Health and Social Care Bill

Lord Walton of Detchant Excerpts

Monday 28th November 2011 Lords Chamber

[Baroness Royall of Blaisdon]

My Lords, I speak to Amendment 110ZA. In tabling the amendment and Amendment 343A, I was mindful of information from the Prostate Cancer Charity, which I strongly support, and from members of the Epilepsy Society. Of course I am aware that many other people with different chronic diseases, and those who care for them, are concerned about these issues.

As noble Lords are aware, prostate cancer is the most common cancer in men in the UK. In England, 30,000 men are diagnosed with it every year, and there are 215,000 men living with and beyond the disease. Ten thousand men die from prostate cancer every year. Currently, clinical nurse specialists for men with prostate cancer have to care for a worryingly high number of new patients compared to nurses for people with other common cancers. I am therefore worried that the financial pressures on the NHS and the cost of reform will threaten those already overstretched specialist nurses, who are so vital in driving up the quality of care for people with cancer.

Access to a clinical nurse specialist improves the experience of people with cancer at every stage of their journey and ensures that they have access to the vital support and information they need. This has been evidenced by the results of the 2010 National Cancer Patient Experience Survey. If patients are to have more control over decisions related to their care and report a good experience of care, they need the clinical and emotional support, information and expertise that a clinical nurse specialist can provide.

As the noble Earl will be aware from his association with the epilepsy organisations, NICE guidelines state that epilepsy specialist nurses should be an integral part of the medical team providing care to people with epilepsy. Even with investment made under my Government, 60 per cent of acute trusts and 64 per cent of primary care trusts did not have an epilepsy specialist nurse in 2009. SIGN guideline 70 states that,

“all epilepsy care teams should include an epilepsy specialist nurse”.

There are around 150 epilepsy specialist nurse posts, with a further 250 to 300 nurses who have undertaken training but are not in a role due to the shortage of posts.

As all noble Lords will be aware, specialist nurses save the NHS money by releasing consultants’ time, reducing A&E admissions, enhancing patients’ adherence to treatment and reducing the use of hospital beds. Therefore, I am proposing two amendments that would place duties on the NHS Commissioning Board to have regard to the continued access of patients to clinical specialist nurses. The first would support the board’s existing duty as to the improvement in quality of services and the second would create a new standalone duty. I trust the Minister will be able to accept my amendments.

[Lord Walton of Detchant]

My Lords, I rise to support Amendment 109A. There is no doubt at all that for many years now the work of the National Institute for Health and Clinical Excellence, NICE, has made a major contribution to the National Health Service. There is a widespread feeling in the public at large that NICE deals with nothing other than whether or not to recommend the approval of certain drugs for the treatment of disease within the NHS. However, NICE’s commitment spreads much more widely than that. It examines procedures; it examines complicated interventions of all kinds; it examines the introduction of new and innovative techniques, new instruments and other procedures in the NHS. Its remit is exceptionally wide.

I know full well that the noble Lord, Lord Newton, says he is not going to pursue this amendment to a vote, but it is important that we have some assurances from the Minister. As my noble friend Lord Butler says, it is clear that, although NICE guidance in general terms is something with which health authorities and health bodies of all kinds will be expected to comply, there are clearly circumstances, particularly at a local level, where, for the reasons he gave, such compliance would be inappropriate. The amendment takes full note of that as being an important issue.

However, we must be sure, in implementing the recommendations of NICE, that we do not overlook the crucial importance of ensuring that the national Commissioning Board will have a duty to promote innovation in its annual report. It is also crucially important, when we come to look at innovation tariffs much later, in Amendment 288H, to see that the tariffs system will not act as a counterincentive to the adoption of innovation and of new technologies. These are issues upon which it is important to seek assurances from the Minister.

Perhaps I may also add to what the noble Baroness, Lady Royall, said. The work of specialist nurses is extraordinarily important to the NHS, and not least in my own field of neurology, where nurses who are specialised in multiple sclerosis, Parkinsonism, epilepsy and many other conditions have made an outstanding contribution to the clinical care of patients. In many instances, their work and advice have prevented unnecessary admissions to acute wards of patients suffering from these conditions. They are invaluable. Unfortunately, over the past five or six years, we have identified instances where cash-strapped health bodies of various kinds have diverted some of these specialist nurses into standard nursing care. I hope that the Minister can give us an assurance that the role of specialist nurses in the NHS is going to be enshrined in the Bill and that the Government will recognise that such nurses are there for a special purpose, not to provide general nursing care in hospital wards and out-patient departments.

