Children and Families Bill

Lord Patel Excerpts

Wednesday 29th January 2014 Lords Chamber

This has been an interesting debate. Is it better to have legislation or a public-education campaign? The latter would probably be effective. My own view, backed up by the statistics on wearing seat belts given by my noble friend Lady Finlay, is that having the two together is the most effective. We are not talking either/or; it is a clear case of both/and. I hope that today we send out a message, loud and clear from this Chamber, that it is simply not acceptable to expose your children to second-hand smoke in the car.

[Lord Patel (CB)]

My Lords, I am delighted to take part in this debate. Before I start, I shall not miss this opportunity to chide both Front Benches. I have spoken about this in the past and tabled many amendments on different health Bills. The last time that I tried was with the Labour Government. The Minister taking the legislation through was not the noble Lord, Lord Hunt, but the noble Baroness, Lady Thornton. I did not succeed on that day in getting my amendment through. Obviously, the government Benches were not going to support me, but I did have the support of the noble Baroness, Lady Barker, who is not in her place and who was the Front Bench health spokesman of the Liberal Democrats. I did not have the support of the noble Earl, Lord Howe, at the time—hence I did not succeed.

However, I am delighted to congratulate the Government on having, in a step-wise fashion—and as a result of efforts made by many other noble Lords, including the noble Baroness, Lady Finlay, and the noble Lord, Lord Faulkner—reached a place where they can bring forward an amendment to address the public health evidence that plain packaging will make a difference to the uptake of smoking of cigarettes, in particular by children. I am particularly delighted that the government amendment includes not just external packaging but internal packaging. I remember my days as a young medical student, when one would rush out and buy Sobranie Black Russians because the cigarettes were wrapped in nice black paper with gold tips. At the same time, we would also buy a packet of Sobranie Cocktails to impress the ladies we were taking to dances because they came in multicoloured wrappers—so packaging makes a difference, even to a young medical student.

I am therefore delighted to see the Government’s amendment. I have no doubt whatever that Sir Cyril Chantler, whom I know well as a friend, will be absolutely meticulous in looking at the evidence. I am convinced by the evidence and I hope that he will be, too.

Let me turn to the issue of smoking in cars when children are present. I have taken the trouble to look at all the evidence about second-hand smoke in confined spaces. I have looked at the public health evidence from the Surgeon General of the United States, from Australia, from New Zealand and from Great Britain—both epidemiological and observational studies. The findings are quite interesting: undoubtedly, second-hand smoking is harmful. It is harmful to children—more so because their metabolic rate is higher, so any injurious substances that they inhale are bound to have a greater effect. It is harmful also to adults, particularly older people who have respiratory conditions or cardiac disease. It is harmful also to pregnant mothers who do not smoke, among whom there is a higher rate of still-births and infant deaths because of the epigenetic effects of the inhalation of injurious substances during their pregnancy. It is worse if they smoke during their pregnancy, but even if they do not, the effect of second-hand smoke is harmful to them.

There is further evidence, mentioned by the noble Lord, Lord Ribeiro, that some of the injurious substances in tobacco smoke persist on certain surfaces for a very long time. So this issue is not just about smoking when there are children in a car; it is also about making that car harmful to children because injurious substances persist. That also applies to any confined space. So the question is: what legislation will have the greatest public health effect? Will it be legislation that stops smoking in cars when children are present? Will it be legislation that bans smoking completely? Of course, it will be the latter, but that will not be possible—such legislation is too draconian. Could it be a good educational programme that teaches people that if you smoke in front of children, whether in a confined space or in an open space, or if children just see you smoking, that is wrong and harmful?

I was accused by my wife of smoking 20 to 40 cigarettes a day. All young doctors smoked in those days; it was the thing to do. Not all doctors smoke these days. When I saw my daughter, who was 11 months old, watch me lighting a cigarette, it was the day that I stopped smoking. She might object to me giving her age, but she is past 40—just, and she is a cancer doctor, so she understands these things. I felt that her observing me lighting a cigarette would be as harmful to her as her taking up smoking. The issue that we should therefore debate is what would have the greatest public health gain, whether for children—more importantly for children—or for young adults, older people and pregnant mothers.

The amendment of the noble Lord, Lord Ribeiro, seeks more targeted education and some consultation to find the evidence. The amendment of the noble Lord, Lord Hunt, seeks to have on the statute that a regulation must be brought in. I was talking about regulations pertaining only to cars. The evidence that I have looked at would suggest that we should ban smoking in cars completely, because that way there would be no possibility of anybody smoking in cars and leaving injurious substances behind that may harm children. That may or may not be a better deal than that proposed by the noble Lord, Lord Hunt, but my plea is, “Let us look at what would be the best public health gain”.

[Lord Cormack]

My Lords, I begin by congratulating my noble friend Lord Howe on his amendment. I wholly support what he said about packaging and about appointing Sir Cyril Chantler. I have the good fortune of knowing Sir Cyril. Like the noble Lord, Lord Patel, who spoke a moment ago, I believe that he is a man of impeccable integrity and great knowledge and I am sure my noble friend could not have chosen anyone better. I do not want to dilate on that subject.

