Health and Social Care Bill

Lord Walton of Detchant Excerpts

Wednesday 29th February 2012 Lords Chamber

[Lord Harris of Haringey]

That does not alter the point I was about to make, which is that, on the basis of those remarks, it is important to recognise in the Bill that that is the expectation on local healthwatch organisations. That reflects the growing concern of people outside that, despite the Government’s best intentions for how healthwatch will be organised, those organisations will not be anything like as effective as your Lordships would hope. We hear, for example, that there is widespread concern that the Government will remove the statutory nature of local healthwatch organisations—we will no doubt come to that in due course. We are told that the Government are indifferent to the consequence of not ring-fencing their finances. The concerns expressed by the noble Baroness, Lady Northover, in Committee, that those organisations may be too small and unable to cope with some of these loads are real. Therefore, it is all the more important not only that we provide a framework which enables healthwatch organisations to be effective but that we make clear in the rest of the legislation the importance of giving a clear statutory role to healthwatch organisations—in particular, in the vital role of commissioning local services.

[Lord Walton of Detchant]

My Lords, this is a disparate group of amendments. I shall speak in particular to Amendment 96, which has been so ably proposed by my noble friend Lady Finlay. I do not propose to redeploy the arguments that I expressed when a similar amendment was discussed recently. One thing that is beginning to emerge as the Bill continues its progress through your Lordships’ House is that the size and, perhaps, quality of the clinical commissioning groups will be extraordinarily variable. Some will be large and contain a large number of GPs, and so on; therefore, with the secondary care individuals who will become members of the group, and others, some will deploy a wide range of expertise.

However, it is perfectly clear that in some parts of the country the clinical commissioning groups are going to be very much smaller. The range of issues in highly specialised services will be very limited and the smaller clinical commissioning groups will lack the knowledge and expertise to handle those areas well. For that reason, it is crucial that the national Commissioning Board should have the major responsibility for commissioning highly specialised services, in which I include not only the neurological services, about which I spoke in some detail last week, but cardiological services, cardiothoracic services and many other specialties.

On Rare Disease Day, the point that my noble friend Lady Finlay made about rare diseases is very important. There are thousands of rare diseases affecting a very small number of patients throughout the UK. The Rare Disease UK consortium, chaired by Dr Alastair Kent, the former chairman of the Genetic Interest Group, is deeply concerned, as is the Neurological Alliance, about the mechanism by which these diseases will be given attention in this legislation and proper understanding, control and attention by the national Commissioning Board. As my noble friend said, there are several thousand rare diseases, some affecting very small numbers and some larger numbers.

I spoke in detail last week about muscular dystrophy. As an example, last week I was asked by a former medical colleague in Newcastle to see, with him, a patient—not as a consultation but to look at the problem posed by a condition called haemolytic uraemic syndrome. This is due to a genetically determined disorder of the complement system. It is a disease that affects the kidneys, is steadily progressive and is ultimately fatal. However, recent research has identified and produced a licensed medicine which is effective and which in the patient whom I met, with her husband, has proved to be virtually life-saving. The problem is that there are only 200 patients in the UK with this disease and the cost of the medicine for that patient is £250,000 a year. At the moment, it is paid for by the drug company, which is carrying out trials.

That is one example but there is a huge number of genetically determined rare diseases for which new drugs are coming on stream. There are many cases where the causal, abnormal or missing gene product has been identified and where, slowly but surely, drugs which are beginning to have a beneficial effect on these progressive, disabling or ultimately fatal diseases are beginning to emerge. These are called orphan or ultra-orphan drugs. Whatever happens in the future with the National Health Service, the possibility—the probability—of having a special mechanism to deal with the needs of people with these rare diseases, as well as the needs relating to the orphan and ultra-orphan drugs, is going to be a massive problem. It is crucial that there is a very clear indication in the Bill that rare diseases deserve special consideration. For that reason, I warmly support Amendment 96, which has been proposed so ably by my noble friend Lady Finlay.

[Lord Newton of Braintree]

Perhaps the noble Lord could comment on one specific point. In my experience, the biggest problem in respect of these rare diseases is not providing the services—although that can be a problem—but the fact that they are not identified in the first place because no doctor has ever seen one before. Identification is at least as big a problem as treatment but that is not addressed in this amendment.

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[Lord Walton of Detchant]

My Lords, the case for supporting these amendments has been put very clearly by my noble friend Lord Patel and the noble Lord, Lord Turnberg. I do not wish to repeat those arguments but I should like to mention a point or two about history. My reasons for doing so I hope will become clear in a moment or two. When I was a young doctor, medical officers of health in major centres of population were very notable specialists in public health. Indeed, when I was a particularly young houseman, the medical officer of health in Newcastle upon Tyne was John Charles, who later became Sir John Charles and the Government’s Chief Medical Officer. He was succeeded in Newcastle by Professor WS Walton—I can assure noble Lords that he was no relation—who later became a very distinguished professor of public health in London.

