Regenerative Medicine: S&T Committee Report

Lord Turnberg Excerpts

Thursday 13th March 2014 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I am delighted to reiterate the remarks of the noble Lord, Lord Patel, in congratulating the noble Lord, Lord Krebs, on chairing our Select Committee so ably, and on the support of his expert adviser and secretariat. I also commend the noble Lord, Lord Patel, for introducing this topic and for explaining so clearly the enormous potential of regenerative medicine to cure diseases that are hitherto incurable, and for pointing out the considerable benefit we have from our expert scientific base in the UK.

I express my interests as scientific adviser to the Association of Medical Research Charities, many of whose members have strong interests and involvement in regenerative medicine.

It is worth noting that our report was produced last summer after taking evidence for more than a year and that things have moved on since then. It is a rapidly moving field and some things have changed for the better while others have been thrown into starker relief. There have been more advances in the science; clinical applications are being developed; the mood in the investment community, oddly enough, has improved—I am told that there is a greater appetite among venture capitalists to take the risks needed to invest in the field; and there is some hope that we will see some of the recommendations of our report being put into action.

However, I want to focus on only three aspects: the complex regulatory framework; the MHRA and MEA approval processes; and our capacity to manufacture and scale up production.

First, on the regulatory framework, I hope to build on the words of the noble Earl, Lord Selborne, and I know that the noble Lord, Lord Willis, will also take up the cudgels on regulation. Under the regulatory framework, a researcher or a small biotech company wanting to take a discovery forward for further development in a clinical trial or commercialisation will be faced with no fewer than 11 regulatory bodies that they may have to apply to. This morass of bodies, with a mix of acronyms from the HFEA to the HTA, from GTAC to the MHRA, from the EMA to the HRA—to say nothing of having to jump through the hoops of NICE—is extremely confusing, and not only to the novice. The UK has many more regulators than virtually any other country in the world, and certainly more than the USA, which seems to have one.

Our recommendations focus on the need to take a grip of this complexity and suggest that the Health Research Authority should expand its current role in streamlining the regulatory process. The HRA is doing an admirable job within its limited resources. It is under the expert guidance of Professor Jonathan Montgomery, and in a pilot study that it has already carried out, it has demonstrated that it could do much more. The authority has shown that it could provide a sort of one-stop shop for researchers so that a single application made to the HRA would be fed through a gateway for approval by the authority where it has the competence to do so or distributed to those other bodies that need to give their approval. This would be a remarkable achievement if it could be done and would transform the atmosphere for researchers. However, of course, it requires more funding for the HRA. It would not need vast sums, and could indeed be achieved with a modest investment, while the gains made, both financially and in saving wasted time, would be enormous. My first question for the noble Earl is whether he will examine whether there is some way to find the modest extra money needed. I know that a bid from the authority has gone in to the department, and it would be helpful if he could tell us how far it has got.

I turn now to the processes by which new treatments are assessed by the Medicines and Healthcare products Regulatory Agency. Here the timescale is almost always very long, and sometimes it can several years and involve large and expensive phase III trials. However, for treatments such as those using regenerative medicines, stem cells and the like, such a lengthy process is quite inappropriate. This has been recognised in Japan and the USA, where a much more flexible approach has been taken. In Japan, as the noble Earl, Lord Selborne, mentioned, the law has recently been changed so that approval for regenerative medicines can be based on phase II trial evidence alone, without the need for phase III trials. In the USA, the FDA has introduced what is called a breakthrough therapy designation that provides a similar phase II-only requirement. I know that the MHRA recognises the need for something similar here, and it would be extremely helpful if the noble Earl could indicate how far the expert group set up by the MHRA has progressed in its efforts to develop an adaptive licensing system to speed up approval of these types of innovative treatment. The Government are paying much more attention to the need for innovation in healthcare, and certainly those in the field would find the efforts of the MHRA encouraging. It would allow us to keep up with our rivals around the world.