I have smoked two cigarettes in my life. I was 15 years old; they were Woodbines and it was behind the bike shed. They were thoroughly disgusting—I have never smoked since and I never want to smoke. I am afraid I cannot say the same for my wife, although I think she has cut down a bit; she certainly does not smoke in my presence, either in the car or at home.

It is beyond doubt that we can and should accept everything that has been said about the dangers of smoking by the noble Lord, Lord Patel, and my noble friend—my friend in every way—Lord Ribeiro. We should do everything possible to deter people from smoking. I am sure I speak on behalf of everyone in congratulating my noble friend Lord Ribeiro on the birth of his grandson. I would be entirely in favour of the parents of the grandson of the noble Lord, Lord Ribeiro, being sent a note about the dangers of smoking. I would be entirely in favour of the parents of every newborn child being specifically warned about the dangers to children of passive smoking. I would be entirely in favour of increasing the taxes on cigarettes. I would be in favour of extra insurance premiums for people who smoke. I would not object to there being a column about smoking on car insurance forms, and, if you tick the smoking box, there being an extra premium that goes directly to the battle against smoking. I would be entirely in favour of all those things or permutations of them. There are many that we could all think of.

However, when it comes to the question of smoking in motor vehicles, my noble friend Lord Ribeiro introduced his amendment skilfully, tactfully and undogmatically. I have no argument with that, but I believe that his essential premise is wrong. To advocate any law that is going to be exceptionally difficult to police and enforce, and moreover brings the state into the private space of individuals, is to be deplored.

Health: Flour Fortification

Lord Patel Excerpts

Tuesday 21st January 2014 Lords Chamber

[Earl Howe]

The noble Lord is absolutely right. I agree with him that the incidence of rickets is a cause for concern. At the same time, he characterises the case for mandatory fortification as incontrovertible. There are risks that SACN pointed out. Its advice to government stated that fortification of flour with folic acid might have adverse effects on neurological function in people aged 65 years and over with vitamin B12 deficiency. Treatment with folic acid can alleviate or mask the anaemia and therefore delay the diagnosis of vitamin B12 deficiency, which can lead to irreversible effects.

[Lord Patel (CB)]

The noble Earl referred to two things. His immediate answer just now suggested that folic acid levels might interfere with B12 anaemia in older people. That would require a dosage of about 15 milligrams per day; the dosage we are talking about for fortification would hardly reach 1 milligram per day. The risk, therefore, is pretty minimal. Secondly, he suggested in his opening Answer that the folate level of the population might help to devise the policy. How would that help to devise the policy for women in early pregnancy who need the folic acid to reduce the incidence of neural tube defects?

[Earl Howe]

I am sure the noble Lord would agree that we have to take a decision based on the most up-to-date data. The data that we had prior to this were 10 years old and it is important to take a decision in the context of the nutritional state of health of the population. On his first question, all I can say is that the risk to which I referred was considered as part of SACN’s overall assessment and we will draw on that in reaching our decisions on the fortification of flour and give it the appropriate weight that it deserves.

Health: Birth Defects

Lord Patel Excerpts

Wednesday 18th December 2013 Lords Chamber

[Earl Howe]

My Lords, we recognise that some women do not always access maternity services early or attend regularly for antenatal care, and that poorer outcomes are therefore reported in some cases for mother and baby. Maternity services need to be proactive in engaging all women. To help reduce variation and improve services, NICE has published a comprehensive suite of evidence-based clinical guidelines and quality standards for maternity services. We are also promoting the taking of folic acid supplements through a number of channels including Healthy Start, NHS Choices, Start4Life, and the Information Service for Parents.

[Lord Patel (CB)]

My Lords, what do the Government think are the contraindications for fortifications of flour with folic acid, knowing that the evidence shows that it would cause a reduction of about 300 in the number of babies born with neural tube defects?

[Earl Howe]

My Lords, I recognise the opinion that is shared among many members of the medical community on this. However, the advice we received from SACN, our expert adviser, clearly showed that there are risks and benefits associated with this proposal. It is not an open-and-shut case. Among the things that we have had to consider are the practical implications of implementing SACN’s advice, which is no small matter.

G8 Summit on Dementia

Lord Patel Excerpts

Tuesday 17th December 2013 Lords Chamber

Asked by

[Lord Patel]

To ask Her Majesty’s Government what was the outcome of the G8 dementia summit.

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

My Lords, the G8 agreed to work together to tackle and defeat dementia. The declaration announced the G8’s ambition to identify a cure or a disease-modifying therapy by 2025 and to increase collectively and significantly the amount of funding for dementia research. The G8 also welcomed the UK’s decision to appoint a dementia innovation envoy who will work to attract new sources of finance, including examining the potential for a private and philanthropic fund.