As the years went by and the National Health Service matured, physicians in public health began to argue that they were actual physicians who, unlike physicians looking after groups of individual patients, were looking after communities. The situation developed until they were no longer directors of public health or medical officers of health. Instead they were transferred into the National Health Service as physicians in community medicine. They became individuals holding consultant appointments, and that was true of doctors and dentists working in community medicine. Eventually the faculty in the Royal College of Physicians grew into the Faculty of Community Medicine. Later it became clear that there were widespread public health functions which were not fully covered by that arrangement and therefore the title reverted to “public health”.

The questions I want particularly to ask relate to Amendment 125 about the:

“Appointment of directors of public health”.

This amendment seeks to ensure that public health specialists employed,

“by a local authority or in an executive agency of the Department of Health shall be employed on terms and conditions of service no less favourable than those of persons in equivalent employment in the National Health Service”.

First, could the Minister go a little further in confirming that medically and dentally qualified directors of public health who are transferred to work in local authorities will retain honorary consultant status in the National Health Service? It is crucial that they should have a formal arrangement whereby they have full access to all the NHS facilities necessary in relation to issues such as the control of epidemics and a whole range of other activities where access to those facilities will be needed.

My other question is one that I have raised before but to which I have not had a satisfactory answer. What is the position of young doctors and dentists who at present are training in the NHS as specialist registrars seeking to become qualified in public health? What is going to be their future? Where will they be employed and how will they continue to undertake a formal training programme if the directors of public health have been transferred into local authorities? This is an important issue that needs to be resolved. Finally, the regulation of non medically or dentally qualified specialists in public health is an issue that also has yet to be resolved.

[Baroness Masham of Ilton]

My Lords, in supporting these amendments, I want just to say that many demands are made on local authorities. If the Bill becomes law, they will have added responsibilities for public health. The control of infectious diseases is vital. We have increasing levels of drug resistance in conditions such as tuberculosis and sexually transmitted infections. We have the problems of alcohol and drug abuse. Food poisoning is always a risk. One never knows what new infection is around the corner—one has only to look at the recent very worrying virus in lambs. We need senior officers of public health because they are the important link between health and local authorities. They need to be in senior positions and to have a clear voice.

Health: Neurological Conditions

Lord Walton of Detchant Excerpts

Monday 27th February 2012 Lords Chamber

Asked by

[Lord Walton of Detchant]

To ask Her Majesty’s Government how they propose to improve outcomes-led neurological services following the National Audit Office report Services for People with Neurological Conditions published in December 2011.

[Lord Walton of Detchant]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In so doing, I declare an interest as a former neurologist holding honorary positions with many neurological charities.

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

My Lords, we will be providing a detailed written response to the National Audit Office report Services for People with Neurological Conditions in due course. While some progress has been made, we acknowledge that there is more to do to improve care for people with neurological conditions. Work is under way to develop a new outcome strategy for long-term conditions and to introduce more personalised care, including piloting of personal health budgets.

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[Lord Walton of Detchant]

My Lords, I thank the noble Earl for that reply. This report was extremely critical in demonstrating serious inequalities in the standards of care for patients with various neurological conditions, not least Parkinson’s disease, multiple sclerosis, neuromuscular disease and many more, in different parts of the UK. That is highlighted by two major inquiries conducted by all-party groups demonstrating serious deficiencies in the care of patients with parkinsonism and neuromuscular disease. Is it not time that the Government appointed a neurological tsar to oversee the situation and to recommend improvements?

[Earl Howe]

My Lords, I pay tribute to the noble Lord’s extensive work in Parliament on behalf of those with neurological conditions. We have taken the view that the appointment of a tsar or a clinical specialist in this area should be one for the NHS Commissioning Board. It is satisfied with that position and we must await its determination on that.

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Monday 27th February 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, in moving Amendment 38A, I must explain to your Lordships why it is so important. I wish only that the Minister, the noble Earl, Lord Howe, was moving it.

When legislation is before your Lordships it is our duty to try to improve it. For years there has been a serious cover-up and a closing of ranks in many cases when something has gone wrong with patients’ treatment and they or their next of kin have not been kept informed. If there is not openness and honesty, there could be years of frustration and consternation resulting from trying to find the truth through litigation. The only winners are the lawyers.

