[Earl Howe]

I entirely agree with the noble Lord. This is a vital programme which will bring real benefits to patients. It has major potential benefits for research and public health. It commands generally wide stakeholder support. However, there is no doubt that concerns over how this has been explained to patients have been raised and those concerns need to be addressed. I agree that the next six months will be crucial in pursuing that aim but it is essential that this programme commands public support.

[Lord Kakkar (CB)]

My Lords, I declare an interest as professor of surgery at University College London. What assessment have Her Majesty’s Government made of the proposed European data protection regulation which, if passed, has the potential to impact seriously on our national strategies with regard to health informatics and biomedical research?

[Earl Howe]

My Lords, we take that concern extremely seriously. The draft text that has been published by the so-called LIBE committee would, if enacted, pose serious obstacles for our research effort in this country. We are taking every opportunity and using every effort to persuade both the Parliament and the European Commission that the original text is the one we should go with. That work is on-going and the Ministry of Justice is leading on it.

Tobacco: Packaging

Debate between Lord Kakkar and Earl Howe

Thursday 28th November 2013 Lords Chamber

[Earl Howe]

My Lords, it is clear from the debates in the other place and from our debates in Committee on the Children and Families Bill, that there is emerging evidence that needs to be considered. That evidence has emerged since the consultation. I am not in a position to make a judgment on that. I think Sir Cyril Chantler is the best person to do it.

[Lord Kakkar (CB)]

My Lords, I declare my interest as a member of the board of UCL Partners, currently chaired by Sir Cyril Chantler, and I congratulate Her Majesty’s Government on the excellent choice of Sir Cyril to lead this important review. Can the noble Earl confirm that Sir Cyril will be completely free to define both the methodology that he will apply for the review and the question that he will address?

NHS: EU Legislation

Debate between Lord Kakkar and Earl Howe

Monday 21st October 2013 Lords Chamber

[Lord Kakkar]

To ask Her Majesty’s Government what recent assessment they have made of the impact of European Union legislation on training and service delivery in the National Health Service.

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

We are aware that concerns exist about the impact of EU legislation on some areas of training and service delivery within the NHS. That is why we recently announced the review of the implementation and impact of the working time directive, to be led by the Royal College of Surgeons. This follows the balance of competences review for health, which included concerns about the impact of this directive on continuity of care and doctors’ training.

[Lord Kakkar (CB)]

My Lords, I declare an interest as professor of surgery at University College London. In 2010, the then Secretary of State for Health and Secretary of State for Business, Innovation and Skills were due to commence robust negotiations with our European partners on the working time regulations. Despite the welcome announcement of the current Health Secretary’s further review of the impact of those regulations, do the Government stand by their commitment to repeal this detrimental legislation as it applies to healthcare? This is now increasingly cited by coroners as having contributed to patient harm. Moreover, our trainees tell us that it is now undermining their ability to acquire the necessary skills for future independent consultant practice. Patients and doctors alike now blame these regulations for a destruction of professionalism in our health service.

[Earl Howe]

My Lords, it is the impact on our health service that we want the Royal College of Surgeons to look at specifically. In the coalition agreement, we committed to limiting the application of the working time directive in the UK, including in the NHS. Nobody wants to go back to the bad old days of tired doctors, but it is important for the working time directive to have more flexibility for a health service that operates on a 24-hour basis. Increased flexibility for the NHS would allow it to take account of local needs and practices, while at the same time ensuring the health and safety of the workforce. We stand prepared to work with partners in Europe to that end. I believe there is strong support in the NHS for this.

NHS: Accident and Emergency Services

Debate between Lord Kakkar and Earl Howe

Thursday 25th July 2013 Lords Chamber

[Earl Howe]

My Lords, there are many factors at play here. There is no doubt that the GP contract severed the legal responsibility that individual GPs had to look after their patients out of hours. It would be idle for me to stand here and say that that has had no effect on A&E attendances. Patients are confused now about whom to contact out of hours and many turn up at A&E when perhaps they should not have done so.