[Lord Patel (CB)]

My Lords, I thank the Minister for his reply. Dementia is the dreaded diagnosis, particularly for the elderly, as it affects more than 5% of people over 65 and between 20% and 40% of those aged over 85. Because of the increasing number of elderly people, an increasing number of people are affected. I commend the Government and congratulate them on taking the initiative at the G8 and particularly on involving the WHO, because now it will become a global initiative. I have two questions. The first is about the funding that the Government announced. There is a great deal of confusion. Is it new money, money that has already been allocated to research or money that the Department of Health is giving for better diagnosis of dementia? Research on dementia must also focus more widely on understanding the biology of the disease, the inflammatory process and the epidemiology. Ring-fencing around a disease will not necessarily get to the point that the Government wish to get to. Secondly, what impact do the Government think the EU regulation on data protection will have on dementia research?

[Earl Howe]

The noble Lord asked a number of questions. The Government have stated an ambition to double research funding in dementia. That will depend on the quality of the proposals that come forward and on the rate of scientific progress. We very much hope that arising out of the summit, momentum will be gained, not only in this country but internationally. As regards the noble Lord’s second question, we recognise how important this is for future dementia research and I can tell him that the Government, through the Ministry of Justice, are negotiating with member states in Europe and are aware of the impact that the proposal would have on research. It is likely to be some months before there is an agreed approach between member states and the Commission, and the Parliament is unlikely to vote on the proposal before 2015.

Tobacco: Packaging

Lord Patel Excerpts

Thursday 28th November 2013 Lords Chamber

[Lord Patel (CB)]

My Lords, I declare an interest as a fellow of several medical royal colleges, the Academy of Medical Sciences and the Royal Society of Edinburgh, which have all previously backed, and continue to back, the argument that legislation should be brought forward to make cigarette packaging plain. I have spoken on many occasions in relevant debates under both this Government and the previous one and have tabled amendments to bring in legislation for the plain packaging of cigarettes. I have done so on the basis that the evidence is conclusive, as shown by both the British Heart Foundation and Cancer Research UK, that glamorised packaging is used by the industry to recruit young, new smokers. Now we have to wait until the evidence is produced by Sir Cyril Chantler. Disappointed though I am that we cannot legislate now, I can afford to wait a few months because I know that Sir Cyril Chantler, who is a friend, is a man of principle and will look at the evidence as it is. However, once that evidence is presented, what is the timeline for the Government to introduce legislation for plain packaging?

[Earl Howe]

My Lords, I am grateful to the noble Lord, who has indeed been a consistent champion for plain packaging over the years. I also appreciate his endorsement of the choice of Sir Cyril Chantler to lead this review. Noble Lords will know that Sir Cyril has a very distinguished record as an academic and paediatrician. As regards the timeline, I cannot be definite at this stage. All I can say is that, should the Government decide to lay regulations in the light of Sir Cyril’s recommendations, we believe that, taking into account a period of consultation and the statutory provisions surrounding European law, we would be able to introduce the regulations within a reasonable time.

NHS: Clinical Commissioning Groups

Lord Patel Excerpts

Wednesday 27th November 2013 Lords Chamber

[Earl Howe]

My Lords, very definitely yes. It is precisely to avoid any perception of political interference that we made NHS England responsible for the allocation of resources to clinical commissioning groups. However, we were very specific in the mandate, as the noble Lord will recall, that the principle on which NHS England has to operate is equal access for equal need, with particular attention being paid to health inequalities while not destabilising the NHS. Those are the things we discuss in our regular meetings with NHS England but the actual nature of the formula that it will decide in its board meeting next month is entirely up to it.

[Lord Patel (CB)]

My Lords, we know that the single most significant factor associated with poor health outcomes is deprivation, particularly for diseases such as chronic lung diseases, cardiovascular diseases and cancers—and, even more importantly, for chronic diseases in children. Would it not be wrong therefore if the tariff did not include the deprivation in the population when setting it for the community?

[Earl Howe]

My Lords, the CCG target formula recommended by ACRA this time a year ago was rejected by NHS England for the very reasons that the noble Lord cites: because it did not include an adjustment for deprivation and health inequalities. At a recent Health Select Committee hearing, Paul Baumann, the chief finance officer of NHS England, indicated that the proposed new formula would have an adjustment for a health economy’s unmet need—in other words, an adjustment for deprivation where low life expectancy suggests that people are not accessing health services.

NHS: Accident and Emergency Units

Lord Patel Excerpts

Tuesday 26th November 2013 Lords Chamber

[Lord Patel (CB)]

My Lords, in my three minutes, I will make some brief comments that will lead up to some questions for the Minister. In my view, the pressures on A&E departments are but one component of wider pressures in the NHS. There is a disconnect between A&E and other departments in hospitals, such as diagnostic and in-patient services, which, in contrast to A&E, are both geared to a five-day, nine-to-five working schedule. Added to that of course is the fragmented nature of patient services in the community, which leads to bedblocking and further pressures on A&E. We will have to address the problems of A&E, and the Keogh report goes some way to doing that, but the problems in A&E will not be solved by focusing on just one aspect of the service. The whole system needs to be co-ordinated and to work seamlessly.