Last Monday at 8 pm on Radio 4, and today, there was a programme entitled “Doctor—Tell Me the Truth”. The programme explores how patient safety can be improved by doctors admitting to mistakes. In some states in America, medical practitioners must be open about their errors. Instead of increasing litigation, this has lessened it.

I was involved through the Patients Association with some of the next of kin of the patients who tragically died in the Mid Staffordshire NHS Foundation Trust hospital. I congratulate the Government on holding a review into the hospital, where the culture was the very worst and there was a fear to disclose the truth. Surely it is time we put something into legislation to help change this culture.

I was sorry that the amendment which I previously moved—which would have introduced a statutory obligation to provide a duty of candour applying to all providers registered with the Care Quality Commission—did not succeed. However, it was made clear by the Minister that the CQC could not undertake this role. Perhaps it has too much to do satisfactorily and it is just not up to it.

The Minister, the noble Earl, Lord Howe, said:

“I remind the House that the Government’s preferred position is to place a duty of candour in the NHS standard contracts. We have chosen that route because we feel that it has the best chance of working. The view that we have taken, on the basis of clinical advice, is that responsibility for ensuring openness needs to rest as close to the front line as possible, rather than being the responsibility of a remote organisation such as the CQC”.—[Official Report, 13/2/12; col. 591.]

An independent body still seems to me to be the best option as it is transparency and honesty that we need, and front-line medical personnel may still try to cover the mistakes made by members of their profession. I hope not.

Amendment 38A covers what the Government say is the best route to go down. I have had letters imploring me not to give up as so many members of the public, who have been patients or who are their next of kin, have had bad experiences and feel now is the time to change this culture of fear and secrecy. The amendment makes provision for,

“a requirement to be placed upon any organisation that enters into a commissioning contract to provide healthcare with the Board or with a clinical commissioning group to take all reasonable steps to ensure that a patient or, in the event of death or incapacity, their next of kin, is fully informed about incidents which occur as a consequence of providing the contracted healthcare to that patient where the incident has resulted in”—

and the amendment goes on to mention various harms. If the amendment is not quite correct, perhaps the Minister would accept it and correct it for Third Reading. It would be a start to something that must happen if patients and families are to have much-needed trust in the professionals who care for them. I beg to move.

[Lord Walton of Detchant]

My Lords, I added my name to this amendment for one reason and one reason only: in the hope of seeking assurances from the Minister. When I first joined the General Medical Council in 1971, the president was the late Lord Cohen of Birkenhead, who was a wonderful man. He was a fine physician, but he was an autocrat and his views were very traditional and in some respects, I have to say, somewhat backward. He told me, “Never apologise to a patient. The lawyers will get after you”. He told me, as a young man, “Never speak to the press or to the television. They will misquote you always”. Happily, since that time the General Medical Council has progressively changed its view. Now the recommendation made to all medical practitioners is that, if you have made a mistake, if you have committed an error, it is your duty to apologise to that patient sincerely. An apology does not mean an admission of liability; it is simply a sincere apology for a mistake. I hope that is the case in respect of all other healthcare professionals whose activity is regulated by law. I would like an assurance from the Minister that that is the case.

The purpose of this amendment, which has been so well proposed by my noble friend, is to confer on health bodies, whether clinical commissioning groups, independent foundation trusts or other organisations providing medical care, a similar obligation and, indeed, the duty to apologise for errors that have occurred under the auspices of those organisations. I simply ask the Minister whether, in the contracts that these bodies hold with the NHS, such an obligation is a part of the contract. If it is, it may not be necessary to have such an amendment on the face of the Bill. I hope the Minister can give me those assurances.

[Lord Harris of Haringey]

My Lords, I support this amendment because I believe that it is a sincere attempt by the noble Baroness, Lady Masham, to help the Government out. I do not intend to repeat the arguments that we had a few days ago on Report about placing on institutions a rather stronger statutory obligation to inform patients where mistakes had taken place, partly because we have had that debate. During that debate, the Minister repeatedly expressed the view that the objectives of the amendment could be achieved by placing a contractual obligation on organisation to do this. This amendment quite simply requires that that contractual obligation takes place. I am assuming, therefore, that the Minister will accept the amendment, because it does exactly what he said he wanted to do in his previous speech.

The amendment also expresses the concerns raised by a number of your Lordships in Committee and one or two on Report that perhaps placing the duty and obligation directly on organisations and the individuals involved would be inappropriate and that that would provide too rigid a framework. However, as the amendment does what the Government said would solve the problem, I hope that the Minister will indicate that he is happy to accept it in this form.

