NHS: Association of Medical Research Charities Report

Lord Rea Excerpts

Thursday 27th June 2013 Grand Committee

[Lord Rea]

My Lords, I apologise for missing the deadline yesterday and hence being squeezed into the gap. I wanted to say a few words about the position of general practice in the health service. As my noble friend pointed out, the AMRC report finds that fewer GPs than hospital doctors are interested or involved in research, most of them citing time as the reason. Setting aside dedicated time for research is not easy in the average primary care setting. It is also possible that fewer GPs are research-minded and that, except for academic general practice, publishing peer-reviewed research papers is less important in their career advancement.

However, research in general practice is alive and well. Every medical school now has an academic department of primary care linked to the Royal College of GPs, supporting research in primary care through the RCGP innovation and research centre. The director of the centre suggested to me that the academic status of general practice would be enhanced if more research-minded and bright medical students or doctors could be recruited into general practice. One way in which to do this would be for the NIHR to proactively offer to fund PhD or MSc fellowships in general practice. This would be attractive to research-minded medical students or practitioners contemplating a career in general practice but uncertain about its research possibilities. Does the noble Earl have any influence over the funding decisions of NIHR? I suggest that this might be promising territory.

My experience, in answer to various noble Lords who have mentioned patients in research, is that patients are nearly always willing to take part in research projects if it is recommended to them by a doctor, hospital or care unit that they trust and its purpose is fully explained to them.

Care Bill [HL]

Lord Rea Excerpts

Monday 10th June 2013 Lords Chamber

Moved by

[Lord Rea]

31: Clause 88, page 74, line 32, at end insert “to this end promoting the use of joint interprofessional education of clinical and social care staff where appropriate,”

[Lord Rea]

My Lords, I must apologise for not moving this amendment in its proper place on the first day in Committee. That was due to a misunderstanding on my part, and I apologise.

I put down this probing amendment to draw attention to the importance and relevance of interprofessional education in preparing different health and social care staff to work well together. It is recognised across the board that caring for the increasing proportion of the population with long-term problems requires teamwork. This will be more effective and economically efficient if the different members of the team understand the role and approach of other members of the team with whom they need to collaborate, be they social workers, nurses, physiotherapists, pharmacists or doctors. At present, each healthcare worker may have no proper conception of the abilities and skills of those in another discipline, and that may lead to inefficient working, inappropriate decisions and learning by trial and error, if at all. One thinks perhaps of Stafford.

The duty to promote integration is much used in legislation but is mainly directed to administrators at a high level. For example, in last year’s Health and Social Care Act the NHS Commissioning Board and clinical commissioning groups were directed to take note of the need for integration, and in this Bill promoting integration is a requirement on local authorities. In Clause 88, in which this amendment sits,

“HEE must have regard to … the desirability of promoting the integration of health provision with health-related provision”.

The detail of how integration is to be achieved is left to the bodies concerned, although there may well be, and certainly should be, guidance, which I have not seen but which is perhaps to be published later. Perhaps the Minister can fill me in here. My amendment could perhaps be considered when formulating such guidance.

Interprofessional education needs to be carried out at educational or training institutions for clinical and social care professionals but also in continuing postgraduate education. Therefore, it is not only to Health Education England but to the General Medical Council, other professional bodies, royal colleges, universities, postgraduate deans and LETBs that this amendment is directed.

I do not have much time to describe the details of how IPE works, and this is not the right place to do so. Suffice it to say that it is not something I have invented off the top of my head but is a recognised discipline, led in this country by CAIPE, the Centre for the Advancement of Interprofessional Education. It has branches in several countries on both sides of the Atlantic and has produced a number of publications describing the method and the institutions that have adopted it. It has also commissioned several evaluative studies which have confirmed its effectiveness. CAIPE is in touch with the Department of Health, and positive discussions have taken place. The Minister will probably know about them. In fact, I understand that CAIPE is due to meet Health Education England to discuss possible future collaboration. Interprofessional education is up and running in at least five universities, including Leicester, De Montfort, Bristol, Sheffield Hallam and Aberdeen.

I am aware that there are plenty of problems involved in getting different professions to receive co-ordinated education, not least logistics and timetabling. Students may not at first appreciate the need for understanding and co-operation, so do not always take kindly to what they may see as a diversion from their task of learning the skills needed for their chosen profession. However, once they meet each other, understanding can grow. Directors of education need to be convinced of the benefits of IPE. Its benefits are summarised well in a recent WHO task force report:

“After almost 50 years of inquiry, there is now sufficient evidence to indicate that interprofessional education enables effective collaborative practice which in turn optimizes health-services, strengthens health systems and improves health outcomes ... In both acute and primary care settings, patients report higher levels of satisfaction, better acceptance of care and improved health outcomes following treatment by a collaborative team”.

I shall be most interested to hear the Minister’s views on IPE and whether he agrees that it deserves to be more widely used in the National Health Service. I beg to move.

[Baroness Wheeler]

My Lords, I shall make a brief intervention in support of the desire of my noble friend Lord Rea to draw our attention to the importance of interprofessional education if we are to develop health and social care staff’s mutual respect, understanding and knowledge of each other’s professions that will bring about the collaboration, joint working and integration of care and support that we need. My noble friend describes this as staff knowing “how the other half lives”—in other words, staff knowing about each other’s services and how they operate, and being aware of boundaries, interdependence on achieving outcomes and competing agendas. He commends IPE because it provides an established model of collaboration and co-operation on the ground.

The amendment refers back to our earlier debate on integration and the need for multidisciplinary teamworking, and it will also be relevant to the debate that we will come to shortly on the importance of continuing professional development for healthcare workers. It adds promoting the use of joint IPE for clinical and social care staff as a matter that HEE must have regard to in relation to its responsibility for promoting the integration of healthcare and health-related provision.

