Healthwatch England

Lord Lansley Excerpts

Tuesday 26th April 2016 Lords Chamber

[Lord Prior of Brampton]

I disagree. I had a private sector background when I became chairman of the CQC, I might add, so perhaps I am slightly biased in this regard. Having a mix of people from all different backgrounds, whether private, public or voluntary sector, is a very good thing.

[Lord Lansley (Con)]

My Lords, would my noble friend the Minister agree with me, as one who was responsible for the creation of Healthwatch, that there is a powerful rationale for its close working relationship with the CQC? The CQC needs to listen to the patient voice in the exercise of its responsibilities, and Healthwatch benefits significantly from being able to trigger action by the CQC where it finds that things are going wrong.

[Lord Prior of Brampton]

I agree with my noble friend. Healthwatch has two principal roles: first, to gather intelligence locally, which it can then feed into the CQC and its inspections; and secondly to be the strong voice of patients at a national level.

Royal National Orthopaedic Hospital: Redevelopment

Lord Lansley Excerpts

Thursday 17th March 2016 Grand Committee

[Lord Lansley (Con)]

My Lords, I am pleased to have the opportunity to contribute to the debate and to join colleagues in congratulating the noble Baroness, Lady Dean, on securing the debate and on the way she introduced it. She absolutely captured a sense of what the RNOH is and has been, and what it means for the patients whom it has looked after.

In that respect, I share with my noble friend Lord Tebbit a sense of gratitude for how the RNOH has looked after Margaret Tebbit. Indeed, it was at exactly the same time 30 years ago that I first got to know Stanmore because I was the Civil Service Private Secretary to my noble friend, who was then Secretary of State. When I was not carrying his box to and fro at Stanmore, I was learning about the hospital. About 25 years later, it was somewhat ironic that my noble friend was lobbying me as Secretary of State to secure the rebuilding of Stanmore. I believe he was right when he said that it would have been wholly wrong to have pursued the PFI route to secure the rebuilding of Stanmore. It was my responsibility in 2011 to say that that was not the way I thought Stanmore should go. I am pleased that that is not the way that the RNOH chose to go.

I will quickly say three things. First, I believe in specialist institutes in the NHS. That was not always the case. I remember that probably 25 or so years ago, Stanmore was being pushed to merge with Northwick Park. Subsequently, there were other proposals for the hospital to be absorbed into a large trust. All the evidence tells us that this is the wrong way to go. Amazingly, specialist institutes in the orthopaedic field, not just the RNOH but the Robert Jones and Agnes Hunt Orthopaedic Hospital in Gobowen near Oswestry, obtain excellent results. That is true for clinical outcomes and for innovation and research. When we introduced the friends and family test, I was especially struck by what fantastic numbers the specialist institutes, such as Stanmore and Gobowen, got on recommendations through the friends and family test from staff and patients. That is incontrovertible. That being the case, we have to find ways to support them where they are.

Secondly, the partnerships that they create are tremendously important. Papworth Hospital in my former constituency is going alongside Addenbrooke’s. It will remain a specialist institute but it needs to be alongside for clinical partnerships and research partnerships. Given its location, Stanmore does not need to move anywhere else for these partnerships to function. Indeed, as the noble Baroness said in introducing the debate, it has drawn UCL into an excellent bioengineering centre based at Stanmore. That is evidence of the partnerships that are integral to specialist institutes’ future success, not least because they need to be part of the academic health science networks to make that success work. Creating those partnerships is tremendously important and can secure its position.

Thirdly, and finally, however, we need to understand where the difficulties lie. RNOH is an extremely well-run hospital and has been for a very long time. The calibre of staffing and clinical leadership is excellent. For example, when we looked at MRSA bloodstream infections, notwithstanding the circumstances in which RNOH works, I do not think it has had such an infection for about seven years. That is a wonderful record. When you look at clinical leadership, Tim Briggs, a clinician at Stanmore, has been integral to the work that the noble Lord, Lord Carter, and his team are doing on delivering improvement and efficiency by demonstrating how it was done at the RNOH.

However, since the NHS is the overwhelming customer for this work, it is very hard if the tariff does not support it. We must recognise that the heart of the issue lies in the prudential work done by the TDA—and before it by the strategic health authorities and others—to ensure that the project and the hospital are financially sustainable for the long run. Frankly, it is not just about asking, “Is this a good project?” or, as my noble friend asked, “Do the numbers all stack up?”. I am sure that it can be afforded in the sense of borrowing being available, but what also needs to be affordable in the long run is the revenue to support it. That is where NHS England and Monitor, working together, need to bring in tariffs—not least through the latest iteration of ICD tariff structures when they get to them—that recognise the additional costs involved in the complex and specialised work done by hospitals such as the RNOH. Many big hospitals used to be able to carry such specialist work in the midst of very large amounts of routine work, but a specialist institute cannot do that. Indeed, many large hospitals cannot afford to do it now either. We need the NHS and Monitor together to design a tariff that recognises not only the quality but the cost involved in continuing to deliver this world-leading work.