Finally, I come to another concern. Our report described a reluctance among venture capitalists to invest in biotech in general and in regenerative medicine in particular, and I mentioned earlier that the situation here may be changing. The so-called valley of death between invention and commercialisation may not be as deep as we thought, even though we remain way behind the more adventurous investors in the USA. However, as prospects for investors are now improving and more cell-based therapies appear to be coming on stream, the problem of the lack of manufacturing capacity to take these advances to the market has been shown to be much more obviously rate-limiting than had been thought. We have drawn attention to this problem in several of our recommendations and we have had supportive responses from the Government and others, but much more needs to be done. Our ability to scale up the production of these highly specialised treatments so that they can become available to large numbers of patients is sorely lacking. I feel that the UK Regenerative Medicine Platform, which has been asked to take this on and which could have had all this in hand, has been just a touch complacent. In this light, can the noble Earl tell us how far the Ministerial Industry Strategy Group, which met in November, got with its discussions on manufacturing capacity? What recommendations, if any, emerged as a result of that meeting?

I note that the Cell Therapy Catapult is gathering evidence on capacity, but that alone will not solve the problem if we do not offer some inducement to those who need to build up our manufacturing capacity. It is also the case that the resources available to the catapult are limited and will only go a little way in offering this inducement. Is there any prospect that the Technology Strategy Board will offer more support for this purpose? Will the UKTI Life Science Investment Organisation play a role in helping fill this gap? It will certainly be offering advice and information to potential investors overseas. What practical encouragement will it be able to offer companies that they will be supported if they come here?

The potential for regenerative medicine to transform healthcare in the next few decades is enormous. We must take advantage of the lead we have in basic research and convert it into therapies for patients and economic benefits for the UK. There are encouraging signs, and the Government are clearly aware of the importance of investing in this area, but there is much that remains to be done. In particular, we must make sure that we have a regulatory environment that is efficient and fit for purpose, that we keep up with the competition with a responsive and speedy approval system, and that we are well prepared with the capacity to manufacture to scale these potentially remarkable treatments.

Medical Act 1983 (Amendment) (Knowledge of English) Order 2014

Lord Turnberg Excerpts

Tuesday 11th March 2014 Grand Committee

[Lord Walton of Detchant (CB)]

My Lords, I cannot say how welcome this order is. Forty-three years ago I was elected dean of the medical school of the University of Newcastle. By virtue of that election, I was immediately appointed to the General Medical Council. I became a member of its education committee and three years later I became the chairman of that committee. By virtue of being chairman of the education committee of the GMC, I was then appointed, under the new arrangements for the European Union, to the Advisory Committee on Medical Training, which met twice a year in Brussels and was required to make recommendations on basic medical education, specialist medical education and the mutual recognition of qualifications.

That was an interesting experience. Under the treaty of Rome, the first directive derived from that treaty said—I am not quoting exactly but the meaning is clear—that in the movement of doctors across the European Union there should be mutual recognition of qualifications and registration should be granted, but that it should be up to the host country to see to it that the incoming doctor had such ability to communicate with patients to make him or her safe to practise. That seemed to give us at the GMC full authority to embark upon establishing a language test.

At that time, for historical reasons, some doctors from outside the European Union—from Commonwealth countries such as Australia, New Zealand, the West Indies and many others—had enabled the General Medical Council to inspect their examinations and qualifications so they were automatically granted full registration under the Medical Act. But doctors from many other countries who had not had that ability to have inspections were required to apply for temporary registration if they wished to come to the UK, and they had to take a test set by the Professional and Linguistic Assessments Board, which established tests of not only clinical and academic competence but language capability. That was the so-called PLAB test.

It is important to make the point that the rights of doctors graduating in any other member country of the European Union applied only to those who had graduated in those countries but who were also nationals of EU member states. For instance, if a doctor from a country outside the European Union graduated from, say, Heidelberg, they were not entitled under that treaty to come to the UK and had to go through the same procedure as a doctor from India, Pakistan or other parts of the world.

Indeed, there was one such doctor, an Iranian, who qualified in medicine in Heidelberg. He applied for registration with the General Medical Council and was turned down. He took the GMC to a judicial review. Of course, he lost because he did not qualify. The result of this was that I was interviewed by Special Branch because he had made serious threats against my person, including threats of violence. However, we will leave that alone for a moment.