My noble friend helpfully sent me a considerable amount of background information on his amendment in which, as a former HR professional, I was genuinely interested. It included extensive research by the Centre for the Advancement of Interprofessional Education, which my noble friend referred to, supporting the effectiveness of interprofessional education and training. My noble friend also referred to discussions between CAIPE and Health Education England to explore HEE’s role in taking IPE forward and embedding it in professional curricula. This is to be welcomed. Two-thirds of UK universities with two or more undergraduate programmes in health and social care include IPE, so these discussions will be helpful. These programmes cover a wide range of professions, including nursing, social work, physiotherapy, pharmacy, clinical psychology and radiography—all professions that are increasingly required to work flexibly across different care settings as part of multidisciplinary teams.

The Nuffield Trust evaluation of the first year of the inner north-west London integrated pilot that I referred to earlier underlined the importance of staff in multiprofessional teams having a high level of commitment to the pilot as a key factor in improving collaboration across different parts of the local health and care system. However, the evaluation also reminds us of the international evidence that integrated care takes years to develop and that a minimum of three to five years is needed to show impact in relation to patient experience and outcomes. Culture change, moving from silo to collaborative working among professionals, is a slow process, however committed we are to trying to make it work. I look forward to the Minister’s response to my noble friend’s amendment.

[Earl Howe]

My Lords, if I may say so, the noble Lord, Lord Rea, has explained his amendment in a very compelling way. Amendment 31 seeks to amend Clause 88(1)(h) so that Health Education England must have regard to the promotion of joint interprofessional education of clinical and social care staff where appropriate. As he is aware, much of the ground on these issues was covered in our earlier debates, when I hope I was able to reassure noble Lords that the Government take this issue very seriously. Clause 88 of the Bill, in listing the matters that Health Education England must have regard to in exercising its functions, is clear that Health Education England must support integration between health and care, and support staff so that they are able to work across different settings in health and social care.

In establishing Health Education England with a multiprofessional remit with responsibility for the development of all the professions, the Government have reinforced the importance of planning and developing staff in an interprofessional manner. As I mentioned, this approach is reinforced further in the Government’s mandate to Health Education England, which places a clear requirement on Health Education England, where appropriate, to develop multidisciplinary education and training programmes. I hope the noble Lord will agree that that is very much consonant with the principles that he was propounding in his contribution.

We entirely appreciate the importance of close working between the professions. I am sure that that is something Health Education England will consider carefully. I will write to the noble Lord if I can add any useful detail once I have had a chance to investigate further the issues that he raised and once I have discussed them with my officials.

However, I point out, as the noble Baroness, Lady Wheeler, did in our earlier debate, the importance of the recent commitment entered into by 12 of the national leaders of health and care, who signed up to a series of undertakings on how they will help local areas to integrate services. This was the document Integrated Care and Support: Our Shared Commitment—the first ever system-wide shared commitment. That document set out how local areas can use existing structures such as health and well-being boards to bring together local authorities, the NHS, social care providers, education, housing services, public health and others to make further steps towards integration. The ambition here is to make joined-up and co-ordinated health and care the norm. It works towards the first ever agreed definition of what people say good integrated care and support looks and feels like. That will be developed by national voices. There will be new pioneer areas around the country, to be announced in September of this year. One of the 12 partners of that shared commitment is Health Education England.

I hope that the noble Lord will be reassured by what I have said. I am entirely in tune with the spirit of his remarks. I will be happy to write to him if I have further and better particulars to impart, but for now I hope that he will feel able to withdraw his amendment.

[Lord Rea]

My Lords, I thank the noble Earl for a very full reply and for the sentiments that he expressed. I shall read with interest his reply in Hansard, and I look forward to any further information that he may send me. I am sure that CAIPE will be very interested to read his remarks, too. I thank the Minister very much. I beg leave to withdraw the amendment.

Amendment 31 withdrawn.

NHS: Mid Staffordshire NHS Foundation Trust

Lord Rea Excerpts

Monday 11th March 2013 Lords Chamber

[Lord Rea]

My Lords, I had not originally intended to take part in this short debate but on Friday I was encouraged to do so by the Royal College of Physicians—incidentally, after I had gone away for the weekend without any briefing material. As the noble Earl knows, that college has made detailed comments and recommendations related to the inquiry, along with a number of other professional bodies, including the BMA, the Royal College of Nursing and many others, as the noble Lord, Lord Patel, said.

I want to consider just a few ways in which the blatant failures of care at Mid Staffs might have been prevented or at least brought into the public domain much earlier. These suggestions relate mostly to points made by the professional organisations that the noble Lord, Lord Patel, has just mentioned, as well as by the Francis report itself. First, GPs could be more involved by listening to their patients or their relatives, and thus be more in touch with their in-patient experience. GPs can act as strong advocates for their patients through their contact with consultants and managers. If they are aware of the reality of patients’ experience, clinical commissioning bodies will be more discriminating.

Secondly, clinical and managerial staff with concerns should be encouraged to come forward and not be intimidated. Whistleblowers should be encouraged to speak out at regular open meetings where innovative ideas by NHS staff could also be put forward and discussed. There is a wealth of ideas waiting to be tapped among staff at all levels, which could be used to improve patient experience and outcomes, and often cut costs at the same time.

Thirdly, auxiliary staff should be registered. This would mean that they had to receive training of a set adequate standard. This would improve not only the quality of their work but their morale, and give them vocational pride and recognition. Those who wished should be given the opportunity of career advancement through gaining further qualifications.