Mental Health Taskforce

Lord Lansley Excerpts

Tuesday 23rd February 2016 Lords Chamber

[Lord Lansley (Con)]

My Lords, does my noble friend the Minister agree that in order to secure parity between physical and mental health services, it is important to ensure that mental health service providers are properly and fairly reimbursed for the activity they undertake rather than subject to a block grant system where physical health service providers are paid for the work they do? In that respect, will the Government commit to working with NHS England and NHS Improvement to make progress now in the development of tariff-based systems for mental health services which fairly reimburse for delivering quality in outcomes?

[Lord Prior of Brampton]

My noble friend is absolutely right. I am glad he finished by referring to quality in outcomes rather than just activity. That is the critical thing about getting the tariff right, that it is based not just on activity but on quality in outcomes.

Junior Doctors

Lord Lansley Excerpts

Monday 8th February 2016 Lords Chamber

[Lord Prior of Brampton]

It was always agreed that the package offered to junior doctors would be cost-neutral.

[Lord Lansley (Con)]

My Lords, does my noble friend the Minister recall, as I do, that it was a Conservative Administration who introduced the new deal for junior doctors and established a process by which unsafe, excessive hours for doctors were not to be pursued? That started happening in the early 1990s and no one is thinking that we would go back to that. I was delighted that my noble friend was able to make it clear how the negotiations can introduce additional guarantees about not having unsafe hours for junior doctors. However, I put it to him that at this stage in the negotiations there may be an alternative approach—an objective of enabling seven-day rostering for junior doctors, in this instance but also more widely, and an overall financial envelope. It might be put to the BMA that rather than it standing aside from the negotiations, it should take responsibility and say how it proposed that junior doctors should be remunerated within that financial envelope to meet those objectives.

[Lord Prior of Brampton]

My Lords, we certainly do not want to go back to the days when junior doctors were working very long and unsafe hours but nor should we ignore the fact that they do not, by and large, like being treated as shift workers. The continuity of care is very important to most professional doctors. As for the actual negotiations, I have not been directly involved with them so I do not know to what extent the junior doctors have been asked to consider what my noble friend Lord Lansley has suggested. However, what he says has much merit.

Health and Social Care: State Pension

Lord Lansley Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I am afraid that I cannot today give my noble friend that chink or that hope, because we are supporting the NHS’s plan, which was developed and produced by the NHS. We believe that it would be wrong to set up an alternative at this stage.

[Lord Lansley (Con)]

My Lords, would my noble friend agree that, while the Government are fully funding the NHS five-year forward view, which is very welcome, the sustainability of NHS funding depends on the sustainability of social care services as well? Before establishing any other commissions, would not it be advisable for the Government to make progress on implementing the Dilnot commission’s recommendations? In that respect, will the Government specifically consider enabling that to proceed by removing the exemption on one’s principal personal residence when calculating the means test for domiciliary social care?

[Lord Prior of Brampton]

My Lords, as my noble friend knows, the Government accepted the findings of the Dilnot review but felt that now was not the right time to introduce them, given the financial pressures on local government. We are committed to introducing the Dilnot reforms by the end of this Parliament.

National Health Service

Lord Lansley Excerpts

Thursday 14th January 2016 Lords Chamber

[Lord Lansley (Con)]

My Lords, I join noble Lords in thanking the noble Lord, Lord Turnberg, for this debate and I look forward to the maiden speech from the noble Baroness, Lady Watkins. With regard to debates, I put on record that it would be very useful for this House in particular each year in the late autumn to debate the draft mandate that the Government give to NHS England. That is the primary basis upon which the accountability through the Secretary of State to Parliament should be exercised. It was not debated here or in the other place, and it should have been.

I am very proud that, as my party’s spokesman over nearly 10 years, we made unambiguous and absolute our commitment to the values and constitution of the NHS, as my noble friend Lord Fowler equally made clear, and that we made a commitment to increase the budget of the NHS in real terms. Frankly, in the last Parliament it was 0.5% in real terms on average per year; the long-term average has been something over 4% in real terms per year, so the pressure on NHS budgets is unambiguous.

I agree with the noble Lord, Lord Turnberg, that the only reason that in 2014 the Commonwealth Fund could say that we had the best healthcare system among leading economies was because NHS staff deliver a superb service with modest resources. Over the last five years, they continued to deliver substantial efficiencies; in doing that they met the so-called Nicholson challenge of delivering £20 billion. We did it in part not least because—my noble friend the Minister and his colleagues hid this away on 21 July last year—the reform process cost £1.4 billion but delivered £6.9 billion of direct savings during the course of the last Parliament.