Figures show that the main pressures on A&E come from people with long-term conditions. This in turn leads to pressures on in-patient services. This is due in part to poor access to primary and community care. What is needed, as has been discussed on many occasions, is better management of patients with long-term conditions so that they do not end up needing emergency care.

There are other issues. The issue of workforce problems in A&E further compounds the problem. I understand that there is a serious problem with recruitment of trainees, particularly specialist trainees, in A&E. There are also, of course, the vagaries of the tariff, which is set more in favour of elective work than emergency work. I note that the Keogh report tries to address that, or at least intends to explore it. I know that recently the Government have allowed more funds to help with A&E pressures but I am not sure what these funds are to be used for. I hope that the Minister will comment on that. It would be helpful if he could comment on whether the Government have a long-term strategy to cope with the increasing number of patients with long-term conditions, and on what plans the Government have for Health Education England to address the issue of workforce planning, which would help with A&E.

NHS: Mid Staffordshire NHS Foundation Trust

Lord Patel Excerpts

Tuesday 19th November 2013 Lords Chamber

[Earl Howe]

My Lords, I very much agree with the spirit of my noble friend’s questions. Certainly as regards complaints, the public should have a clear view of the nature of the complaints that have been registered with a particular organisation. They should be able to have a sense of what those complaints relate to and what action the organisation has taken to address the matter in question.

On my noble friend’s first point, we are currently working through the question of the care certificate and will seek advice. It is important to arrive at an agreed formula that gives the maximum assurance, both to care assistants and to those they look after, that basic standards of training have been learnt and are being adhered to. It is important to define as closely as we can what we mean by that, and as soon as we have further details we will announce them.

[Lord Patel (CB)]

My Lords, I thank the Minister for repeating the Statement, and I welcome the Government’s comments on the Francis report. I apologise on behalf of my noble friend Lady Emerton, the matron, who is not here today as she is unwell, and also my noble friend—he is a friend, although he sits on the wrong Benches—Lord Willis. He cannot be here because he has been asked to undertake the duties of my noble friend Lady Emerton. They asked me to represent their views—which I will not do, because I would get them wrong, but perhaps I may make my own comments. I realise I am not allowed the same time as the noble Lord, Lord Hunt, had. That is a pity, because I have much to say about the Statement.

I welcome the statutory requirement to give notification of any harm or serious misses that have happened. During my time as chairman of the National Patient Safety Agency I tried to get that into statute and failed; it was not under the current Government, but that does not matter. I am therefore delighted that this will be a statutory requirement. The important thing is that, as Don Berwick said, this is about learning; reporting by itself is not enough. The Minister referred to the airline industry, which learns from what has happened by doing root-cause analysis. We need that system established in the NHS if we are to learn from avoidable harm and near misses. Whose responsibility will it be to do that, and how will that expertise be gained?

On staffing ratios, the Minister knows that if my noble friend Lady Emerton had been here she would have asked about ratios of trained to untrained staff. Now that there will be a new care certificate to ensure training for all care assistants and nursing assistants, which I welcome, she would have asked for regulation. However, we have passed that stage, and I welcome the fact that there will be a new care certificate following the training. Why, however, is all this to be only for hospitals? What about care homes? Why were care homes excluded from reporting on staffing ratios?

[Earl Howe]

I apologise, but I did not quite hear the last part of the noble Lord’s question. Was it why care homes were excluded?

[Lord Patel]

The Statement refers particularly to hospitals. They will have to report on staffing ratios, but it did not say that care homes will have to do that.

[Earl Howe]

I am grateful to the noble Lord. I am in complete agreement with him on his first point. The best thing might be for me to read out a very short passage from Professor Don Berwick, who said:

“The best keys to health care safety do not lie in blame, or regulation, or punishment, but rather in learning, support, and encouragement to the health care staff, the vast majority of whom are dedicated to excellence in care.

Leaders who aim for safe and effective care have a duty to supply the workforce with the tools, knowledge and encouragement to do the work that adds meaning to their lives”.

We have attempted, as far as we can, to make that philosophy the guiding principle of our response on patient safety. We do not want to create a blame culture; we want to create a culture that encourages everybody to feel ownership of the work that they do, and to feel well led. That is the other side of the coin to the culture that we have spoken about in other debates about innovation—about making innovation everybody’s business in an organisation. It comes down, in the end, to good leadership.

We are not insisting that every organisation should carry out root-cause analysis. On the other hand, we are saying that it is the business of trust boards to make complaints, mistakes, and lapses in patient safety central to their work and to the scrutiny that they undertake of their organisations, and for those matters to be discussed openly and resolved openly.

As regards care homes, as I said, we have commissioned NICE to work through the guidance that will underpin safe staffing. It is not yet apparent whether that will cover care homes and it is difficult to see how it could do so because care homes are clearly very different organisations from acute trusts. On the other hand, we expect the CQC to have some way of judging whether a care home can call itself safe. We will certainly look at the noble Lord’s points as we carry that work stream forward.