Fourthly, the best features of community health councils should be brought back. Current arrangements through the CQC, or its equivalent in 2008, for voicing patient concerns clearly did not function in Mid Staffs. An up-to-date CHC-like organisation would give patients and their relatives ready access to a representative, truly independent, body where they could freely voice any concerns that they had about their hospital experience. CHCs had the right to speak directly to NHS authorities, to visit any NHS entities and attend trust meetings. CHCs’ own meetings were open and transparent, and were often reported in the local, and sometimes national, press. CHCs were of course of uneven quality and received barely adequate funding. However, they could prove to be an embarrassment to NHS administrators when unwelcome truths were openly discussed. Perhaps it is understandable why they were abolished by the previous Government in 2003. As the noble Earl will remember well, I strongly opposed their closure at the time. I remind him that he also opposed their abolition. As I recollect, we were then in agreement, although from opposite sides of the House.

NHS: Clinical Commissioning Groups

Lord Rea Excerpts

Wednesday 16th January 2013 Lords Chamber

[Earl Howe]

My Lords, ACRA, the independent committee, will take advice from all relevant quarters. I am sure that the advice it receives will be taken on board. I do not think that there will be a public consultation as such but, if I am wrong about that, I will write to my noble friend.

[Lord Rea]

Will the noble Earl reassure us that this new allocation committee will take fully into account the fact that poor people have worse health and, therefore, in an equitable system, it will cost more to include them in the full services that the NHS can provide? Will he reassure us that that will be taken adequately into account and that proper measurements will be made of the health differences between social classes?

[Earl Howe]

I can give the noble Lord that reassurance. ACRA is not a new committee; it has been long-established, and was a fundamental part of the previous Administration’s approach to funding allocations. I can say to the noble Lord that, by using diagnosis information, the formula that has been adopted for CCGs directly picks up a great deal of the increased prevalence of ill health due to deprivation. It also takes account of the proportion of the population in social housing and in semi-routine occupations, and the number of DLA claimants, which is closely related to deprivation.

NHS: Reconfiguration of Services

Lord Rea Excerpts

Tuesday 15th January 2013 Lords Chamber

[Earl Howe]

I do not agree with the noble Lord. Competition issues arise within the health service and the matter in the noble Lord’s Question is specifically a health service issue. There are, of course, competition issues involving the independent sector and the charitable sector as well but that is not the focus here. It was the previous Government who recognised the benefits of competition for patients. Our attitude to it is very pragmatic. The key objective for commissioners is to ensure that patients receive the best possible services irrespective of whether they are from the public, voluntary or private sectors. It is for commissioners working with patients to decide where competition is appropriate. It is a means rather than an end in itself.

[Lord Rea]

There have been recent press reports that Monitor has heard requests from private sector providers of NHS services to be exempt from corporation tax. Can the Minister say what the view of Monitor is on this and what its decision is likely to be?

[Earl Howe]

I am aware of that issue. It is very much in the sights of Monitor as it conducts the fair playing field review which, as the noble Lord will remember, was the product of an amendment proposed by the noble Lord, Lord Patel of Bradford, and passed in your Lordships’ House. The report that will ensue from that commitment by the Government will be published later this year and I am quite sure it will embrace the point mentioned by the noble Lord.

Health and Social Care Bill

Lord Rea Excerpts

Tuesday 13th March 2012 Lords Chamber

[Lord Walton of Detchant]

My Lords, I, too, support these two amendments on the regulation of clinical physiologists, and I think that the case my noble friend Baroness Finlay made about clinical perfusionists is extremely strong.

Clinical physiologists work across a wide range of disciplines. Some work in cardiac investigations, some in respiratory investigations, some in gastrointestinal investigations, but my particular interest relates to clinical neurophysiologists, who carry out a wide range of different investigations involving patients.

Many years ago in my early days as a neurologist, I was involved in the interpretation of electro- encephalograms, and I also introduced into the north-east a technique of electromyography, which is a means of identifying and studying the electrical activity of muscles in health and disease. In all these activities, I was supported by well-trained clinical physiologists. In those early days, those individuals quite often became members of the EEG society, as it was called, of which I was a founder member.

Later, as the interests and the techniques broadened and became much more extensive and much more sophisticated, that organisation, which included doctors working in the field as well as the people called technicians, who were in a sense clinical physiologists, changed its name to the British Society for Clinical Neurophysiology, and the so-called technicians became part of a body called the Electrophysiological Technicians Association—the EPTA—an organisation that later became the Association of Neurophysiological Scientists. It is now very well trained. It works not only in EEG and EMG but in techniques including evoked potential recording, peripheral nerve studies—the measurement of nerve conduction velocity as an aid to diagnosis in disease—and techniques of magnetoencephalopathy. A whole series of new techniques has been developed in which these clinical scientists or clinical physiologists—technicians as they once were—are very deeply involved. They are sufficiently well organised in their professional bodies, which represent their interests, and in the voluntary registers, of which many of them are already members, that they fully deserve registration under the Health Professions Council. Such a statute is long overdue. For that reason, I strongly support the amendments.

[Lord Rea]

My Lords, Amendments 253, 254 and 255 concern various clinical scientists, particularly clinical physiologists. In Committee, I declared an interest in that I have received skilled care from clinical physiologists for nearly five years in monitoring my pacemaker. From 2008 to 2010, when the previous Government were in office, I asked four Questions for Written Answer, pointing out that the Health Professions Council had recommended in 2004 that clinical scientists be included in its regulatory regime. This recommendation was accepted by the Secretary of State at the time. The Answers that I received respectively from my noble friends Lady Thornton and Lord Darzi said, in impeccable ministerial speak, “This will be done not this year, perhaps next year, but certainly some time”. However, the noble Earl, Lord Howe, suggested in Committee that it would be sufficient to continue the voluntary registration scheme that exists now.

Perhaps I may read a small extract from a note sent to me by the Registration Council for Clinical Physiologists, which compiles a voluntary register. The council states that it has,

“substantial evidence suggesting that voluntary self-regulation is not effective for clinical physiologists. Our register has no power of enforcement and is completely toothless because it cannot protect patients from continuing to be treated by practitioners who have not been registered and who are potentially unfit to practise. Where a complaint is made and upheld about a practitioner, he or she usually ‘disappears’ from the voluntary register, which means it is impossible for the RCCP to do further investigations, while the practitioners under investigation are able to find employment elsewhere”.