However, we need to do more in the future. Time does not permit me to do more than list the things we need to do. We need an NHS digital infrastructure that is user led and that delivers what the Wanless report called for but which did not happen. We need a preventive system. In the creation of Public Health England, the responsibilities of local authorities and the public health strategy in the White Paper of 2010-11 there is a strategy, but it needs to be funded, as my noble friend said, and as Wanless recommended, it needs to be delivered. On commissions, Wanless is a cautionary tale. To agree that a large amount of money should be available for the NHS does not necessarily deliver the preconditions for the success of that service in using that money effectively. We also need new models of care—integrated and personalised care—and better procurement, on which I look forward to hearing from the noble Lord, Lord Carter of Coles. We need the Dilnot report on social care to be implemented, as we heard in the debate before Christmas. Not least, we need tariffs for the acute sector to be realistic, even if challenging in terms of quality and efficient care.

Finally, we need a long-term future for the NHS, and I am not just referring to the next £20 billion of efficiencies over the next five years. There needs to be an understanding that, while there is a requirement to continue to be efficient, there is light at the end of the tunnel and that when we get to 2020 and beyond, the NHS budget, having gone down from 7.8% to probably 7.1% of GDP, does not go down any further and prove unrealistic in relation to rising demand. From that point onwards, for the subsequent five years, NHS England can then build a vision around a commitment to a sustained level of NHS funding relative to the income and wealth of this country.

Four Seasons Group

Lord Lansley Excerpts

Monday 11th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the idea of having a commission has been discussed a number of times in this House, and there will be a long debate on this matter on Thursday. In the spending review the Government are enabling local authorities to increase their precept by 2% and they are increasing the contribution to the better care fund by £1.5 billion, which will see a real increase in the resources available for adult social care.

[Lord Lansley (Con)]

My Lords, does my noble friend agree that in circumstances of provider failure one of the most important things is for residents to be maintained in their existing homes? In fact, that was achieved in the overwhelming majority of cases following the Southern Cross collapse. It is often possible to separate the going-concern basis of individual homes from the commercial situation of the provider as a whole.

[Lord Prior of Brampton]

I fully agree. Our interest is in the residents in the homes. The CQC’s oversight regime is not intended to prop up a provider—that is an entirely different matter. My noble friend is absolutely right that when Southern Cross went into insolvency, very few homes—in fact, I do not think that any homes—closed as a direct result at the time; most of them carried on as going concerns.

Residential Care: Cost Cap

Lord Lansley Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Lansley (Con)]

My Lords, I am grateful to have the opportunity to contribute to this debate and to thank the noble Baroness, Lady Wheeler, for initiating it. It is my privilege, not having been here for long, to hear your Lordships on this important subject.

It is important that we are discussing this two weeks after the Autumn Statement and the spending review. I am sorry that the noble Baroness, Lady Wheeler, characterised the spending review, albeit perhaps quoting others, as she did at the end of her remarks. I think that the spending review offered considerable additional resources over the course of this Parliament. I am frank and realistic enough to recognise, not least from conversations with directors of adult social care over the past couple of weeks, that they are sufficient at best to maintain the level of local authority-funded care in circumstances where the demand continues to rise and therefore the gap between availability and demand will grow. At worst, we will be in the situation, as we have been recently, where the availability of local authority-funded care has been falling at a point where demand is rising.

The noble Baroness’s point that there is a need for strategic vision is well taken. It is not simply a matter of resources, even though they are an integral part of the issue. Some of that strategy is being implemented and more is available to us. I pay tribute to my friend Paul Burstow who was a Minister with me in the Department of Health. In the coalition Government, we led together on the preparation of what subsequently became the Care Act. It contains a very important set of measures, including the availability of assessments, additional carers’ rights, more consistent eligibility for care and the availability of universal deferred payments.

We need to go further. Social care and healthcare need to be integrated. Everybody supports that in terms of the integration of service design and commissioning, but, vital as that is, we can and must go further. Integration will only be real if and when care users are increasingly able to exercise control and choice through personal health and social care budgets. To make that real we have increasingly to aggregate the availability of personal health and social care budgets to those care users so that the service providers have an aggregated level of demand to be able collectively to respond and create a market for this.

We must also recognise that this will mean integrated providers with the NHS working with private sector social care providers and housing providers. There is enormous potential for housing providers and other services, particularly personal care services, to redesign the nature of the service they provide. For example, extra care housing providers together with social care providers are able to put together packages that work really well for people who are able to choose between different kinds of accommodation and service.