[Lord Kakkar]

My Lords, I declare my interest as professor of surgery at University College London and chair of quality for University College London Partners. What progress has been made in the commissioning of integrated care services across hospitals and the community for frail, elderly patients with multiple co-morbidities, who frequently have to attend A&E for the lack of such services?

[Earl Howe]

Not for the first time, the noble Lord hits on an extremely important aspect of the problem that we are facing. It is the frail elderly who often turn up at A&E with a crisis in their health when that crisis could have been averted. That is why Sir Bruce Keogh has been tasked to look across the piece at the whole system to see how we can ensure that the frail elderly in particular are served better by the health service, not least to prevent the exacerbation of long-term conditions.

Health and Social Care

Debate between Lord Kakkar and Earl Howe

Wednesday 5th June 2013 Lords Chamber

[Earl Howe]

I can indeed, and I can do so with confidence because the three chief inspectors that we propose to create—one of whom, the Chief Inspector of Hospitals, has already been appointed—will be working as part of the Care Quality Commission. They will be senior employees of the CQC and their job will certainly be to align the methodology that they use to assess good and poor care.

[Lord Kakkar]

My Lords, I declare my interest as professor of surgery and consultant surgery at University College London Hospital. During the passage of the Health and Social Care Act 2012, there was a discussion about the need to ensure that there was an ongoing focus on integrated care between community hospitals and tertiary services. This needed to be attended by a focus on the development of metrics that would describe whole pathways of care outcomes for patients. What progress has been made with regard to the development of those whole pathway metrics?

[Earl Howe]

The noble Lord hits upon a point of central importance. The outcomes framework clearly sets out where the different parts of the health and care system share responsibility for outcomes and support joint working in the way that I have described. However, we are committed to developing a measure of people’s experience of integrated care for use in the outcomes frameworks. That is a work in progress. Meanwhile, a place holder was included within both the NHS and adult social care outcomes frameworks when they were refreshed in November last year. We have highlighted the development of this measure in the public health outcomes framework, so I hope to give the noble Lord further news in a few months’ time.

Health: Cancer

Debate between Lord Kakkar and Earl Howe

Monday 14th January 2013 Lords Chamber

[Earl Howe]

My noble friend is absolutely right to raise the point. To support the NHS in tackling regional variations in cancer survival rates, we are providing data to providers and commissioners that allow them to benchmark their services and outcomes against one another and to identify where improvements need to be made. Surgical resection is currently the best curative intervention for pancreatic cancer, and through the National Cancer Intelligence Network we have already made available data collections on the survival rates and surgical resection rates across a range of cancers, including pancreatic cancer.

[Lord Kakkar]

My Lords, what proportion of patients diagnosed with pancreatic cancer is managed in specialist centres by a specialist, multidisciplinary team? What proportion of patients in those centres is entered into clinical trials? We all recognise that participation in clinical research improves clinical outcomes in these centres.

[Earl Howe]

My Lords, the UK now has the highest national per capita rate of cancer trial participation in the world, which is something that not everybody realises. We have improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I will write to the noble Lord with information about specialist centres, but he will know that surgery for pancreatic cancer is a complex business and needs to be undertaken by those who are very well versed in that particular line of clinical activity. I am sure that a high proportion will be treated in those centres but I will find out more if I can.

NHS: Clinical Networks

Debate between Lord Kakkar and Earl Howe

Wednesday 12th December 2012 Lords Chamber

[Earl Howe]

My Lords, I am grateful to my noble friend. As regards cancer, it is important to look at what the Government are doing across the piece. As the noble Lord may recall, the cancer strategy that we published a while ago is backed by more than £450 million of investment. This is specifically to target earlier diagnosis of cancer; to give GPs increased access to diagnostic tests; to allow for the increased testing and treatment costs in secondary care; to support campaigns; and so on. That is a large sum of money and it is committed.

[Lord Kakkar]

Does the Minister envisage a role for the to-be-designated academic health science networks in delivering clinical networks in the future? I declare my interest as chair for quality, University College London Partners academic health science partnership.