The noble Baroness, Lady Finlay, gave an example of precisely that. Surely that should not be allowed to continue, and I hope that the noble Earl will reconsider his position and agree that statutory registration is the way forward for this very important group of skilled health professionals.

[Earl Howe]

My Lords, the amendments deal with two discrete areas. The first set of amendments relates to our proposal to establish a system of assured voluntary registration and seeks to extend compulsory statutory regulation to clinical perfusionists and clinical physiologists, and to make further amendments to legislation to account for this.

The second set relates to the transfer of the regulation of social workers in England from the General Social Care Council to the Health Professions Council, to the protection of the function of social workers, to the office of the chief social worker and to the approval of the training of best-interests assessors. Also included in this second group is a minor and technical government amendment intended to correct an inconsistency in drafting.

As for assured voluntary registration, the vast majority of workers give the very highest quality of care. However, a minority let patients down. This is a cause for concern for all of us and it is right that there is discussion about how we can ensure high standards of care. The Government’s view is that compulsory statutory regulation is not the only way of achieving this and can detract from the essential responsibility of employers to ensure that any person whom they appoint is suitably trained and competent for the role.

As I reminded the House earlier, there are already existing tiers of regulation that protect service users, including the standards set by the Care Quality Commission and the vetting and barring scheme. We also need to be clear that professional regulation is not a panacea. It is no substitute, as I said previously, for good leadership at every level and the proper management of services. It can also constrain innovation in some circumstances and even the availability of services.

Experience clearly demonstrates that a small number of workers who are subject to compulsory statutory regulation from time to time fail to ensure that their practice is up to date and delivered to the standard that we expect. In these circumstances, it is too often the case that regulation can react only after the event. The regulation of individuals will not prevent another Mid-Staffordshire, but strong and effective leadership of the workforce may do, and we believe that employers and managers who are closest to the point of risk must take responsibility for ensuring standards.

The Government believe that a system of assured voluntary registration will support commissioners, employers and supervisors to deliver their responsibility for assuring standards by providing independently assured standards of conduct and training for those on accredited registers. We believe that this approach will work well for clinical physiologists, clinical perfusionists and other groups of health and social care workers. Here, we are building on the work started under the previous Government.

The noble Baroness, Lady Finlay, is right that clinical perfusionists are not subject to statutory regulation, but I assure noble Lords that where failures or risks on the part of clinical perfusionists have been identified in the past, action has been taken action to address them. The Department of Health issued guidance in 1999 that the NHS should use only accredited clinical perfusionists, and further guidance in 2009 that clarified the systems and processes needed to ensure high-quality perfusion services. However, employers, commissioners and patients currently have no objective or independent way of determining how robust the accreditation arrangements are, as they not subject to independent scrutiny. In future, if the voluntary register is accredited by the PSA, they will be subject to such ongoing independent scrutiny.

The noble Baroness, Lady Finlay, asked me about the administration of drugs by perfusionists and compliance with the Medicines Act. Perfusionists cannot prescribe drugs, although they do of course administer perfusions. I would say in my defence to the noble Baroness that compliance with the Medicines Act is rather a technical legal point. If she will allow, I am happy to write to her on that legal position.

Both she and the noble Baroness, Lady Masham, indicated their view that voluntary registers already exist and do not work. Voluntary registers do exist, so standards for these professions exist as well. It has to be said that the Department of Health has little if any evidence of a general problem with the standards of practice for these groups, but, as I said previously, we currently have no objective way of saying to employers that if they rely on professionals who are on existing voluntary registers they can be sure that they are meeting appropriate standards. In future, where voluntary registers are accredited by the Professional Standards Authority, that will be possible.

--- Later in debate ---

[Lord Walton of Detchant]

Will the noble Earl accept that, as the noble Lord, Lord Rea, said, clinical physiologists, and in particular clinical neurophysiologists, have been aware for years that they have produced a very satisfactory standard of voluntary regulation and registration? They have been talking about the possibility of achieving statutory regulation for years. It has been hinted at by Government after Government. They now feel very strongly that the failure of Governments to accept their need for statutory regulation is, in a sense, a kind of downgrading of the status of their respective professions alongside other professions of individuals who work with patients which are regulated by the Health Professions Council: physiotherapists, occupational therapists, and many more. They feel that it is in fact a mark of a lack of respect by the Government that they are being refused statutory registration.

[Lord Rea]

I hope that it is in order to ask the noble Earl a question. When he was talking about the registration and regulation of clinical physiologists, he spent quite a long time saying how voluntary registration could be improved and how good and suitable it was, but he has not actually said why the Government have such a big objection to statutory regulation. I do not quite see why the Government are so unwilling to go ahead immediately with this.

[Earl Howe]

My Lords, if the clinical physiologists feel as the noble Lord, Lord Walton, says they do, I would simply urge them to read what I have said about the merits of assured voluntary registration. It is true that this issue has been on the table for a number of years. The difference between the start of that debate and the point that we have now reached is that there is more than one option on the table. Assured voluntary registration did not exist 10 years ago, but it is now about to become a reality. We come back to the basic point that regulation in itself is not a panacea. Those who think it is need to examine those cases where failures of care and services have taken place. It is much more about upskilling people, making sure that employers are aware of their responsibilities and ensuring proper supervision in the care setting.

Health and Social Care Bill

Lord Rea Excerpts

Wednesday 29th February 2012 Lords Chamber

[Baroness Cumberlege]

My Lords, I have added my name to Amendments 121 to 125, 128 and 152. Noble Lords will be grateful to learn that I am only going to speak to two of those amendments. I want to reinforce the views that are being expressed, and I too pay tribute to the noble Lord, Lord Patel, on the way he has introduced all these amendments in such a comprehensive fashion—but not the government amendments, of course—and other noble Lords who have spoken. I am interested in the situation of the status and accountability of directors of public health. They are going to be very important people. They have access to elected members and senior officers in a new way in terms of recent history. I shall go into that history a little later in my remarks.