The reason why I think that it is helpful to the Government is, as may not have escaped the Minister’s attention, a certain amount of criticism of the Department of Health and of this Bill is prevalent at the moment. For example, a letter was published in the Telegraph this morning which said:

“The Coalition Government promised to ensure greater NHS accountability to patients and the public. We believe this aspiration has now been abandoned”.

That was signed by a large number of people active in representing the interests of patients around the country. It is not specifically about this issue; it is about an issue that we will come on to very shortly in terms of HealthWatch. But there is a very widespread concern that, despite all the rhetoric that we have heard from the Government about “no decision about me without me”, that aspiration has been lost in this Bill.

Part of the way of getting patients to have confidence in their health service is through the knowledge that if something goes wrong the fact will be shared with them. The Government said that they did not want a statutory obligation to be placed on individuals or institutions to do that, but they said that they would like contractual arrangements to be put in place. This amendment makes sure that those contractual arrangements are put in place, and I would have thought that the Government would want to accept it so as to demonstrate that even now there is some good faith left around their desire to put patients at the centre of the NHS changes.

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We have a group of amendments here covering a wide range of aspects of the structure and functioning of clinical commissioning groups. I hope that we will shortly find that a declaration of interests is included in the Bill, in whatever form, and that the Minister will be amenable to revising the rigid stance taken over insisting that the secondary care representative and nurse come from outside the area.

[Lord Walton of Detchant]

My Lords, this is an exceptionally complex issue and I believe it is absolutely crucial that in some way and in some form the issue of a conflict of interests is covered in the Bill. The membership of clinical commissioning groups will consist very largely of general practitioners, but it is important to remember that GPs are not employed by the National Health Service but are independent contractors. As such, it is therefore inevitable that they will have a pecuniary interest in the activity of the clinical commissioning group. I am aware of a number of general practitioners from large practices who have shares in or part-ownership of care homes for elderly patients. I am also aware of some who have shares in private hospitals and in many other organisations. If we were too rigid about declarations of interest, we could end up excluding virtually every GP from membership of clinical commissioning groups, meaning that CCGs could not really exist. Therefore, the provisions must not be too draconian, but at the same time, it is desperately important that they should protect the public interest and that some mechanism be found to ensure that matters of financial and other public interest are not in any way detrimental to the work of the clinical commissioning groups.

I am therefore very attracted by Amendment 79A, which I believe goes a long way towards covering the major issues concerned with conflicts of interest. The amendment so ably proposed by the noble Lord, Lord Hunt has many attractive features, but it is immensely lengthy and complex. I appreciate entirely the point that he made about sanctions, but to go back for a moment, the Minister misunderstood me when I was talking about the duty of candour. I fully appreciate that doctors working for clinical commissioning groups, foundation trusts, and so on, have the same duty of candour as defined by the regulations of the GMC as any other doctor. I intended to ask the Minister whether the actual clinical commissioning groups and foundation trusts, as corporate bodies—not the individual employees of those organisations—had the same responsibility of a duty of candour in relation to patients.

Here, of course, the same problem arises in relation to the whole issue of conflict of interest. How is it defined? It is necessary to recognise, as the noble Lord, Lord Hunt, said, that there has to be a sanction. But the same sanctions apply to individual doctors and other healthcare professionals working for clinical commissioning groups. If they were seen to breach the rules laid down in such an amendment on conflicts of interest, they could be called to account by their regulatory authority. The GMC would no doubt take a serious view of anyone who breached that duty under conflicts of interest. It is crucial that the Government should put something about conflicts of interest in the Bill based, I hope largely, on Amendment 79A, which I strongly support. That is an excellent basis on which to go ahead, and I shall be fascinated to hear what the Minister has to say.

[Lord Warner]

My Lords, I had not intended to speak for very long on this set of amendments but some issues have cropped up which are worth reflecting on, particularly by those of us who have sat in Richmond House and have had to deal with them. It is easy to assume from listening to the debate that we have a wonderful set of arrangements in place to deal with conflicts of interest. That is very far from the case. The noble Lord, Lord Walton, made the point very well that many doctors already do a range of activities—rightly, appropriately and well within their competence—that potentially involve conflicts of interest. One of the great dangers in this area is that we tie ourselves up in a labyrinth of controls that actually work against innovation in an area where science is driving change rapidly. We want people to use their creativity and to change the way they work. We want them to take on new roles. We should not always assume that in doing that they are just seeking to line their pockets. There is a danger that we might do a very British thing and create a large number of rules that will prevent innovation. We had that debate over research and we are in danger of going down the same track in this area.