[Earl Howe]

My Lords, yes. National guidance is being produced by the NHS Commissioning Board, setting out the different areas of focus for academic health science networks, health and well-being boards, local education and training bodies and clinical senates. The defined geographies of the 12 network support teams have been developed precisely to gain close alignment and therefore promote close relationships and co-operation with the other structures in the new system—including academic health science networks.

NHS Commissioning Board: Mandate

Debate between Lord Kakkar and Earl Howe

Tuesday 13th November 2012 Lords Chamber

[Earl Howe]

My noble friend makes a series of extremely important points and I agree with everything she said about maternity services. Emergency services will be commissioned at a local level by clinical commissioning groups but that cannot be the end of the story. She rightly implied that paramedics and trauma care doctors require skills in sometimes very sophisticated techniques of maintaining life at the scene of an accident, for example, and hospital procedures. These skills must be maintained and improved. The short answer to her question is quite consciously missing from this mandate. This is the need for Health Education England to work very closely with the board because the Centre for Workforce Intelligence and Health Education England will have to ensure that we have not only the right numbers in the NHS workforce but those with the right skills and the right level of skills. As she rightly said, we also need to educate the public that the health service does not consist of a series of buildings; it consists of a network of services. We will have advanced considerably if the public can understand rather better than they generally do that the continuation and improvement of services matter, rather than bricks and mortar.

[Lord Kakkar]

My Lords, I declare my interest as Professor of Surgery at University College London Hospitals NHS Foundation Trust. I very much welcome the noble Earl’s indication that the five objectives of the mandate are now clearly linked to the five parts of the outcomes framework. However, successful and meaningful commissioning decisions will critically place intense focus on the development of metrics in the outcomes framework. Local commissioning will be completely meaningless without objective metrics set as part of the commissioning process at a local level and without the ability to measure those outcomes. With specific emphasis on chronic conditions, what progress has been made on integrated care pathway metrics for integrated care both in the community and in the hospital? If there is little progress, when will we ensure that we have integrated care pathway metrics available to ensure that we drive forward meaningful local commissioning decisions?

[Earl Howe]

The noble Lord has alighted on an extremely important area. We have been very careful in constructing the outcomes framework to make sure that we define deliverable outcome indicators. The NHS Commissioning Board is satisfied that the indicators are realistic but I have to be candid with him. This represents work in progress as the precise way in which the board will demonstrate that it has made progress against each of the indicators has not been defined in every case. I can assure him that it will be. It will be up to the board, however, to construct a system of local accountability to ensure that the clinical commissioning groups are held to account against realistic demonstrable indicators which match those of the NHS outcomes framework, not least in the area of chronic conditions. The patient pathway is work in progress, too, but much of its quality can be measured by reference to the patient experience. That is one of the central domains of the outcomes framework, on which a lot of work has been done. I would be happy to write to him on that.

NHS: Professional Qualifications Directive

Debate between Lord Kakkar and Earl Howe

Monday 15th October 2012 Lords Chamber

[Lord Kakkar]

To ask Her Majesty’s Government what progress they have made in negotiations at European level on the working time and recognition of professional qualifications directives in the light of their impact on the delivery of care in the NHS.

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

My Lords, negotiations on both directives are ongoing. The Government remain of the view that both measures should support labour-market flexibility without imposing significant extra costs on member states to ensure that any negative impacts that we have seen are ameliorated and, most importantly, to ensure that patient safety is maintained.

--- Later in debate ---

[Lord Kakkar]

My Lords, I declare an interest as professor of surgery and consultant surgeon at University College London Hospitals. In today’s Daily Telegraph the presidents of the Royal College of Surgeons and the Royal College of Physicians make an urgent plea for action on these two elements of legislation to halt a devastating deterioration in clinical training and patient safety. Do Her Majesty’s Government collect data on the number of patients harmed as a result of the implementation of these two directives, for instance from coroners’ inquests where they have been implicated in patient deaths, and on the financial consequences in terms of the employment of locum doctors in the NHS to ensure that hospitals are 48-hour-week compliant? If these data are not collected will the Minister commit to organising for their collection in the future to better inform this Parliament and to add impetus to the Government’s negotiations with their European partners?