Their responsibility is to consult and advise the members and senior officers directly on a range of issues from emergency preparedness to concerns around access to local health services and many other activities, some of which have been mentioned. Acting as the lead officer for health in a local authority and being the champion of health across the whole of an authority’s business is very responsible work, along with the day-to-day management of the ring-fenced public health budget, which is going to be delegated to them by the chief executive. They are also statutory members of the health and well-being boards. It is their direct accountability to the chief executive of the local authority and head of the paid Civil Service that I am concerned about.

This is a good measure to be putting forward. I have read the new Public Health England’s Operating Model published by the Department of Health, particularly the fact-sheet covering the role of the director of public health. It states that,

“we would expect there to be direct accountability between the Director of Public Health and the local authority Chief Executive for the exercise of the local authority’s public health responsibilities and that they will have direct access to elected members”.

So far, so good, but I am not sure that that is actually happening. On this occasion I should like to declare an interest, as I often do, as the executive director of Cumberlege Connections, which is a training organisation. Recently we have been working in an area with a shadow CCG. I had a lot of correspondence after the workshop we ran, particularly from the director of public health. He said:

“It is apparent to me that, especially with organisational development plans in … Council, as in other councils, it is intended to reduce the number of ‘senior’ directors at the top table … in many such instances the director of public health will not be a member of the most senior management team nor report to the chief executive, but report to another director. This is not necessarily the likely model everywhere”.

Here he mentions another authority, and says that,

“the City Council chief executive is currently proposing that the DPH report directly to him and should be part of the most senior management team. It thus seems likely that there will be different models in different local authorities”.

We of course accept that in terms of localism, but there should be some basic principles that all local authorities adhere to, which I believe is the Government’s intention. He goes on to say:

“It is also apparent that a number of medically qualified consultants and directors of public health consider that the likely change of status in becoming a local government officer and being made to leave the NHS … is not what they want”.

I can think of at least three directors of public health who have already quit their jobs to return to general practice, to take up a medical director post in the PCT cluster—that seems to be a rather short-term career move, but there we go—or to take very early retirement. The Government need to put out some very strong messages about this and we need a monitoring system to ensure that their intentions are being carried out.

A point has been made about the termination of employment of directors of public health. In Committee, we discussed quite fully the position that used to be the medical officer of health—it certainly existed in my council when I was a local councillor. They would be a person of huge character and have great clout within the council and the whole geographical area. One of the reasons for their being able to be so robust and to say how they really saw the health situation within a geographical area was that the only person who could terminate their employment was the Secretary of State for Health—in those days, he was called the Minister for Health. That was a very good safeguard. I know that the Government are keen to involve the Secretary of State, but I would like to know to what degree, and that it is not just consultation via e-mail or a piece of paper but something that is real and is going to make a difference.

Let us suppose that in an area where childhood obesity is presenting a real problem a fast-food company wants to build a restaurant in close proximity to a school. That could clearly conflict with the director of public health’s work to reduce childhood obesity. Local authorities, which will have some strong local interests, will be tempted to influence, with local councillors, situations that may go against the professional view of the director of public health. I hope that my noble friend Lady Northover will be able to give me some comfort on these issues.

[Lord Rea]

My Lords, I apologise to the noble Lord, Lord Patel, for not being here when he spoke to his amendment and for wanting to ask the Minister a question that may already have been covered in the debate. It is on the relationship of directors of public health, who are going to be situated in local authorities, with the clinical commissioning groups, which are going to cover very much the same area—although we still do not know exactly what it is going to be. At the moment, directors of public health work closely with primary care trusts. I imagine they will be largely the same people who move to local authorities.

However, many of the activities of PCTs concern directors of public health. I am not sure that we have yet agreed on whether the local authority director of public health will have a seat on the board of the clinical commissioning groups in the same area. We still do not know whether they are going to be precisely contiguous and/or whether there will be several CCGs in one authority boundary. I would be grateful if the Minister could clarify the relationship between local authority directors of public health and the local CCGs.

[Lord Beecham]

My Lords, two shows in the West End have taken the theatre-loving population of London by storm in the past year. One of them was “Noises Off”, a farce that might be thought of as an apt metaphor for some of the relations on the government Benches; the other was “One Man, Two Guvnors”, which is perhaps relevant to the position of directors of public health. I am very glad, therefore, that the amendments proposed by the noble Lord, Lord Patel, and some of those which the noble Baroness will propose, reinforce the position and status of directors of public health. It is crucial that they are independent and are employed on conditions that are comparable to those of fellow clinicians in other parts of the health service. Therefore, the Opposition support the amendments of the noble Lord, Lord Patel, particularly in relation to Clause 30 and disease control.

I perhaps have reservations about the requirement for the Secretary of State to consent to the dismissal of a director; it is right that it should be in the form of consultation. It would be a foolhardy authority that ignored the strong views expressed by the Secretary of State. Given the relationship between central and local government, it is right that it should be a question of consultation rather than consent.

I endorse the views of the noble Lord, Lord Turnberg, about the relationship with Public Health England, which is another example of that dual relationship which directors must have. I equally endorse the observations of the noble Lord, Lord Brooke, who seeks to ensure that the responsibilities cover the entire population, resident or working, of the appropriate area.

The Government have moved significantly on some of their amendments. We are on the right track. I hope that they will look sympathetically at the amendments of the noble Lord, Lord Patel, and strengthen further that crucially independent role of the director, who should certainly be a chief officer of an authority and be accountable to the chief executive. It is an important safeguard, which I commend to the Government.