The point I wish to make is that it is so important that we have this language test. We at the GMC, having read what the directive said, tried to impose a language test on incoming doctors from the European Union, but we were threatened with being taken to the European Court because we were told very clearly by our lawyers and by the lawyers from Europe that this was contrary to the treaty of Rome. We tried again 10 years later when I became president of the General Medical Council, again with a total lack of success. All we were able to do then was to persuade the employing authorities in the UK, through the Department of Health, that they could impose a language test as a condition of employment. Regrettably, that agreement with the Department of Health was never properly or widely fulfilled across the UK, so a language test as a condition of employment for European doctors was not widely employed. Our attempts at that time were lost.

The great thing about this order is, first, that it makes it clear that the GMC can properly design and employ a test of the language ability of an incoming doctor from the EC as a condition of registration. Secondly, the responsible officer can make certain that any doctor coming up for revalidation speaks English adequately. Finally, when any doctor who is already a specialist from the EC or is working either in general practice or in a specialist grade and is brought before the GMC on the question of fitness to practise, the fitness-to-practise procedures can take note of the doctor’s ability to speak English. These are extremely welcome developments. Perhaps I am wrong about the condition of registration but the GMC, I think, is hoping that that is the effect of this order. Perhaps the Minister can clarify it for us. The whole process set out in this paper is extremely welcome and long awaited.

[Lord Turnberg (Lab)]

My Lords, it is always a challenge to follow the erudition of my noble friend Lord Walton, who certainly has no difficulty with the English language. I am sorry to add to the noble Earl’s load of potential medical speakers this afternoon but it is a pleasure to welcome this initiative which at long last gives the GMC the powers to ensure that doctors coming to work in the UK can speak and understand English. It has been long awaited and although it has always been part of the assessment of non-EU doctors it will now be a requirement for EU doctors too. After all that, it might sound a little churlish to say that there remain some things to be done about long-running issues that are not addressed in this statutory instrument. I hope the noble Earl will forgive me for mentioning them here.

I go back a little while, not quite as long as my noble friend Lord Walton, to when I was chairman of the Specialist Training Authority and the EU directives were being produced in the 1990s. Since those directives governing the free flow of workers across the EU came in, doctors trained in other member states can come to practise in the UK quite freely. However, we recognised from the very beginning that we know relatively little about the training of specialists in other EU countries. We have no knowledge of the curriculum they go through or the skills and knowledge of, for example, cardiologists, neurosurgeons and paediatricians from a selection of EU counties such as France, Italy, Spain and Germany. They may be perfectly fine, of course, and they probably are, but apart from knowing that they have spent a certain minimum number of years in training, we are not allowed in the UK to assess any of their knowledge or skills before they are put on the register of specialists. That is not the case for specialists coming from, say, America, Australia, New Zealand or any other non-EU country; they have to have their training and skills properly assessed and they may be required to take more.

Questions about the safety of our patients as far as EU doctors are concerned have been raised in this House in the past, but I have little confidence that we will be able to change the arrangements now when we would, it seems, have to convince the other EU member countries of this problem. Will the noble Earl seek advice from the GMC on how it intends to check on the safe practice of specialists from other EU countries? It is possible that its system of responsible officers may help. However, the GMC can act only after a doctor is already on the specialist register. There is a question of whether there is sufficient capacity in the responsible officer network. It would helpful if this issue could be aired a little further. I hope that the noble Earl will be able to find out from the GMC how far it can go on this.

Health: Multiple Sclerosis Nurses

Lord Turnberg Excerpts

Wednesday 5th March 2014 Lords Chamber

[Earl Howe]

My Lords, something can be done. First, patient groups can speak up and can speak to commissioners. As I said in my original Answer, we are committed to putting patients right at the centre of services, which means giving them a voice in the services that are commissioned. I am not aware of the situation in the Chelsea & Westminster Hospital, but my noble friend may like to know that there are now more than 3,300 more nurses working on NHS hospital wards than there were in 2010. That is a positive trend.

[Lord Turnberg (Lab)]

My Lords, is this not part of a wider problem, in that we have seen a marked reduction over the past few years in specialised nurses working in the community, where they can do so much to help keep patients safe and out of hospital? Should we not be seeing joint funding between the local authorities and the CCGs to fill this gap, which is looming all the time?

[Earl Howe]

Yes, my Lords, that is why we are creating the Better Care Fund, with £3.8 billion worth of shared money between the NHS and social care, starting in 2015, to make care seamless for the patient, whether it is NHS or social care. That fund has scope to do exactly what the noble Lord wishes to achieve.