[Earl Howe]

My Lords, it is the responsibility of individual NHS trusts to ensure that service rotas are compliant with the working time directive. In line with the Government’s coalition agreement to reduce duplication and resources spent on administration, the department reduced bureaucracy for the service by removing the burden of central monitoring of compliance and we are leaving this role to organisations at local level. The last assessment of the working time directive was undertaken in January 2010 and reported that nearly 99% of doctors’ rotas were compliant with the directive but we are in no doubt about the concerns that exist within the medical professions about the inflexibilities within the rules of the directive. As regards the mutual recognition directive, the department does not plan to collect directly any data relating to it. The professional regulators. who are the competent authorities, collect data in respect of the number of people applying for recognition under the directive.

NHS: Health Workers

Debate between Lord Kakkar and Earl Howe

Thursday 19th July 2012 Lords Chamber

[Lord Kakkar]

My Lords, how will clinical leadership be developed to secure the appropriate culture and values essential for delivery of safe, effective and dignified care for all NHS patients?

[Earl Howe]

There is a clear role here for the professional bodies. Training should be done in the right disciplines and numbers and in the right way. I am sure I do not need to tell the noble Lord that in virtually all the medical royal colleges and through the Royal College of Nursing, there is an increasing emphasis on leadership backed by resources from the Department of Health. We are seeing a drive forward for innovation and the breaking down of professional barriers, which is another aspect of this issue.

Health: Local Healthwatch Organisations

Debate between Lord Kakkar and Earl Howe

Monday 11th June 2012 Lords Chamber

[Earl Howe]

My Lords, the noble Lord is absolutely right to raise the question of the cost-effective commissioning of Healthwatch and I have no doubt, from the Local Government Association, that both the efficient and effective functioning of Healthwatch is something that is well within its sights. The noble Lord has raised a series of hypotheses which I think are somewhat extreme, of local Healthwatch organisations parcelling out their functions all over the place. Our aim is to have as locally inclusive a body as possible in each local Healthwatch area to enable Healthwatch to perform its functions as much by itself as with the aid of others. Indeed, the pathfinder events to which I have referred have been clear that there is a local appetite to do that.

[Lord Kakkar]

My Lords, how do Her Majesty’s Government propose to mobilise interest, enthusiasm and participation in local Healthwatch organisations by patients and members of the public?

[Earl Howe]

We are working with the Local Government Association and the Care Quality Commission to provide support for the implementation of local Healthwatch organisations. As I mentioned, the LGA is running a series of master classes for local authority commissioners. It has published 15 case studies taken from the 75 Healthwatch pathfinders, and a small number of Healthwatch experts will be available to help spread learning. As regards making the public aware, it will be very much for local authorities to decide what is appropriate in their particular areas in order to ensure that patients and the public are engaged in the important work of Healthwatch and understand what the statutory remit of local Healthwatch consists of, because that is the only way in which local Healthwatch will make its voice truly heard.

NHS: Health Tourism

Debate between Lord Kakkar and Earl Howe

Monday 28th May 2012 Lords Chamber

[Earl Howe]

My Lords, the Home Office, with our agreement, drew up a list of high-risk countries where TB was prevalent. In those countries, if someone seeks a visa to come to this country for six months or more, they will have to undergo TB testing. Questions on other medical conditions are not relevant in this context. We do not screen for other things. TB is an exceptional case because it is an airborne disease and poses a public health risk.

[Lord Kakkar]

My Lords, what assessment have Her Majesty’s Government made of potential future health tourism from eurozone countries facing imposed austerity measures and cuts to their own local healthcare provision?

[Earl Howe]

The best answer I can give the noble Lord is that this entire area of health tourism is one which we in the department are looking at extremely closely. A review has been carried out by officials and Ministers are considering the recommendations flowing from that. It is a complex set of issues but clearly the context to which the noble Lord rightly refers will need to come under the spotlight.