Health and Social Care Bill

Lord Rea Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Rea]

Would the Minister look at the experiment mentioned by the noble Baroness, Lady Jolly, in Torbay, where there has been considerable merging of health budgets and social services? That was locally led, but would it not have helped to spread it further with an amendment such as this in place, so that it could be encouraged from the centre?

[Baroness Thornton]

My Lords, I support these amendments, and I do so because I agree with the noble Lord, Lord Patel, that there was a grave omission from the Bill that would allow strategic reconfigurations to take place that are not based on failing institutions. It was certainly not clear to us—and I rest on the authority of my noble friend Lord Warner on this—how, with the abolition of the SHAs from April 2013, strategic reconfiguration of specialist services would take place. Ministers have said, “Oh no—it’s all going to be okay”, but they have not explained how you would reconfigure the stroke services in London, as the noble Lord, Lord Patel, said, after the abolition of the strategic health authority. We support the amendments and hope that the Minister will do so as well.

--- Later in debate ---

[Lord Walton of Detchant]

My Lords, I have put my name to two of these amendments so ably proposed by my noble friend Lord Kakkar. I have been on the medical register now for 67 years. I am a registered medical practitioner and I actually have a licence to practise which allows me to prescribe—not that the opportunities of clinical practice in my present world are very widespread, except on the very rare occasions when I have been called upon to minister to one of your Lordships who may have been taken ill in the precincts of this House. The licence to practise will be subject later this year to a process of revalidation.

If I go back to the days—forgive me again—when I was president of the General Medical Council and served on a number of occasions on its conduct committee’s hearings, it became perfectly clear that some of the doctors referred to the GMC were not actually guilty of serious professional misconduct. However, some of them who came before the conduct committee were in fact practising at a standard which was not adequate in a clinical sense. In other words, there was a question in a number of cases of their clinical competence. In those days the GMC began a process to examine whether, alongside the conduct procedures, we should introduce procedures to be able to identify doctors who were practising at less than an adequate standard of care. In the end, under the noble Lord, Lord Kilpatrick of Kincraig—my successor as president of the GMC—it eventually introduced performance procedures to assess clinical performance. Those performance procedures have continued and have been very effective in identifying and handling appropriately, often with retraining, doctors who were found to be practising at less than an adequate standard of performance.

The Minister may say that when, later this year, doctors will be able to retain their licence to practise subject to a process of full validation of their clinical competence, that may be enough. The fact is that I do not believe it will be, and it is therefore crucial that we have a mechanism in the Bill to deal with this potential issue. After all, over the past 40 or 50 years, there has been a massive improvement in the standard of general medical practice in the UK, following the introduction of compulsory vocational training. Every doctor wishing to be fully capable of being a general practitioner has to undergo, at a minimum, three years’ vocational training. The improvement has been immense, but everyone will recognise that not all practices are of such a uniformly high standard. Some doctors in practices may be less competent than others.

The same may be true—who knows?—of clinical commissioning groups. There is clear evidence that most clinical commissioning groups or consortia of GPs will be providing a high standard of care in the community, but there may be a few that are not up to that standard. It is therefore crucial that we have a mechanism whereby the Secretary of State can be in a position, through amendments such as those proposed by my noble friend Lord Kakkar, to identify those practices and clinical commissioning groups that are not producing clinical care of the adequate and appropriate standard which we all expect and which our communities deserve. For this reason, some kind of monitoring of this sort under the mandate is essential.

[Lord Rea]

My Lords, as a former general practitioner I very much welcome this amendment. As the noble Lord, Lord Walton, has just said, the standard of general practice has certainly gone up enormously since vocational training started. However, a number of my colleagues are not up to scratch. The Royal College of GPs and the BMA would be the first to admit that all in the garden is not lovely. I would ask the proposers of the amendment, and the noble Earl, if he is minded to accept it, how the monitoring system will be set up.

As has been mentioned, there are already two different systems in operation to monitor the standards of clinical practice—in fact three, if we take the GMC competence system. However, as mentioned by the noble Lord, Lord Patel, QOF is not a very effective measure. Its standards are set far too low. We have yet to see whether revalidation will effectively identify weak practice. If this monitoring is going to be set up, would it not be sensible to involve the General Medical Council, the Royal College of GPs and the BMA in consultation in designing the performance monitoring system that will be adopted? It could be a very good idea. It is high time that there was a more effective system. Most GPs would welcome it enormously and only a few would regret it.

[Baroness Finlay of Llandaff]

My Lords, I would like very briefly to speak in support of these amendments and ensure that we do not confound QOF, revalidation and the principle of these amendments. They are three different things. The principle behind the amendment is really important because it will identify the range of practices. There was an interesting paper in The Lancet Oncology this week showing the variation in the number of times patients have attended a GP before diagnosis of some cancers like lung, pancreas and so on, whereas those where there has been much greater publicity, such as breast and melanoma, have been referred much more quickly and there is less variation.

Revalidation is about making sure that people are, in the broadest sense, safe to practise and it is hoped that it will filter out those who are really unsafe across the board. However, that is not just what we are talking about with these amendments. We are talking about trying to improve the spectrum of care, including care by those who will get revalidation and who may well be collecting QOF points, but to whom other clinicians in the area would not necessarily want to sign up as patients. So it is about driving up those lower standards to meet the higher standards that we expect. Those data in the public domain will be really important to help patients decide who they register with. I hope, therefore, that the Government will look favourably on the amendments. The amendments are coming from those of us on these Benches who are medically qualified. I should declare an interest as a fellow of the Royal College of General Practitioners.

Health and Social Care Bill

Lord Rea Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Rea]

My Lords, I have a question for the noble Earl on this amendment. What will be the relationship of Public Health England, the national body that will take over the functions of the Health Protection Agency and other areas, to the national Commissioning Board? I wonder whether the noble Earl can guide me to the statutory framework for Public Health England, as it does not seem to be in this long Bill, although it is possible that I am just incompetent and have not spotted it. It seems to me that the chief officer—I hope that he will be a highly qualified public health specialist—who is the senior officer in Public Health England, should have a seat on the national Commissioning Board. That should perhaps not necessarily be permanent, but he should be consulted frequently by the Commissioning Board.