NHS: Patient Data

Lord Turnberg Excerpts

Tuesday 25th February 2014 Lords Chamber

Asked by

[Lord Turnberg]

To ask Her Majesty’s Government what is their assessment of the proposal to establish a national collection of data about patients, in the light of the decision by NHS England to postpone its introduction.

[Lord Turnberg (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I declare my interest as scientific adviser to the Association of Medical Research Charities.

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

My Lords, NHS England’s care.data programme takes forward the ambitions set out in the Government’s information strategy for health and care in England, The Power of Information, published in 2012, in particular elements of chapter 5 of the strategy. The Department of Health strongly supports NHS England’s decision to do more engagement work before data collection takes place. This is a vital programme which will bring real benefits to patients.

[Lord Turnberg]

My Lords, I am grateful to the noble Earl for his response. Few people doubt that there are enormous benefits to be gained from patient data, both for the care and treatment of patients at the moment and for research into treatment for future patients. However, does the noble Earl agree that NHS England has been remarkably unsuccessful so far in communicating both the benefits and the safeguards to confidentiality? Does he further agree that it is vital that NHS England uses the next six months, which is the delay, to develop some robust and convincing methods of communicating with the public?

[Earl Howe]

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

Health: Meningitis B Vaccine

Lord Turnberg Excerpts

Monday 24th February 2014 Lords Chamber

Asked by

[Lord Turnberg]

To ask Her Majesty’s Government whether they plan to introduce a vaccine for meningitis B in children.

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

My Lords, the Joint Committee on Vaccination and Immunisation, the independent expert committee that advises the Government on immunisation matters, has not yet made a final recommendation about the use of the meningococcal B vaccine, Bexsero. The JCVI is due to report in March 2014, having reviewed additional evidence at its meeting earlier this month. We will respond to any JCVI recommendation as quickly as possible.

--- Later in debate ---

[Lord Turnberg (Lab)]

My Lords, I am grateful to the Minister for that response. Meningococcus B causes a very nasty form of meningitis. It affects about 1,000 cases a year, mostly in children. It kills about one in 10 and causes severe and lasting disability in one in three. It is no wonder that it is a parent’s worst nightmare. Yet the safe and licensed vaccine that can prevent most cases was turned down by the JCVI after what seems to have been rather a doubtful cost-benefit analysis. Will the Minister make sure that when the JCVI comes to look at it again, as it is doing, it uses a more relevant discount value for the quantity and quality of a child’s life; and that once the Government have received the committee’s advice, they will make a rapid decision to make the vaccine available?

[Earl Howe]

I can give the noble Lord an assurance on the latter point. We will take a decision as rapidly as we can once we receive the JCVI advice. I appreciate that the JCVI’s interim position statement will have been disappointing to many people. I know the noble Lord recognises that it is important that decisions about the introduction of new vaccines into the national immunisation programme take account of evidence of their effectiveness, safety and cost-effectiveness compared to other healthcare interventions. We need to wait and see what the JCVI’s final advice is. I am aware that it is looking at the cost-effectiveness methodology that is used for vaccines of this type.

NHS: Competition

Lord Turnberg Excerpts

Monday 10th February 2014 Grand Committee

Asked by

[Lord Turnberg]

To ask Her Majesty’s Government what assessment they have made of the place and value of competition in the National Health Service.

[Lord Turnberg (Lab)]

My Lords, I am delighted to have this opportunity to debate the place and value of competition in the NHS. It is perhaps a little unfortunate that I received notice that I had secured this debate rather late last week. As a result, we have a rather select and distinguished band of noble Lords speaking today.

I want to make the case that we now have an unhealthy degree of competition, but in doing so I do not want to suggest that competition per se is necessarily a bad thing; nor do I want to get sidetracked into an ideological argument about the relative merits of free markets versus collective action. I want to try to tease out what the evidence really is for the value of competition in the NHS.

It is probably a basic human urge to compete. When I was a physician working in a hospital in Salford and when I was dean of Manchester’s medical school—here I express my interests in both—I have no hesitation in admitting that I was competitive in wanting my hospital and my medical school to be the best in the country if not in the world. It so happens that Salford Royal hospital is now lauded as being one of the most advanced in the way that it provides its services—it has obviously taken advantage of my absence to do great things.