Care Bill [HL]

Lord Patel Excerpts

Monday 21st October 2013 Lords Chamber

[Lord Kennedy of Southwark (Lab)]

My Lords, although I sit in this House as Lord Kennedy of Southwark, I actually live in Lewisham, very close to the hospital. I agree with the comments made by my noble friend Lord Hunt of Kings Heath. This is a major change of policy being sneaked through the door by the Government. I am amazed that the Minister has brought his amendment today when we are just a few days away from the case being heard in the Court of Appeal—it will be heard next week, I believe.

I live close to the hospital and I refer noble Lords to my declaration of interest that on a voluntary basis I chair a small committee in the hospital. Whatever the problems of the South London Healthcare NHS Trust, I cannot adequately describe to noble Lords the sense of injustice, unfairness and hurt about what is being imposed by the administrator. We have a good local hospital, which is supported by the local community, delivers on its targets and objectives and is financially solvent, but the administrator came along and ripped the heart out of the hospital.

I contend that the purpose of this amendment is to try to stop the campaign that we have seen in Lewisham over the past few months. The campaign has united the community like never before. We had more than 25,000 people on our march. Streets are plastered with posters to save the hospital. Any political party would be envious of the posters up in people’s windows about this campaign. Our local campaign is chaired by a local GP and has brought together health professionals and the local community.

Will the Minister tell the House whether he has visited Lewisham hospital? I asked him that question earlier this year; I know that he had not been then and hope that he has been there since to see the amount of local support and what a good local hospital it is. More important, there is no support at all for what the Government propose today. I hope that the House will support the amendment of my noble friend Lord Hunt of Kings Heath and reject the amendment of the noble Earl.

[Lord Patel (CB)]

My Lords, I find myself in a strange position, because I agree in part with the amendment moved by the noble Earl and in part with the amendment moved by the noble Lord, Lord Hunt, although that is not a solution.

I agree with the noble Earl that we need to find a way of reconfiguring NHS services. That reconfiguration cannot just be done through dealing with failing hospitals. It must include other hospitals which currently seem to be delivering good-quality services. We have to find a way out of that. The question is therefore whether the amendment allows us to move forward with reconfiguring NHS services. This is where I find myself more in tune with the suggestion of the noble Lord, Lord Warner, that it may not and that more is required.

Another concern I have is that the commissioners may express views. I would like some explanation of why the commissioners of the NHS foundation trust are to be treated separately from those who commission services from other hospitals. Another issue is that, if the commissioners disagree, NHS England would make the decision. That means that, ipso facto, they will agree with a special administrator—or they will not. In that case, what happens?

Another issue is consultation. Clearly, none of the configuration can occur smoothly unless the public are consulted. At what point will the special administrator consult both the public served by the failing hospital and the public served by the hospital that is not failing but whose services may require reconfiguration?

In summary, therefore, there is a need for amendments that will allow us to move forward with the reconfiguration of services throughout England. In that respect, I am with the noble Earl, but I wonder if he needs to go a bit further. He might consider looking at this further and tabling more amendments at a later stage.

[Lord Mackay of Clashfern (Con)]

My Lords, there is of course quite a long process still to be gone through on the Bill. As the noble Lord, Lord Warner, has said, it seems clear that there is a serious problem. It occurs to me that the special administrator’s primary emphasis will be on the trust to which he or she has been appointed. It is also obvious that changes to one trust may affect neighbouring trusts. Some solution to the problems in the special administrator’s trust may rely on something done in a neighbouring trust.

On the other hand, in that situation it is extremely important that concentration on the problems of the neighbouring trust is given considerable emphasis. Otherwise, the situation may be distorted by too great an emphasis on the special administrator’s trust at the expense of neighbouring trusts brought in to try to help. I wonder whether the wise course might be for us to accept the amendment, in so far as it goes, with an undertaking that, as the Bill proceeds in the other place, that matter would be seriously considered.

This may be an opportunity for legislation that will not quickly arise again. As the noble Lord, Lord Warner, said, there is a serious problem and it might not be wise to put it off indefinitely. I can see the difficulties and understand the situation of the noble Lord, Lord Patel, but it is very difficult to see how to sort this out today. On the other hand, it might be unwise to lose the opportunity to take a step forward in the hope of improving the situation in later stages of this Bill.

--- Later in debate ---

[Lord Warner]

My Lords, I also thank the Minister for his persistence within Whitehall in actually getting progress in this area. I think we all feel that he has put a lot of personal effort into it and deserves a great deal of credit.

If I may, I will ask a couple of slightly nerdy questions. I think that the issue of where this stands in the pecking order is vital. Is it down at NVQ levels 1 and 2? Is it up at level 3? How far away is it from the degree-level professional qualifications? In some ways, the title that has been given to this rather diminishes its standing up the food chain, so to speak. A certificate of fundamental care sounds a bit basic, and I am not quite sure what signals are given about the level that Health Education England should strive for in overseeing this particular work. A lot more work needs to be done on that.