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[Lord Walton of Detchant]

My Lords, I thank the noble Earl for confirming that the Government are working with the BMA. Is it not also very important, in relation to confidentiality, that they should also work with the General Medical Council which, after all, has provided very detailed advice to doctors about confidentiality issues?

[Earl Howe]

My Lords, the noble Lord is quite right, and my understanding is that we are doing that as well. Meanwhile, I can tell my noble friend Lord Marks that we will consider the provisions highlighted by Amendments 153ZZA and 153ZZB as part of this process.

My noble friend also raised the issue of inequalities. In earlier debates I highlighted the very significant departure made in the Bill that, for the first time ever in this country, the Secretary of State will be legally obliged to have regard to the specific need to reduce health inequalities, whatever their root cause. The board and the CCGs will also have this duty, which clearly emphasises our commitment to equity and fairness across the health service. We believe that the phrase “have regard to” completely captures the intention of the legislation; that is, that the board and the CCGs must consider the need to reduce inequalities in every decision they take. That, I hope, addresses the essence of Amendment 118. This is consistent, as I think it should be, with the public sector equality duty, which is phrased in exactly the same way. As the board already has a responsibility for all patients in the population, its general duty on inequalities also applies this widely.

Under Amendment 119, the board would have to have regard to the duty on inequalities in allocating resources to CCGs. We recognise fully the importance of ensuring that allocations give CCGs the resources to meet the distinctive needs of their local population. Again, our preference is not to place particular weight on one factor or set of factors in legislation. In fulfilling this duty, the board will also need to work in collaboration with health and well-being boards and local authorities. We have already debated the various duties on the board to participate in certain activities of health and well-being boards.

On Amendment 137A, of course it will be important to ensure that all providers contribute to the fulfilment of these duties. Some public sector duties, such as the duties under the Equality Act, already apply to anyone exercising a public function, which includes private providers who supply NHS services. The specific duties in the Bill are placed on the board and CCGs, and they remain responsible for exercising them even when they contract with another body to provide services. It is, therefore, incumbent on them to ensure that these commissioning arrangements, and the ongoing monitoring of services provided under them, support the fulfilment of their duties.

I am not sure whether the noble Baroness, Lady Royall, spoke to her Amendment 343A, but if I cover it briefly, it may be helpful to her. The amendment probes how long it will take NICE to produce the full range of quality standards. As the noble Baroness probably knows, the ambition is to create a core library of NICE quality standards that covers the majority of NHS activity, and supports the NHS delivering against the outcomes in the outcomes framework. The programme is ideally placed to deliver a steady stream of quality standards over the agreed timescales and this will lead to a comprehensive library of quality standards within, we hope, about five years. Therefore, I am afraid the timescale envisaged in her amendment is too short.

I turn now to the group of amendments introduced by my noble friend Lady Cumberlege on maternity services. I am grateful to her and, indeed, the noble Baroness, Lady Thornton, for giving us the opportunity to consider this question. I hope I can provide some reassurance that the new commissioning arrangements will provide a very secure basis for quality improvement in these services. Women should always expect—and always receive—excellent maternity services that focus on the best outcomes for them and their babies, and which optimise women’s experience of care. Getting maternity care right from the start can help tackle the negative impact of health inequalities and begin to improve the health and well-being of mother and baby.

We are committed to improving outcomes for women and babies, and for women’s experience of care. Three of the improvement areas in the NHS Outcomes Framework for 2011-12 focus on improving maternity services, by reducing perinatal mortality, by reducing admissions of full-term babies to neonatal units and by improving the experience of women and families of maternity services. My noble friend spoke of variation in services and that was the theme of the very powerful speech by the noble Lord, Lord Mawson. We are committed to ensuring consistency in the quality of maternity services. From April 2012, a maternity experience indicator will be introduced as part of the NHS outcomes framework. It will allow us to chart a woman’s experience of care through antenatal care, labour, delivery and postnatal care.

To support the NHS in improving outcomes in pregnancy, labour and immediately after birth, the National Institute for Health and Clinical Excellence is developing new quality standards based on the best available evidence on antenatal care, intrapartum care and postnatal care. It is outcomes and quality that matter, and the NHS Commissioning Board will be publishing a commissioning outcomes framework for clinical commissioning groups. The commissioning outcomes framework will rely on the national outcomes framework set for the board and NICE quality standards. On top of that, the NHS Commissioning Board could decide to include guidance on the matter in the commissioning guidance that it must publish for CCGs and to which CCGs must have regard.