The other point raised by the noble Lord, Lord Walton, which is very important, is in relation to the role of professional bodies. We had a case—I will not mention the name—of an eminent businessman doctor who was the chief executive of a large chain of nursing homes. He was taken to the GMC because of something that went wrong in one of the nursing homes for which he had no direct responsibility whatever. Although the governing bodies of the professions have an important role, their role was constructed in relation to the actions of a doctor towards individual patients, not in relation to a doctor who was performing other business and organisational functions. It is very important that we do not rely on professional bodies to deal with what is organisational malfeasance rather than lack of professional integrity in dealing with individual patients.

My noble friend Lord Hunt made a very important point. It is very strange that at this stage we are still arguing the toss around corporate governance of some of the bodies in the Bill, particularly the clinical commissioning groups. That is a bit of an indictment of the Government for not getting some of this material thought through at an earlier stage rather than well into Report stage in the House of Lords after having gone through the Commons. However, we are where we are and I think we should not tie ourselves up in knots and prevent incumbents.

Lastly, a very important point that has come out in a number of speeches today is that two issues are critical. First, it should be clear legally to all people participating in these new sets of arrangements that declarations of interest are essential. Secondly, it should also be clear in the Bill exactly what the consequences are of not declaring those interests and pursuing deliberately a conflict of interest for your own advancement, financially and otherwise. Those are the two issues about which we need to be clear in the Bill and I rather agree with the noble Baroness, Lady Barker, that much of the rest of it should be for regulation, provided that the Bill has sufficiently powerful regulation-making powers.

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[Lord Patel]

My Lords, I support the amendment. I spoke at length in Committee on a similar amendment and my noble friend Lord Kakkar has covered quite extensively why we need some kind of primary care outcomes framework which assesses the performance of primary care. Primary care will be involved in prevention, diagnosis, treatment and long-term care of patients. Hitherto what we have had is QOF, which has already been found to be lacking in identifying the quality outcomes that demonstrate improvement in care. For example, in cardiovascular disease, evidence was presented from 1,000 primary care practice interviews and their performances as assessed did not show that there was improvement through QOF. Of course in certain other areas, there might be. The management of hypertension again shows no improvement. In a study carried out of chronic hypertensive patients, there is still a high incidence of complications related to hypertension. So we need other measures and in the absence of a primary care outcomes framework, we do not know how primary care will be performance managed.

[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.

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Monday 27th February 2012 Lords Chamber

[Baroness Williams of Crosby]

My Lords, perhaps I may briefly intervene in the debate on this extremely important amendment. In countries like the United States, where there is no effective health system for those who cannot afford very substantial sums of money, emergency admission has become the last resort for such people. The noble Baroness, Lady Finlay, is right but we should take it one stage further. We know, from very recent reports on the difference between the likelihood of survival in an emergency situation between weekdays and the weekend, that out-of-hours provision is of substantially lower quality than that provided by regular doctors in a good hospital. This is very serious. One of the great mistakes made in the last contract for general practitioners was the almost complete transfer of out-of-hours work to private agencies which did not demand the same standards in respect of doctors, ranging from their ability to speak different languages through to experience of medical treatment. In consequence, we now have a troubling kind of medical roulette where a great deal depends on whether you get ill on Thursday or on Friday. The statistics are quite frightening, showing not a narrow but a very substantial difference.

Before the noble Lord, Lord Hunt, comes in—if he does—and before the Minister responds, I would like to raise two points. The first is about the degree to which the noble Lord believes we can begin to re-establish out of hours work to a higher level of quality broadly equivalent to that offered by general practitioners and other medical staff to patients who conveniently fall ill on Monday through Friday but not later or after that. Secondly, what does the Minister feel about the dependence of some groups in our community on emergency services, not because they want to use them but because they are not familiar with ways to establish their proper relationship with people who could look after them in difficult conditions? This goes back to one of the particular concerns of the noble Baroness, Lady Finlay, which is the impact of alcoholism on emergency entry. This is not just another amendment; it is a crucial one which points to a very troubling discrepancy which could grow worse if we do not succeed in addressing it.

[Lord Walton of Detchant]

My Lords, it would be difficult to overstress the crucial importance of this issue, which has been a matter of grave concern to the specialist medical community. People with less common conditions often require specialist services for treatment unavailable through generic NHS support. At Question Time today, I posed a Question to the Minister about the report of the National Audit Committee which had demonstrated the serious inequalities of neurological services throughout the United Kingdom. People with neurological conditions rely not only on skilled neurologists but on a specialist multi-disciplinary team of nurses, physiotherapists, occupational therapists, speech and language therapists and others to maximise their independence and quality of life. The Bill proposes that these services be commissioned at a local level by clinical commissioning groups which will be able to determine the size of the population for which they have responsibility and which, as matters stand, will have no duty to collaborate with other clinical commissioning groups in the commissioning of services. Grave anxieties have been expressed by the Rare Disease Consortium and by the Neurological Alliance, which is the only collective voice for more than 70 national and regional brain, spine and neuromuscular organisations working together to make life better for 8 million children, young people and adults in England with a neurological condition.