Perhaps I may also pick up the point that my noble friend Lord Hunt hinted at. At the end of the day, if employers are to make this operate, they need some kind of register of who has the certificate. They also need to know what happens when they fire somebody and take disciplinary action against someone who has this certificate. Who do they tell? That seems a quite critical issue, because this is a very large workforce and it would be quite surprising if each year we did not get a steady flow of bad cases where an employer has fired someone for a breach of good practice of one kind or another. This would all be set to nought if there was no record of where these cases of disciplinary action have been taken, and people with a certificate were still floating around the system when they have actually been released by an employer for poor practice.

[Lord Patel]

My Lords, I have put my name to Amendment 158. I also thank the Minister for pulling a rabbit out of the hat, so to speak. However, I am not as gobsmacked as the noble Lord, Lord Willis of Knaresborough, because I have lost count of the number of times and days in this Chamber that we have debated the need for training healthcare support workers. I am at least glad that it has now paid some dividends.

I am also glad that the noble Earl said that Health Education England would take the lead on this, and will involve the NMC in devising the standardised training programmes, because it has the expertise to do it. I agree with the noble Lord, Lord Hunt, and others that this inevitably means there will need to be some sanctions for those who do not fulfil the requirements for training and therefore fail to be regulated. I am not sure whether that is for this Bill or subsequently, but it will inevitably lead to that. However, I thank the noble Earl for his amendment.

[Lord MacKenzie of Culkein]

My Lords, I join in the congratulations to the Minister on his words this afternoon. For a long time I have felt that trying to get some movement on this issue of education and training for healthcare assistants was rather like the sufferings of Sisyphus pushing that stone uphill. Fortunately, I was wrong and the debates that we have had on this issue over the past few months have clearly borne fruit.

I join the noble Lord, Lord Willis, in saying that the permissive “may” in Amendment 153 should be changed to “must”. It is extremely important that that happens if at all possible. For me, regulating healthcare assistants has been an issue since the long preparation for Project 2000 and the eventual demise of the enrolled nurse, leaving the gap which has now had to be addressed in this way.

The Minister has always been careful to say that the Government do not have a closed mind on regulation. I hope that that remains the position because, given the position we have now arrived at, it is inevitable, for the reasons that my noble friends Lord Hunt and Lord Warner have given, that regulation will come some day. To coin the current phrase, it is a can that has been kicked down the road long enough. We ought to stop kicking it and get there sooner rather than later.

I heard the Minister say in the past that regulation is not a guarantor of good care. That, as far as it goes, is true, because if it was a guarantor, there would be no poor practice or misconduct in any profession. That is not an argument against regulation for all the professions that are properly regulated to safeguard the public. I hope that an open mind will be kept on this and that we can come back to the issue of regulation, which is now inevitable. Having said that, I am grateful and delighted that we have made the progress that we have today and again I thank the Minister for his persistence in this matter.

--- Later in debate ---

[Lord Patel]

My Lords, I rise to support the amendment in the name of the noble Lord, Lord Aberdare. He is extremely knowledgeable about issues relating to pancreatic cancer. While the principles of early diagnosis and related outcomes are important for all diseases, this is particularly so for cancers and especially for certain cancers, such as pancreatic cancer. I have spoken before in this House about how two members of my family—my mother and my mother-in-law—both died of pancreatic cancer. Emphasising the need for early diagnosis of any disease is important in the training of doctors and nurses.

[Baroness Wheeler (Lab)]

My Lords, we very much welcome this important group of amendments. If one reads back over the debates on the Bill in Committee, there can be little doubt that the provisions for HEE and LETBs have been considerably strengthened and improved by your Lordships’ detailed scrutiny and deliberations. These amendments consolidate that work.

We have also been encouraged by the progress that HEE has been making under the leadership of Sir Keith Pearson. The website demonstrates this, and the HEE leadership team has been highly visible at conferences and forums, setting out its proposed strategic priorities and consulting on the way forward. In particular, HEE seems to have taken up the key message that, in educating and training staff for NHS and public health, it must have a strategic understanding of the workforce requirements across the boundaries of health and social care and of the need for staff to work in an integrated way. This has been a major concern. I was pleased, for example, to hear the HEE medical director, Wendy Reid, emphasise this at a recent Westminster Health Forum workforce conference that I chaired.

These amendments strengthen the role of LETBs by emphasising that HEE duties under Clause 89 to ensure that quality improvement in education and training, promotion of research—as the Minister has stated—and the NHS Constitution all apply to LETBs. This is an important provision and reflects concerns expressed in Committee that LETBs must pay attention to the maintenance of standards and quality in education and training, as well as ensuring that sufficient numbers of staff are trained locally. This was a point made by my noble friend Lord Turnberg and which the Minister addressed earlier.

Amendments explicitly providing HEE with authority to delegate its functions to its committees, sub-committees, members or other persons are important in allowing HEE the flexibility that it needs to deliver its priorities and functions, and we strongly support them.