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

My Lords, I thank the noble Lord, Lord Hunt, and all noble Lords who have spoken in another excellent debate. I understand the arguments that have been put forward in favour of these amendments. It is important for me to say at the outset that the Government’s general approach is to allow the NHS Commissioning Board as much autonomy as possible in determining its own membership, structures and procedures. It is our firm view that the board is the body best placed to determine how to organise itself in the most effective and efficient way. We would not want to undermine that.

It is also worth restating that, looking across government, it is the responsibility of all departments to ensure that public appointments to arm's-length bodies are open, transparent and made on merit. However, it is not government policy for such appointments to be subject to Select Committee approval—in this case the Health Select Committee. These are ministerial appointments. The Secretary of State is ultimately accountable to Parliament for the performance of the health service as a whole, as we have made clear through amendments to the Bill. The current process under which some posts are subject to pre-appointment hearings by a House Select Committee does not represent a power of veto, which the amendment would amount to. Of course, noble Lords will be aware that we followed this process, as the noble Lord, Lord Hunt, reminded us, in the recent appointment of Professor Malcolm Grant as the chair of the NHS Commissioning Board Authority. When we discussed this last in Committee, I was pleased that the noble Lord, Lord Hunt, said that he thought that this process ensured proper and effective scrutiny of that appointment. I gently wish to hold him to that view. He raised the comparison of the Office for Budget Responsibility, saying that the NHS Commissioning Board was just as important. Importance is not the issue. The Office for Budget Responsibility has a unique role because it has dual accountability to both government and Parliament directly. The NHS Commissioning Board is accountable to government and, through Ministers, to Parliament, which is somewhat different.

I turn to Amendments 21, 21A and 22. We recognise that the Bill strikes a fine balance between giving the board as much autonomy as possible in how it operates, and providing the necessary accountability. It is important to strike that balance accurately and consistently. If we were so prescriptive in the Bill as to set out further requirements for the board's membership, we would be moving too far away from that necessary autonomy. It is right that it should be up to the board to decide whether it has a vice-chair or a senior independent director, as Amendment 21 suggests. Of course, a vice-chair or deputy chair, were they to be appointed, would have to be non-executive.

Likewise, while I agree that it will be key to the effectiveness of the board for it to involve and obtain sufficient advice and input from public health experts, and to have public health well within its purview, it would not be right to specify that it must have a public health specialist as a member, as Amendment 21A proposes. Again, I am sorry to disappoint my noble friend Lady Williams in particular, but we think that the board will be best placed to determine whether it has the right structure and range of skills, knowledge and experience appropriate to the issues that it will face. In the material that David Nicholson published he made it clear that, rather than making token appointments, he intends that clinical leadership will run right through the organisation. That is a very reassuring statement.

Amendment 22 takes the Secretary of State out of the loop of appointing the chief executive. That moves us too far away from one of the key principles that most of us have signed up to: the necessary accountability of the board to the Secretary of State. It also seems at odds with the ethos of other amendments proposed by the noble Lord, such as Amendment 19, which we debated on the first day of Report and which sought to make every other aspect of the exercise of the board's functions subject to direction from the Secretary of State.

--- Later in debate ---

[Lord Beecham]

My Lords, I will speak to the amendments in my name in this group. They are, in many ways, fairly straightforward.

Amendment 24 seeks to add a duty to promote public health as well as to protect and improve public health, as in the Bill as it stands. Promotion is a more positive term than simply protecting or improving public health. It implies a wider range of activities than simply dealing with public health issues and problems as they arise. I would have thought it added somewhat to the Government’s intentions—which we broadly commend, of course—in terms of the direction of public health and the further involvement of local government.

Amendment 25 simply amplifies the list of steps that the Secretary of State may take, in particular around research and training, to specify that he should use,

“the best scientific and other evidence available”,

with this key phrase,

“without regard to special interests”;

in other words, that they should look objectively and seek a wide range of resources to inform the making of public policy.

Amendments 26 and 28 substitute the word “must” for “may” in respect of some of the Secretary of State’s duties. Amendment 27 is perhaps one of the more important in this group, and refers to a duty on local authorities to improve the health of their populations and “to reduce health inequalities”.

In Committee, the Minister referred to the fact that the Secretary of State has that duty as part of his overall duty to provide health services, and that is certainly correct. However, there is no equivalent express duty on local authorities, nor could one be satisfactorily implied. Again, I pray in aid the views of the Health Select Committee, which pointed to:

“The lack of a statutory duty on local authorities to address health inequalities in discharging their public health functions”,

and called that,

“a serious omission in the Government’s plans”,

and recommended that the,

“Bill be amended to rectify this”.

The Government’s response referred to local authorities as “independent, democratic bodies” and said that a,

“ring-fenced public health grant”,

would be made available. At a later stage we will perhaps need to discuss the arrangements for such a grant, because there are concerns about it and about the health premium to which reference is also made in the Government’s response. The Government conclude that,

“these non-legislative levers will be at least as effective as any duty”.

Of course the Government refer to the provisions of the Equality Act, but that is not good enough. Surely it is important to have in the Bill an explicit duty on local authorities to promote health equalities and health improvement. I hope that the Minister will recognise on reflection that the Government will lose nothing by taking such a step. The Government would simply reinforce their intentions and put them in a framework that will send a clear signal to local government.

Amendment 28A, in the name of the noble Baroness, Lady Finlay, seeks to require co-operation between local government, the Secretary of State and quite a list of providers of public health. The amendment is virtually the same as Amendment 28C in my name. There are perhaps one or two slight differences but nothing of any great moment in that respect. I am perfectly happy to defer to the noble Baroness when she moves her amendment.