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Mawhinney]

My Lords, I spoke in favour of training and education at an earlier stage of the Bill, so I have no inherent antagonistic thoughts about the amendment moved by the noble Lord, Lord Patel. However, listening to him and to the noble Baroness, Lady Finlay, and the noble Lord, Lord Turnberg, it was quite clear that there is a financial cost attached to this amendment. They did not spell it out and I wish that the noble Lord, Lord Patel, had. My noble friend the Minister has already responded to the House’s concern about health training. Whether he is minded to accept or reject the amendment, can he tell us his estimate of its cost?

[Lord Walton of Detchant]

I support the amendment and will make a point about costs. As I said last week in a debate on education and training, since the health service began, the actual financial consequences of training specialists in all branches of medicine—surgeons, physicians, psychiatrists and all other specialists—have been the responsibility of the National Health Service. Many of us will remember the days of SIFT—the service increment for teaching—a financial increment that was given to hospitals and other organisations that provided postgraduate training at the same time as training undergraduate students. I have, I believe, an assurance from the Minister that that process is going to continue, which is extremely welcome. So I am not speaking primarily about finance.

However, I want to raise a point with the Minister that was touched on only superficially in the very helpful debate we had last week where the Minister tabled a series of very important and constructive government amendments and gave a number of very crucial assurances. I particularly want to raise the interrelationship between the health education authority and the regulatory authorities, which has not yet been clarified. The Explanatory Notes mention the importance of Health Education England working with professional regulators. I shall refer to the General Medical Council as an example because I was its president from 1982 to 1989, and before that, for seven years, chairman of its education committee. The fundamental point is that under the Medical Act, the General Medical Council’s education committee has the responsibility of ensuring,

“high standards of medical education and co-ordinating all stages of medical education”.

It is the regulator. If a new medical school is created, it has the authority to inspect it and consider whether its curriculum is sufficient. It has the authority to inspect the qualifying examinations of the medical schools in order to make certain that they are achieving an appropriate standard.

The fundamental point is that the GMC and the other regulators are not just stakeholder groups. Their statutory powers,

“provide independent assurance to patients, the professions and the service that national standards apply across the UK both in terms of the quality of medical training and the outcomes it produces”.

Of course, the important difference here is that Health Education England applies only to England, whereas the GMC and the other regulators are responsible for the oversight of education across the entire United Kingdom. What I seek from the Minister—formally, if I may—is an assurance that the activities of Health Education England will not usurp or attempt to usurp any of the statutory responsibilities of the regulatory authorities, which are already enshrined in law.

[Lord Kakkar]

My Lords, I support Amendment 13 in the name of my noble friend Lord Patel and Amendment 16, which again is in the name of my noble friend and to which I have added my name. This is the first time that I have spoken at the Report stage of the Bill and I remind noble Lords of my entry in the register of interests as professor of surgery at University College London, consultant surgeon to University College London Hospitals NHS Foundation Trust and fellow of the Royal College of Surgeons of England, which is one of the royal colleges that has decided critically to engage with Her Majesty’s Government with regard to the further passage of this Bill through its parliamentary stages.

The reason why there is such anxiety among so many bodies associated with the practice of medicine in our country as regards education and training is in no small part due to the fact that there was terrible trouble and a very unfortunate turn of events associated with the medical training application system—MTAS—some years ago. As a result of that, all those who have some responsibility for education and training are obliged to pay particular attention and scrutiny to any provision concerning the future of education and training for all healthcare professionals in our country.

Amendment 13 in the name of the noble Lord, Lord Patel, is very important. It brings together all those with responsibility for the commissioning and provision of healthcare under a single obligation to respond to the responsibilities of the Secretary of State for Health with regard to the specific question of education and training. There can be no doubt that all those who wish to engage in the provision of a national health service must be alive to their responsibilities in this regard. To have that commitment in the Bill would provide a very important opportunity to allay the considerable anxiety that might exist among the regulatory bodies, such as the General Medical Council, which the noble Lord, Lord Walton, mentioned, and the medical royal colleges to ensure that they have done their duty in terms of protecting a structured process for the delivery of education and training for the entire healthcare workforce.

Amendment 16 is very important because it deals with the establishment of Health Education England. At this stage, it is important to recognise the very proper and constructive way in which the Department of Health, the Secretary of State for Health and the Minister have engaged with the professional bodies with regard to education and training. It has been a remarkable process of discussion, which resulted in the important government-sponsored amendments that we were able to debate last week on the first day of Report and the important recognition that in creating Health Education England there is an obligation to bring together all the resources available for undergraduate training in the healthcare system and for postgraduate education and training.