On HEE board and LETB representation, we join other noble Lords in expressing our relief at the government amendments, which ensure that people with clinical expertise are appointed to both bodies. This was a serious omission and its inclusion now greatly strengthens the Bill, as does the Government’s commitment that regulations will place a specific requirement on HEE and LETBs to include a nurse and a doctor. It is particularly important, as my noble friend Lord Hunt underlined in Committee, for the people in the driving seat on education and training requirements, standards and future needs at local level to be those who provide the services. HEE and LETBs must understand the pressures that the service is under in relation to staffing and to ensuring that education and training is flexible and responsive to the rapidly changing face and needs of health and social care. The implementation of the Francis recommendations for a lay patient representative on the HEE board and LETBs is also a key change to the Bill, which we strongly welcome and which will only enhance the work and effectiveness of those bodies.

Finally, as supportive of HEE as we are, it is hard to see in HEE work to date a clear strategy for developing the vital cadre of NHS managers that is needed to lead the NHS in the coming months and decades. There was a strong concern about this in Committee and the need for close working with HEE and the NHS Leadership Academy was acknowledged by the Minister. The Joint Committee wanted to see a statutory commitment for HEE to work in partnership with the academy, to ensure that managers in training work alongside their clinical colleagues and to increase the number of managers in the future who have clinical experience. Does the Minister not agree that this needs to be an explicit, upfront priority for HEE, which translates through to the work of LETBs? How will the Government ensure that this vital issue is addressed?

--- Later in debate ---

[Lord Patel]

I concur with what the noble Lord, Lord Willis of Knaresborough, just said. All of the research councils and charities support these amendments. There are the caveats to which he referred, particularly related to clinical trials and data. There is another important issue about the summary given at the conclusion of the research, which not only has to protect the confidentiality of the patients but also needs to be brief, because otherwise it is too cumbersome. On the whole, these amendments that we debated long and hard are most welcome.

[Lord Mackay of Clashfern]

I also agree with the view that these are important headings. The precise detail has been mentioned by the noble Lord. Regarding paragraph (c) of Amendment 167, I think that access to the data is quite important although it requires consideration. It is important that the experiment or trial can be repeated. One of the difficulties in the past has sometimes been the announcement of research findings. When those in the same area tried to find out exactly what the findings were based on, there was some difficulty in repeating the experiment and occasionally there was something seriously wrong with the research. Therefore, access to the data certainly has to be kept in view if one is going to have proper transparency. However, I accept that, like paragraph (c) of Amendment 167 and the other paragraphs, it requires an amount of restriction in certain cases.

Care Bill [HL]

Lord Patel Excerpts

Wednesday 16th October 2013 Lords Chamber

Moved by

[Lord Patel]

83A: Clause 58, page 47, line 5, at beginning insert “When a child receiving services reaches the age of 14 or”

[Lord Patel (CB)]

My Lords, I shall speak also to the other amendments in my name in this group. I thank the Minister for the government amendments, which go a considerable way towards helping the arrangements for the transition of children to adulthood. My amendments are intended to strengthen that. I thank my noble friend Lady Finlay for putting her name to the amendments.

Amendment 83A is one of a series of amendments which I have tabled with the intention of bringing about better outcomes for young people who need to transition from child to adult palliative care services. These young people are represented by the Transition Taskforce, a partnership of organisations which includes Help the Hospices, the National Council for Palliative Care, Marie Curie Cancer Care and Together for Short Lives. All these organisations support these amendments.

I have spoken previously at other stages of the Bill about the 40,000 children and young people—these are the numbers we are talking about—aged from 0 to 19 in England who live with long-term health conditions, which for most of these children will eventually end their lives and for which they may require palliative care. Medical advances mean, however, that young people with a range of different conditions now live to adulthood—some 10% of the 40,000 children now live beyond 19 years.

Good planned transition, when it works, changes the lives of these young people. Unfortunately, for the majority that is not happening. I will give the example of one young girl, Lucy Watts, who is 20 years old, and has Ehlers-Danlos syndrome, which means that Lucy has a number of inherited conditions which were diagnosed by the time she was a teenager and is unable to eat normal food. Her system does not digest food and she is fed intravenously all the time. While she is able to sit up for a few hours a day, Lucy spends most of her time in bed. Lucy’s mum, who has a full-time job, carries out the majority of her care and all of her day-to-day medical care.

However, Lucy is fortunate, because her transition to adult service was excellent because there was joint working between children’s and adult services over the course of a whole year. That is the important point. It takes a long time for transition arrangements to be put in place for these children. Lucy is quite a feisty young lady. She said:

“Transitioning from children’s to adult in the medical and social world is a huge step ... The people involved in my care have been very supportive and were brought in before I started the transition”.

Lucy’s case demonstrates how important it is for young people and families that their transition is planned well in advance of their 18th birthday and why our amendments to stipulate a timeframe for a child’s needs assessment are so important.