Time permits me to say one more thing which I think is really important. Much of what we already have in place is the product of the implementation of the Dilnot commission’s view. I hesitate because I may be stealing the thunder of the noble Lord, Lord Warner, and others in the Chamber who may have participated in equivalent work on prior commissions. I asked Andrew Dilnot and others to undertake that work and I think the result was important and right. We have included some of it in the Care Act. The Government have not implemented the cap on care costs and, to be frank, the cap that was intended was in my view insufficient. I continue to subscribe to the view that we should aim to implement a cap on care costs broadly in the way that the Dilnot commission recommended, at around £50,000 with a structure of assessment that means that probably no more than 40% of somebody’s assets would be depleted in the process of means-testing.

The combination of these two things would make it attractive to individuals to insure against this risk in so far as they have to meet that cost, and by taking away a much more substantial part of the risk of high-cost care over a longer period of time make it a more insurable risk for private sector insurers. Additionally, since the Dilnot commission reported we have more options in relation to pension flexibilities, and we always have housing asset flexibilities to enable these insurance products to become available if it is necessary for us to have those resources come into the system.

The original intention for the implementation of Dilnot before the election was that it would be funded out of inheritance tax and changes to opting out of national insurance. That moment has gone, but in internal discussions in 2012 from my point of view we were very clear about how this ought to be paid for, but it was not acceptable inside government. There was not agreement to do it because within the system we have discrimination against residential care in favour of domiciliary care. That creates an artificial distinction that we have to escape from, which is the exemption of the main or only home for the means test on charging for domiciliary care. At any given moment, about 120,000 people benefit from that, and £1.3 billion a year is available to them by virtue of that exemption. That is broadly speaking the amount that is necessary to construct a different proposition for people who are facing the insecurity of potentially very high long-term care costs. We need to go beyond simply enabling people not to have to sell their home to pay for care and give them the security of being able to find, as you do in so many other walks of life, the opportunity to insure against the often arbitrary effects of having to receive long-term care in old age.

Alcohol

Lord Lansley Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, I can only repeat that we will have an independent review of the responsibility deal, at which point we will have objective evidence on which to assess it. I agree entirely with the noble Baroness that the health world, including the BMA and many of the royal colleges, takes a very strong view about alcohol. Many doctors see the appalling impact that it has on individual lives day in and day out, so we take their views extremely seriously.

[Lord Lansley (Con)]

My Lords, can I tell my noble friend the Minister—

[Noble Lords]

Ask.

[Lord Lansley]

Can I ask my noble friend the Minister if he agrees that the report from the Institute of Alcohol Studies is purely polemical in character and not a research report at all? Actually, its argument is based on a flawed proposition, which is that the pursuit of voluntary agreements through the responsibility deal prevented the pursuit by government of minimum unit pricing. Does my noble friend agree that from the very outset of the responsibility deal, it was made clear to the industry that its pricing of alcohol and indeed the Government’s attitude in terms of tax and pricing were no part of the responsibility deal, and that within government no discussion of minimum unit pricing was affected by the fact of the responsibility deal?

[Lord Prior of Brampton]

I am happy to be told that by my noble friend and I can only agree with him.

Junior Doctors Contract

Lord Lansley Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Prior of Brampton]

There is a recognition that the weekend effect is caused by many factors. It is certainly not just the ability of trusts to roster junior doctors at weekends but the absence of senior cover and the fact that much diagnostic capacity is not available at weekends. Of course, you also have to be able to discharge patients at weekends, which means that social care has to be working as well. To have a truly seven-day NHS requires a lot more people and resources to be available than just junior doctors.

[Lord Lansley (Con)]

My Lords, my noble friend the Minister’s repetition of the Statement and what he was able to say additionally in response to noble Lords was very welcome. Does he agree that going back more than 20 years, to when the new deal for junior doctors was first brought in and we supported them on their concerns about Modernising Medical Careers, we on these Benches have never been lacking in support for junior doctors? We understand that when one is on the ward in a hospital at the weekend, very often the doctor who you see is a junior doctor. The point is that it is in the best interests of junior doctors and patients for seven-day working to be introduced, with proper rostering, rather than discriminating between Monday to Friday and the weekend as if they were different parts of what is in truth the same service. If we get it right, as my noble friend says, it should be possible to achieve such an agreement without bringing any detriment to junior doctors as a consequence, but rather by supporting them in the work that they have to do.

[Lord Prior of Brampton]

I thank my noble friend for those comments. One of the issues often raised by junior doctors is that they do not always feel properly supported at weekends. I think that having more seniors available at weekends—and late at night, for that matter—will be welcomed by junior doctors. There is also sometimes a misunderstanding in the public mind, as junior doctors can actually be quite senior doctors. A medical registrar is, by most standards, a senior doctor so junior doctors are not just people who have recently finished their training.