However, when one comes to the National Health Service—that is, the national service—naked competition can become very counterproductive. We can certainly have too much of a good thing and the unhealthy degree of competition that we have now is interfering with our need for that collaboration and co-operation that are so vital for optimal patient care, to say nothing of its impact on integration as I will describe.

It is not as if we have never had competition before now; indeed, the previous Labour Government introduced the principle of opening up services to private providers. However, we took a devastating leap forward, or more accurately backward, with the health Act 2012 and the unloved Section 75, which placed a virtual obligation on commissioners to go out to tender for any and every service. It is that obligation that distinguishes it from what went before. We need to get the balance right between healthy and unhealthy competition. I shall give some of the many examples of where we have not got it right in a moment or two.

Those who promote competition in health services say that it improves patient care and efficiency, but what is the evidence for that? Does it work and, if so, in what circumstances and for what particular services? As one might expect, there have been a number of academic studies to try to tease this out and the results have been far from conclusive. The Office of Health Economics report in 2012 was very cautious and found that while some aspects were improved, others were made worse. Let us listen to those who have done the research. Dr Light wrote in the Journal of Health Politics:

“Promotion of competition is guided by political and ideological considerations and is not supported by any scientific evidence”.

Valentina Zigante and her colleagues have written:

“The ideology of competition and choice is running way ahead of the evidence that it improves efficiency, equity or quality”.

Dixon and Le Grand have said that there is,

“no evidence that the choice policy has resulted in significant changes for the patient or to patient pathways”.

However, we do not need to rely on academic studies to recognise the difficulties that we now have with the competition agenda: the problems are absolutely clear in the many day-to-day examples in the NHS. One only has to look at the gross case of Poole and Bournemouth, where everyone involved—the public, local authority, the doctors, nurses and managers—all agreed that amalgamation of the trusts’ services was essential if they were to be able to provide a safe and efficient accident and emergency service, avoid the £8 million black hole that was looming and save £14 million a year. After reportedly spending some £6 million on legal fees and gathering mountains of documentation, the whole thing was blocked by the Competition Commission. You do not need too many examples like that for managers around the country to run a mile before engaging in similar rational mergers or use of resources.

There are many other examples. Let us take the case of the CCGs in Blackpool which had found a better and cheaper way of dealing with patients with headaches than having to send them to a hospital, only to be challenged by Spire private healthcare for not sending them enough cases. The cost to the CCGs in money and time of having to sift through mountains of records to fight the case was very high and will certainly make others think twice before going down the same route. There are reports that in Bristol, the unified cancer care pathway has been put on hold, while at King’s College Hospital the plan to integrate care for the elderly with the local council has been stopped by competition law.

It is not as if this bonanza for the lawyers was not predicted. In our debate on the Section 75 regulations last April, several speakers, including myself, warned of just this sort of costly litigation. As Sir David Nicholson said to the Health Select Commons Committee recently, the NHS is getting,

“bogged down in a morass of competition law”.

Despite all the reassurances given by the noble Earl when we debated the statutory instrument last April, managers in the health service are running scared of coming up against competition law whenever they set up their contracts for services. It is hardly surprising, according to a recent survey in the Health Service Journal, that nine out of 10 chief executives are making their top priority the cutting back of competition rules, and it is not difficult to see why they feel obliged to avoid litigation when they have Monitor breathing down their necks, as well as the Office of Fair Trading backed by UK public procurement regulations and EU competition law looming above them. It is of little use to managers that the kindly David Bennett of Monitor is hinting that he will not pursue them if they take a sensible approach and do not go out to tender for anything and everything, because in practice the law is biting hard.

It is hard, too, to see how multiple contracts with a range of providers can fail to impact on the need to focus specialised services in a smaller number of hospitals or to centralise scarce facilities. These rational and laudable aims can hardly avoid being inhibited by the drive to competition. And, of course, there is the knotty issue of integrating care across the hospital/community divide, which everyone wants to see but which will be inhibited by competition for the different elements of what should be seamless care. There seems little doubt that uncontrolled competition can result in a fragmentation of services that simply frustrates the need for a strong and coherent set of services.