Is it absolutely the intention that all three funding streams—SIFT, MADEL and MPET—will come together as a single budget for Health Education England at the time of its creation and that that budget will be spent by HEE through local education and training boards to engage a variety of providers at a local level in discharge of responsibilities for education and training in a postgraduate sense and to maintain the additional resources available in clinical environments—primary, secondary and tertiary care—for the continued undergraduate education of our medical and dental students and other healthcare professionals?

It is also important for your Lordships to understand how Health Education England will be composed. What will be the process for appointment to HEE once it is established, potentially first as a Special Health Authority later this year? Will the composition and membership of HEE include representatives from medical royal colleges and other organisations, such as the regulators and so on? Will HEE be responsible for the appointment of the chairs of the local education and training boards? There is particular concern with regard to the need to have independent chairs of local education and training boards. It is vital not only that at the local level these boards have appropriate provider, employer, patient and trainee representation, but also that their deliberations are conducted in a transparent fashion. This can be done only if the chairs are indeed independent of all the interested parties.

There is a further question with regard to the relationship between local education and training boards and the proposed academic health science networks. Do Her Majesty’s Government have a view about that? It is particularly important because a process is ongoing at the moment for the designation of 12 or so additional academic health science networks in the country. Those broad networks will have an opportunity to have substantial employer and provider representation, encompassing universities and NHS providers. It would be useful to understand their potential relationship with local education and training boards. Then there is the question of the future of postgraduate deans. Again, this is a matter of detail, but it is important in understanding how the structure of independent deaneries will work in a future system and, in particular, what relationships the universities will have at the level of provision of local training and education.

I think it is well recognised in your Lordships’ House that the Government have come a very long way on the question of education and training, which is much appreciated, but some further detail is important to allay anxieties and to ensure that the best possible advice, expertise and knowledge can be brought to bear in creating a new system for education and training for the future that does not result in unintended consequences and some of the disastrous outcomes associated with the previous MTAS scheme.

--- Later in debate ---

[Lord Harris of Haringey]

My Lords, my name is down in support of the amendment. I want to make it clear at the outset that it is substantially different from the amendment put forward in Committee and has taken on board a lot of comments and points made during the helpful debate at that time.

As far as I am concerned, the origins of this go back to my meeting 18 years ago with William Powell about the death of his son, Robbie, when I was director of the Association of Community Health Councils. Mr Powell was concerned about the failure of the system to give him and his family answers as to why his son had died. Mr Powell is still campaigning for a change in law to place a requirement for some sort of duty of candour. Interestingly, that case eventually reached the European Court of Human Rights in May 2002. In its judgment, the court made it clear that at present there is,

“no duty to give the parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even to refrain from deliberately falsifying records”.

Most of your Lordships would find that a pretty shocking and appalling statement in this day and age, but that is where we are as far as the law is concerned and it remains a continuing consideration.

In September, as chair of the Independent Advisory Panel on Deaths in Custody, I had a listening day with a group of families whose relatives had died while detained under the Mental Health Act. Those families reported a lack of information from NHS trusts. One family reported that they,

“were unaware of any investigation, everything was released in drips”.

Another family claimed:

“They didn’t disclose anything, it was a battle to the end”.

Another said that

“the shutters came down as soon as I started asking questions”.

One parent explained that it was like being,

“in a void whilst waiting”.

These are parents or families of people who have died while in mental health care.

Even more alarming for families was the misinformation frequently provided to them. They thought that there had been a whole series of flaws in the way that the cases of the deaths of their loved ones were investigated. One said:

“The first time I had opportunity to speak to anybody was the consultant. Nobody told me about the investigation. I told the consultant that I wanted a meeting with nurses and see what happened … Consultant and matron came for the meeting with no pen and paper. I was the only one taking notes. After that the matron told me that she would try to get answers for me. I asked how she would remember 20 questions which I asked as she was not taking notes. It took three years for them to give this evidence”.

The problem is that most families feel that the investigations are not independent, and many of them feel that they are presented with lies. The problem is that the existing system does not work. It is not adequate as it presently stands.

The amendment has been significantly changed. It now relates explicitly to organisations rather than individual practitioners. The background is that there is currently no statutory requirement for organisations that provide NHS services to tell a patient, carer, or representative when something has gone wrong during their care and treatment that causes harm. The issue is left to guidance and a non-binding requirement in the NHS Constitution to have regard to the principle of openness. This has allowed cases to occur where NHS organisations have withheld such information from patients, delayed its release or, worse still, actively covered it up.