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[Lord Marks of Henley-on-Thames]

My Lords, I shall speak briefly to Amendments 193 and 197, amendments to proposed new Sections 14T, on promotion of involvement of each patient, and 14U on the duty as to patient choice.

The Bill and our debates on it have been characterised by a recognition of the importance of patient involvement and patient choice, and a great deal has been said about those two things in this debate. It is important that we recognise and welcome the new Sections 14T and 14U to the NHS Act, which will enshrine those in statute, but it is also important to note that this is not an entirely new idea. In many areas of medical care, patient choice has been with us for some time. Patients currently have a choice of GP practice; they have a choice of hospital; they have a choice of the GP whom they wish to see within a practice; and they have a right to be informed.

However, there is in practice all too often a gap between the theory and reality. The reality is that although people may theoretically have the choice, they do not know that they have the choice. They do not know despite the excellent section on choice on the NHS website and the literature that is put out about choice at the national level. The amendments are designed to impose on clinical commissioning groups at the local level the duty to take steps to inform patients about their right to be involved and their right to make choices. They state, in certain terms, that each group,

“must take steps to inform patients, their carers and their representatives of the right to be involved in such decisions”,

and, in the other cases,

“to make such choices”.

They are simple amendments, and it may be a matter of regret that they are necessary, but simply having the right in the statute book will not do unless we can also ensure that patients are informed of those rights.

[Lord Walton of Detchant]

My Lords, I rise briefly to support the principle underlying Amendment 198, so ably proposed by my noble friend Lord Kakkar, relating to the crucial importance of making clear that there must be a relationship between the NHS Commissioning Board, local commissioning groups and academic health partnerships. In using that term, I want to be quite clear in what I mean. I am not referring simply to the five academic health science partnerships which have been created within the past few years specifically in certain areas of the country by the NHS; I am talking about the crucial importance of being involved with everyone who is concerned with the teaching of medical students and the training of young doctors and other healthcare professionals.

There is no doubt that years ago, when the health service began, there was an article of faith to the effect that professors, lecturers and readers in the medical schools and universities employed by the universities, those that had clinical contracts, had a duty to spend half of their time on service to patients. In other words, they had honorary clinical contracts, they saw patients and they carried on in that capacity giving services to the NHS, in return for which there was also an article of faith that consultants employed by the National Health Service in teaching hospitals had a duty to involve themselves in the training of medical students and the supervision and training of young doctors who were being prepared for work in a variety of different professions.

There has been a total transformation of the scene over the course of the past 20 or 30 years, because academic appointments are no longer restricted to a small group of hospitals, which used to be called the teaching hospitals. They also take place and are based, in many instances, in other hospitals, sometimes in old regional hospitals at a distance. In those hospitals, not only do we have academic people employed by the university involved with teaching, but many of those hospitals are now called university hospitals. It is a recognition of the fact that medical students now are trained across a huge number of hospitals in what were the regions. Many of them spend considerable periods away from the centre around the medical school. Therefore, a crucial relationship must arise between the academic doctors working in those other hospitals outside the main centre and the commissioning groups.

We must also not forget the crucial importance to the NHS, as we heard a few days ago in discussion of the amendments of the noble Lord, Lord Willis, relating to research, of not only the academic departments but also the consultants working in general hospitals and others who have significant responsibility for being involved in clinical research. As I said when we discussed those amendments, today's discovery in basic medical science brings tomorrow's practical development in patient care. In particular, these academic relationships are crucial when one begins to consider the importance of clinical trials of new procedures, new drugs, and so on, which may be carried out across not only a wide range of hospitals but in the community. A great deal of teaching is now going on in general practices, which makes the relationship between academic doctors in academic centres and commissioning groups even more important. I therefore support the principle and the purpose underlying Amendment 198.

[Lord Neill of Bladen]

I make one comment on the amendments, which also goes to the Government’s fundamental philosophy, with which we all agree, that patients should be told about their condition and kept fully informed. My experience in recent years has been visiting hospitals and wards with elderly people in them. You cannot but become aware of the inability of a lot of the patients to understand what it is they are being told or to look after their own notes. There is a danger, if we are not careful, of theory and reality moving apart from each other. There has to be a true awareness of the need to get the relevant knowledge to the right person. Sometimes, it will not be the patient; it will be the patient's spouse, daughter, son or whatever. We should keep that in mind.