Health and Social Care Bill

Debate between Lord Kakkar and Earl Howe

Monday 27th February 2012 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Lords, Lord Kakkar and Lord Patel, for their contributions to this debate and, indeed, to other noble Lords who have spoken. We have heard some very powerful and persuasive arguments. I have listened very carefully to them.

Amendments 43A and 43B highlight the concerns that I expect all of us in this Chamber share in relation to the need to ensure high-quality primary care for all patients. The noble Lord, Lord Hunt, made some very telling points in that regard. Of course, there can be no doubt that good primary care contributes to good healthcare outcomes overall. I fully agree that the NHS Commissioning Board should be held to account properly for its performance in commissioning primary care. I do not think, however, that the right way to achieve that is to prescribe that this must be part of the mandate. Our aim is that the mandate should have at its heart the NHS outcomes framework, which covers the range of care that the NHS provides. I make the simple point that good primary care will be essential to improvement against the NHS outcomes framework.

More widely, the department will be keeping under review the performance of the board and the way that it carries out its functions, including its direct commissioning. What matters here are the accountability mechanisms and how those in the system are monitored and held to account. Just as the board will have a commissioning outcomes framework to hold CCGs to account for the quality of their commissioning, it will be important to have robust and transparent information to assess the quality of what the board commissions itself.

We come back to what the Bill already says: it places duties of quality on the Secretary of State, on the board and on CCGs, requiring each of them to exercise functions with a view to securing continuous improvement in the quality of services provided to patients. The Bill also sets out robust arrangements for holding those bodies to account for delivering quality improvement. As noble Lords will be aware, the Bill already requires the board to submit a business plan setting out how it proposes to exercise its functions, and a report setting how it has exercised its functions, to the Secretary of State on an annual basis. In turn, CCGs must also submit their commissioning plans and annual reports to the board. Both the board, in reporting to the Secretary of State, and CCGs, in reporting to the board, will be expected to demonstrate how they have fulfilled their quality improvement duty, including in relation to primary care. Consequently we expect, for example, that both the board and CCGs will wish to monitor the standard of care and services provided by all primary medical services providers in fulfilling their duties.

It is possible that we will need a dedicated objective relating to primary care in the mandate—I am not ruling that out. It would be better, though, not to prescribe that in primary legislation. What matters is that there are clear and effective accountability arrangements, and the Bill as it stands provides flexibility to ensure just that.

The noble Lords, Lord Kakkar and Lord Rea, asked about the QOF. I agree with the noble Baroness, Lady Finlay, that the QOF is a separate issue, but I can say that the whole of the QOF is kept under review in consultation with the profession to ensure that it reflects the best available evidence and supports continuous improvement in the quality of care for patients. Over the coming months we will continue to discuss with the profession and its representatives how to focus the QOF on securing better healthcare outcomes and what that means for existing GP contractual arrangements.

I turn to the final amendment in this group, Amendment 95A. The Bill already ensures that the board has the information that it needs to demonstrate how it has fulfilled its duties. CCGs are required to provide information to the board in the form of the annual commissioning plan and annual report. In addition, the board and CCGs are under a duty to co-operate. In the normal course of business we expect this to involve the sharing of information as necessary but, in the event that a CCG might have failed, be failing or fail to discharge any of its functions, the board’s powers enable it to require any information or documents that it considers necessary from CCGs.

The noble Lord, Lord Hunt, posited the situation that there might be reluctant GPs who did not fulfil their part of the bargain, whatever that was, with the acute sector. There needs to be a way of investigating allegations that actions by GPs in their practices are adversely affecting a clinical commissioning group. Where a general practice is operating in such a way that it is a barrier to a clinical commissioning group meeting its functions, it will be for the commissioning group to work with the members of that general practice to support it to improve and contribute to the work of the commissioning group as a whole. Ultimately, if it is unable to do so, a clinical commissioning group may need to refer such cases to the NHS Commissioning Board, along with the evidence of the failure of the practice and details of any support that the commissioning group has provided to the practice to help it overcome any perceived difficulties.