What can be done about it? We have to tackle the legal driver of competition law which is creating such an expensive diversion of resources and manpower away from more important work like caring for patients. It is no use saying that commissioners have the freedom given by reassurances from Monitor on the one hand when they find that they have to defend themselves from legal action taken by private providers on the other. I have only one question for the Minister. Will he help to obviate this legal quagmire into which we seem to have blundered by repealing this onerous and damaging set of regulations and starting again with a less destructive set?

NHS Property Services Ltd

Lord Turnberg Excerpts

Thursday 30th January 2014 Lords Chamber

[Earl Howe]

My Lords, it has been a good start for the company. It has generated £22 million from sales of surplus assets and savings of £2 million a year on the running costs of those disposed properties. The company is also harnessing economies of scale—for example, savings to date of £1.2 million by standardising the procurement of electricity across the whole estate. The company is now exploring how to make savings across other utilities and services, such as legal services.

[Lord Turnberg (Lab)]

My Lords, following the response to my noble friend Lord Hunt’s question, can the noble Earl tell us why the National Audit Office has decided to conduct an investigation so soon after the establishment of this organisation?

[Earl Howe]

My Lords, the National Audit Office is indeed looking at the company—only to assure us and itself that the company is properly organised and structured. We welcome that, as does the company. There was no sinister purpose or concern underlying that process; it is perfectly normal and natural.

NHS: Cancer Treatment

Lord Turnberg Excerpts

Wednesday 29th January 2014 Lords Chamber

[Earl Howe]

My Lords, I completely agree. The noble Baroness is right that a series of reports has shown that the NHS has too often failed to provide the best possible services to older people. We cannot save lives without tackling inequalities. The NHS has a statutory duty to reduce health inequalities and to improve the health of those with the poorest outcomes. A ban on age discrimination in the NHS services was introduced in 2012, meaning that NHS services need to do everything they can to ensure that they do not discriminate against older people. We will hold the NHS to account for that through the mandate and the NHS outcomes framework.

[Lord Turnberg (Lab)]

To what extent are these shocking figures due to lack of funding for cancer services? In that light, what is the Government’s plan for the cancer drugs fund?

[Earl Howe]

My Lords, the noble Lord may recall that the Government pledged an additional £750 million to support the cancer strategy. We are doing that, and a range of actions are proceeding there. On the cancer drugs fund, we initially pledged a total of £600 million for the first three years of the fund and we recently pledged another £400 million, making £1 billion in all. I am pleased to say that the cancer drugs fund has so far helped more than 38,000 patients.

Health: Flour Fortification

Lord Turnberg Excerpts

Tuesday 21st January 2014 Lords Chamber

[Earl Howe]

I am aware that we have looked at the experience of other countries, but, as I am sure the noble Lord will accept, we need to take a decision on this that is right for all of our population rather than another country’s population. That is why we want to make the decision evaluating risks and benefits based on the most up-to-date data of the folate status of our own population.

[Lord Turnberg (Lab)]

My Lords, the case for fortifying flour with folic acid is now incontrovertible. It is both safe and effective in preventing spina bifida. I should like to follow up the question of the noble Baroness, Lady Gardner, about vitamin D fortification, as there is a rising incidence of rickets in children, particularly Asian children, and we really should take that seriously.

[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.

NHS: Essential Services

Lord Turnberg Excerpts

Tuesday 14th January 2014 Lords Chamber

[Earl Howe]

My Lords, from April this year, CCGs and NHS England will begin to identify formally those healthcare services that they consider essential to protect in the event of the financial failure of their providers. They will be required to designate such services as commissioner requested services. In doing so, they must have regard to Monitor’s published CRS guidance. Should an independent provider of CRS get into financial difficulty, then Monitor will work with the provider and relevant partners to determine the right solution.

[Lord Turnberg (Lab)]

My Lords, what safeguards are in place to make sure that CCGs do not have a conflict of interest when they contract for services in which they may have a direct involvement?

[Earl Howe]

The noble Lord will, I am sure, remember from our debates on the Health and Social Care Bill that NHS England has published guidance for CCGs on managing conflicts. There is also a duty placed on CCGs to have regard to such guidance and CCGs set out in their constitution their proposed arrangements for managing conflicts of interest.