I very much welcome the fact that the Government have amended the Bill to ensure that when it appears to a local authority that the child or their carer is likely to have needs for care and support after the child becomes 18, the local authority must assess them. I appreciate, too, the Government’s stated position that the needs of very young people are different and that their care needs can change between the ages of 14 and 18 in a variety of ways. However, our amendments would provide flexibility by ensuring that assessments could be initiated before the age of 14 if requested by the child or parent or if it appears to the local authority that an assessment is necessary and appropriate. Local authorities would have until the age of 16 to assess the child’s needs. They would not be prevented from reassessing a young person if their needs changed before they reached 18. They would also enable local authorities a period of two years to assess the child’s needs in cases where their care needs become apparent only after the age of 14. Without these important thresholds, it is feasible that a local authority may leave it too late to carry out a child’s needs assessment.

Setting the age threshold for a child’s needs assessment at 14 is also based on the existing statutory requirement for every young person in year 9—that is, aged 14 to 15—with a statement of special educational needs to have a transition plan. Our amendment would ensure that transition planning correlates with that requirement and reflects best practice in exemplary palliative care services in England. It is entirely reasonable that some young people with life-limiting conditions, including those with conditions such as Duchenne muscular dystrophy and cerebral palsy, could be expected from an early stage to live beyond 18. Assessing and planning for their future needs should therefore begin at the age of 14. Our amendments would ensure that this is the case without disadvantaging young people with other disabilities, which is the concern that was expressed. The Bill already stipulates that where a local authority deems a child’s assessment not to be in the best interest of the young person or the young person does not consent to being assessed, an assessment will not take place.

Amendment 89B, which is a long amendment, corrects the anomaly of the transition and the duty on local authorities. While the Bill currently makes provisions to enable local authorities to carry out a child’s needs assessment, there is no duty on local authorities to use the assessment to create a transition plan for the young person. Amendment 89B would ensure that, if a child’s needs assessment finds that a young person is likely to need health or social care when they reach adulthood, a statutory five-year rolling transition plan should be prepared by the time they are 16.

The amendment has a number of other important features. It would ensure that children, parents and carers were involved in the transition planning process and that transition plans are maintained until the young person reaches the age of 25, which 10% of these children would probably reach. Further, one of the provisions included in the Children and Families Bill is to introduce an integrated education, health and care plan—or EHC plan—for young people who have special educational needs. This will include many—but, crucially, not all—young people who need palliative care. Where a young person stays in education or training, they will be eligible for an EHC plan until the age of 25. I recognise that an EHC plan could fulfil the functions which I intend the transition plan in my amendment to fulfil. An optimal position would be for EHC plans to be available to all young disabled people up to the age of 25—but that is not the case. Our amendments will provide similarly joined-up transition provision for young people who need palliative care but do not have SEN.

Amendments 93A, 94A and 94B would amend and address the carer’s needs. In considering young people who need to transition from children’s to adult services, it is also important that we address the needs of those who care for them. I welcome the Government’s aspiration to do so and the amendment that the Government have already tabled to strengthen the Bill. However, as with the clauses relating to planning for young people’s needs on transition, we need to go further in order to ensure that planning for carers also happens in a timely fashion. Amendment 93A would introduce an age threshold of 14 at which a local authority would be duty-bound to undertake a child carer’s needs assessment.

I hope that I have persuaded the Minister that his amendments, excellent as they are, need a bit more tweaking to make it possible to streamline the process of transition of children to adulthood. My amendments merely help to do that. Some children may of course begin to need long-term health or social care after they are 14. In such cases it may not be reasonable to expect a local authority to complete a child carer’s needs assessment before the child reaches the age of 16. I hope that the Minister will be persuaded enough to add to his excellent amendments a few more to fulfil these needs. I look forward to hearing his response.

[Baroness Finlay of Llandaff (CB)]

My Lords, I am most grateful to my noble friend Lord Patel for the way in which he has introduced our amendments. I greatly welcome the Government’s amendments in this area of transition. The reason that our amendments are written as they are is because this group of children are different to adults who are terminally ill. They have life-limiting conditions, but their prognosis may be years. However, during that time they know that they will deteriorate, as do their parents. We are therefore looking at completely different timeframes, and with completely unpredictable prognoses, except for the likelihood that they will live through into adulthood. Some of them, of course, live surprisingly long periods of time and may live several decades into adulthood. They tend to have the inherited disorders of metabolism. They are a different cohort from those who have terminal illnesses such as cancer. There are also those children who, for example, have had very severe sudden injuries, such as a severe head injury, and then develop epilepsy, which can then become so severe that it is life threatening. Many of the children also have learning difficulties and educational needs.

--- Later in debate ---

I trust that I have provided some reassurance on these issues and that the noble Lord will feel able to withdraw his amendment.

[Lord Patel]

I am grateful to the Minister for his comments. If I had known before I started speaking that he was going to produce the guidance to cover all these issues, I might have said that I would not move this amendment. But having heard him say that there will be guidance in statute to cover all these issues, I am extremely grateful. I thank the other noble Lords and noble Baronesses who spoke. I thought for a minute that the Opposition were going to remain silent on this amendment but I am glad that the noble Lord, Lord Hunt of Kings Heath, felt obliged to intervene, and I am grateful to him for that. I withdraw the amendment.

Amendment 83A withdrawn.