Among other matters, the board may wish to consider if the practice’s actions are in breach of the practice’s primary medical services contract. Separately, the NHS Commissioning Board will have the power to investigate the suitability of individual GPs under the medical performers list provisions. As the noble Lord will know, this power is currently with primary care trusts.

In a nutshell, therefore, the Bill already imposes a duty on CCGs in respect of the mandate and allows the board to ensure that CCGs fulfil it. Further specific requirements in relation to providing information to the board are therefore unnecessary, so I hope that what I have said reassures the noble Lords, Lord Kakkar and Lord Patel, sufficiently to enable them to withdraw their amendment.

[Lord Kakkar]

My Lords, I thank the Minister for, as always, his thoughtful response and consideration of the amendments. I remain somewhat anxious about whether there is going to be sufficient attention and opportunity to deal with the question of performance in primary care and the management of that performance to ensure that the very best clinical outcomes are achievable for all patients across the country.

I welcome much of what the Minister has said with regard to potential further consideration of how mechanisms other than a specification in the mandate on the question of primary care performance might work. I wonder whether it might be possible for him to enter into further dialogue on this matter so that there can be clarity. It would be unhelpful for the future if a great emphasis were placed—in fact, if there were a momentum—on moving practice from the secondary care environment, where there is a relentless evaluation of clinical outcomes and which has done so much to improve clinical outcomes for our patients because of the attention paid to those matters, into a primary care environment where an objective assessment of outcomes was not always possible and where, as a result, what we all hope will be achieved through the Bill—a health gain for patients and population—might therefore inadvertently be lost. With the opportunity to have a further conversation with the Minister prior to Third Reading, I beg leave to withdraw the amendment.

Health and Social Care Bill

Debate between Lord Kakkar and Earl Howe

Monday 14th November 2011 Lords Chamber

[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.

NHS: Clinical Excellence Awards

Debate between Lord Kakkar and Earl Howe

Monday 27th June 2011 Lords Chamber

[Earl Howe]

My Lords, those who hold honorary contracts, who are in general clinical academics, are well represented among those who are awarded clinical excellence awards. We are absolutely clear that that should continue as long as possible. We must incentivise those who do not spend the bulk of their day engaged in treating patients so that we ensure that we have a bank of academic excellence driving forward innovation in the NHS.

[Lord Kakkar]

My Lords, what role do Her Majesty’s Government see for the academic health science centres in promoting clinical excellence? In asking the question I remind the House of my interest as a director of the UCL Partners academic health science centre at University College London.

Drugs: Prescribed Drug Addiction and Withdrawal

Debate between Lord Kakkar and Earl Howe

Thursday 23rd June 2011 Lords Chamber

[Earl Howe]

My Lords, the responsibility for commissioning these services in future will lie with local authorities, supported by Public Health England. The noble Baroness will be aware that it is our proposal to ring-fence the public health budget. Local authorities will be informed by the joint strategic needs assessment that they carry out and will work in partnership with local delivery organisations and with local GPs, who, as I have mentioned, will be even better informed than they are at the moment thanks to the Royal College guidance.

[Lord Kakkar]

My Lords, how much research into the problem of prescribed drug addiction is being supported by the National Institute for Health Research?

[Earl Howe]

My Lords, I am afraid that I do not have that figure in my brief, but I shall write to the noble Lord if it is available.

NHS: Waiting Times

Debate between Lord Kakkar and Earl Howe

Tuesday 3rd May 2011 Lords Chamber

[Earl Howe]

My Lords, first, referral-to-treatment times fluctuate. Having looked at how the figures have moved over the past year or two, my advice is that they are broadly stable. The figures to which the noble Baroness referred were struck at a particularly pressurised time for the NHS. As she knows, there are all kinds of reasons why during the winter referral-to-treatment times tend to lengthen. However, the right in the NHS constitution to be treated within 18 weeks remains. On accident and emergency waiting times, our clear advice from clinicians was that the four-hour target should be adjusted to reflect the clinical case mix and clinical priorities.