Amendment 29 seeks to establish the topics of public health that should be included in matters to be addressed by local authorities. The intention, again, is to put in the Bill what may or may not be implicit in the prevailing arrangements. In Committee, the Minister indicated that he did not think that it was necessary to have these references. On the contrary, it is helpful to send a signal of what is expected not only to local government but to those who look to their local authorities to take steps to promote public health on the issues. The list in Amendment 29 includes:

“sexual health … obesity … nutrition … alcohol and substance abuse … air and water quality … adequate housing standards … fuel poverty … occupational health”.

Those are all important issues, most of which also involve inequalities of health. The provision looks very clearly to local government to take those items seriously and to promote advances on each. It is not a mandatory requirement and, of course, the situation will vary from place to place. However, it is a shopping list for local government, citizens and interested organisations to use in pressing that policies and resources be directed at these important areas of public policy. As the amendment makes clear, it is not a restrictive list.

Amendment 31 deals with another issue raised by the Health Select Committee, although it is a matter that we also discussed in Committee. Among the partners of a local authority for the purposes of public health provision, it is very important to include the district councils. In two-tier areas, district councils have a wide range of responsibilities around the environment, housing, food safety and so on, which clearly are integral to the public health service.

It is obviously necessary therefore for a principal authority in a two-tier area to co-operate with a district, but also, conversely, of course, for the district to co-operate with the principal authority. The amendment specifically calls for the relevant partners to co-operate with the local authorities and for it not to be just a one-way street. Again, that raises an expectation on the appropriate local authority and the opportunity for its residents to push for action, if required.

Amendment 32 calls for the Secretary of State to publish annual reports on the public health impacts of budget changes on duties to improve public health. That is a glancing reference to the fact that there is to be a new financial framework and it is important to see how that impinges on what local authorities actually do, and that of course includes district councils. Again, I should emphasise that the position of district councils is yet another matter on which the Health Select Committee was very clear in its recommendations:

“We are concerned that too little attention is paid in the Government’s plans to the role of lower-tier authorities”.

The Government are relaxed, shall we say, about doing anything very specific about that, although apparently they will be issuing draft guidance. It might be thought that that is not really adequate in all the circumstances and that explicit reference should be made to the requirement to involve district councils.

As I said in Committee and I repeat today, the Opposition are keen to support the Government’s approach to returning many public health responsibilities to local government, but it has to be done in a way that encompasses the broad range of issues that affect individuals and communities, and empowers and indeed requires local government that they should take action to meet their part in discharging those responsibilities. Accordingly, I beg to move.

[Lord Rea]

My Lords, I do not know if it is a slight slip on the part of those who drafted the Bill that the word “promotion” is not already in the clause. The coalition agreement on public health states:

“The Government believe that we need action to promote public health, and encourage behaviour change to help people live healthier lives … harnesses innovative techniques to help people take responsibility for their own health”.

That is a bit unfair on people because lifestyles are very much dependent on life chances. People who come from a rotten background may indulge in practices which are not particularly good for their health, but you cannot really ask them to change. We need to take into account a lot of the things which my noble friend Lord Beecham has just gone through because they are relevant to the practice of public health. The word “promotion” should definitely be included at the beginning of this clause.

[Baroness Northover]

My Lords, in Committee noble Lords made a number of helpful and constructive comments on public health. We have carefully considered this feedback, and as noble Lords will see in later clauses, we have made some significant changes to the public health provisions. Amendments 24 and 28 both relate to the Secretary of State’s accountability and his role in the promotion and improvement of health. The Secretary of State is under a duty to protect the health of the public in England. We are clear that the primary legal responsibility for health improvement should lie with local government, although the Secretary of State will have the power to act on health improvement when appropriate. We welcomed what the noble Lord, Lord Beecham, said in Committee about a renewed involvement of local government in public health, and he has reiterated that today. It is extremely important that local government, which is often best placed to take this forward, sees its prime legal responsibility and that there is no duplication of duties. Therefore, in drafting Clauses 10 and 11, we have taken care to avoid duplicating duties and to keep roles and responsibilities clear. We do not believe that additional amendments to the Bill are needed and I hope that noble Lords will understand why we have drafted these provisions in this way.

Amendment 26 takes the list of steps that the Secretary of State may take as part of his health protection duty and turns it into a set of fixed duties. I hope that I can reassure noble Lords that the Secretary of State cannot simply ignore the steps even though we have used the word “may” and not “must”. He must give proper consideration to what steps are appropriate to protect or improve health. Although the duty does not necessarily require the Secretary of State to take all the steps listed under new Section 2A, if after proper analysis he considers that a particular step is appropriate, he must take it. However, we take the view that the Secretary of State needs the flexibility to decide what steps are appropriate. The Bill outlines the areas in which the Secretary of State might take action. It fleshes out the ways in which the Secretary of State must take steps to protect the public. To prescribe these exemplars in statute runs the risk of inflexibility. One duty in the list, for example, is to make available the services of any person or any facilities. What would that mean if it was made a “must”?

Health: Smear Tests

Lord Rea Excerpts

Monday 13th February 2012 Lords Chamber

[Earl Howe]

My Lords, I can reassure my noble friend that the cervical cancer screening programme will be commissioned by the NHS Commissioning Board, so it will be done nationally and centrally.

[Lord Rea]

Is the HPV vaccination being offered also to teenage boys? After all, they are responsible for spreading this virus.

[Earl Howe]

My Lords, inoculation is not being offered to boys as part of the national programme. As I am sure the noble Lord knows, the aim of the programme has always been to prevent cervical cancer in women. Clearly, the best way to do that is to vaccinate girls and young women. However, these vaccines can be purchased privately and health professionals should exercise their clinical judgment when prescribing products for specific indications.