[Lord Kakkar]

My Lords, I am sure the noble Earl is aware of the recent report from the Royal College of Surgeons on emergency surgical standards. Does he share its concerns about the potential detrimental impact of waiting list targets for elective procedures on clinical outcomes for patients requiring emergency operations? In asking the question, I declare an interest as a practising surgeon and professor of surgery.

[Earl Howe]

My Lords, we are quite clear that timeliness remains an important ingredient in the care of patients. However, we are also clear that it is not the only measure of quality. On emergency surgery, there is no reason to expect that patients will be treated any less urgently in the future than they have been in the past. What matters is clinical priorities being set correctly.

NHS Reform

Debate between Lord Kakkar and Earl Howe

Monday 4th April 2011 Lords Chamber

[Earl Howe]

My Lords, when we went out to consultation on the White Paper last summer, concerns were raised that the transition could lead to too much disruption and a decline in the quality of services, as well as a loss of accountability, so the department decided to expand the approach to managed consolidation of PCT capacity and establish the clusters nationwide. That has been done already in London and the north-east and will pave the way for the NHS commissioning board to develop its roles. It will maintain accountability and grip during 2011-12 and the subsequent year, once strategic health authorities have been abolished. We are using existing legislative powers and it will help to oversee delivery in the coming two years.

[Lord Kakkar]

Is the Minister able to confirm that the future GP commissioning consortia will be constituted in such a way that they are obliged to conduct their responsibilities according to the Nolan principles?

NHS: Prebiotics

Debate between Lord Kakkar and Earl Howe

Wednesday 17th November 2010 Lords Chamber

[Earl Howe]

My Lords, I merely meant to indicate that we would welcome good-quality proposals. On probiotics, I understand that one study using live yoghurt showed a patient benefit but my advice is that the study methodology was flawed and its findings were not generalisable. Probiotics are not therefore recommended, as studies have failed to show any convincing evidence that they either treat or prevent C. difficile infection.

[Lord Kakkar]

My Lords, is the noble Earl concerned about the presence of the potentially more aggressive and resistant forms of C. difficile that have been identified in our hospitals? What action is being taken to ensure that they do not spread more widely?

[Earl Howe]

My Lords, the noble Lord is absolutely right. It is appropriate for me to emphasise that, as he will well know, inappropriate prescribing of antibiotics is above all what has caused the high levels of infection that we have seen in recent years. The use of broad-spectrum antibiotics predisposes people to C. difficile infection, so it is important that those in the health service understand the cause and effect relationship involved.

It is also worth mentioning that tomorrow is European Antibiotic Awareness Day, so it is appropriate that this Question has been asked today.

Healthcare: Costs

Debate between Lord Kakkar and Earl Howe

Monday 15th November 2010 Lords Chamber

[Earl Howe]

The noble Baroness is quite right, and I am well aware that she speaks from personal experience. Many hospital trusts, and indeed GPs’ surgeries where applicable, have devised inventive ways of reminding patients of their appointments, either on the day or on the day before, perhaps by text. Good practice in this area is something that we need to focus on.

[Lord Kakkar]

My Lords, clinical leadership is critical if we are to secure the greatest benefit for patients from NHS spending and the appropriate use of resources. What strategies do Her Majesty's Government have for developing clinical leadership in the NHS? I declare an interest as patron of UCL Partners’ NHS staff college.

[Earl Howe]

Again, my Lords, the noble Lord is absolutely right to focus on clinical leadership, which will be critical if we are to deliver the improvements in the quality of care that we wish to see, and also to roll out the vision laid out in the Government's White Paper. The department has a number of initiatives under way, as do deaneries in strategic health authority areas around the country, to promote clinical leadership. There are also active programmes in acute trusts. Without good clinical leadership, the programme cannot proceed as we all hope and wish.