I understand that the Government have agreed that a duty of candour is required, but their preferred route is a contractual duty built into the standard contracts between commissioners and some providers of NHS services. Patient organisations and others do not believe that that is sufficient. It would not include all NHS providers—for example, GPs, dentists, pharmacists, and so on do not have such contracts—and it would not create access to the sanctions which the Care Quality Commission has at its disposal. Under the Government's proposal, as the noble Baroness, Lady Masham, said, the duty would apply only to incidents which are already being reported through official systems, so it would be useless in preventing cover-ups.

The amendment would require the Secretary of State to create a statutory, enforceable duty of candour by amending the registration regulations of the CQC. All healthcare providers would then have to comply with them to be registered. Of the issues raised in Committee, the most important, raised by several noble Lords, including the noble Lord, Lord Winston, who I do not think is in his place at the moment, and the noble Lord, Lord Walton, was that that might overlap or conflict with the clinicians’ professional duties and the existing arrangements under the General Medical Council and other codes of conduct organised by regulatory bodies. The proposal in the amendment is for a statutory duty of candour placed on organisations, not on individual health professionals. It therefore complements, rather than duplicates or confuses, the duties in health professionals' codes of conduct.

Indeed, Harry Cayton, the chief executive of the Council for Health Regulatory Excellence, has said:

“We support the introduction of a duty of candour in the CQC’s registration requirements, which would mean that the ethical responsibility of health professionals would be shared by organisations delivering healthcare services”.

Frankly, at the moment, doctors and nurses can be put in an impossible position where they would want to honour their ethical and professional obligations but are told by managers and lawyers within the organisation for which they work not to be fully open with patients. That would put them in the position of a whistleblower. This duty would remove that conflict for those individual professionals.

Of course, the amendment is not designed to get in the way of culture change. Several noble Lords said that we want culture change. No one disagrees. The point is that this will support the process of culture change. There is no argument for not setting out in regulations what is by any reasonable assessment as important and essential a standard of quality and safety as the others already set out in CQC regulations.

[Lord Walton of Detchant]

In relation to candour, the noble Lord may know that the General Medical Council published guidance just two weeks ago making it incumbent on doctors not to sign a contract or agreement that prevents them giving information which might be detrimental to the organisation that employs them. In other words, gagging orders are no longer accepted by the GMC as being part of a contract into which doctors can enter.

[Lord Harris of Haringey]

I am grateful to the noble Lord, Lord Walton, for that. It is an extremely important step forward and it recognises that there is an existing problem that requires the GMC to take that stance. I think that there is a distinction between gagging clauses and the sort of persuasion and pressure that may be applied to clinicians behind the scenes under such circumstances. This amendment focuses on the organisation’s responsibility and on how the managers and lawyers within an organisation should meet those obligations of candour.

I know that there has been some concern—I think that the Minister has expressed it at various points—about whether the CQC would be able to cope with regulating this duty of candour. It is worth making it clear that there is no question of asking the CQC routinely to monitor every incident with patients; it is simply about the expectation that it will be there as the backstop.

There is already a duty in the CQC’s statutory registration regulations to report to the CQC incidents that cause harm, but it is a duty which requires the organisation to report the incident to the CQC and not to the patient. It is rather anomalous that there is an obligation requiring an organisation to report something to the CQC but not to the patient at the same time. Quite clearly the CQC should have this information and be able to respond to and deal with it.

The point is that the CQC has always said that it could regulate this requirement if the Department of Health so wished. I think that there has been some recent correspondence with the Department of Health which has recognised that the CQC is currently under considerable resource constraints. However, I have seen copies of e-mails released under the Freedom of Information Act—

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Wednesday 8th February 2012 Lords Chamber

[Lord Alderdice]

My Lords, the noble Lord, Lord Patel, has characteristically underplayed his own grasp of this important area, but, as noble Lords have heard, he has on his own behalf and on behalf of the noble and learned Lord, Lord Mackay of Clashfern, and the noble Baroness, Lady Hollins, presented an elegant, informed and very persuasive case for the amendment, to which I have put my name. In many ways, there is not much to say other than to support him. However, when noble Lords say that in your Lordships' House, it is often because they actually have quite a lot to say, and I shall say a few words.

On 2 November last year in Committee, your Lordships debated three amendments which would have placed the responsibility on the Secretary of State, the national Commissioning Board and all clinical commissioning groups to regard mental health on the same basis as physical health. That is to say that they should give full consideration to all those suffering from mental illness in the same way as they would those suffering from physical illness.

One reason for trying to insert such a commitment into the Bill was that, despite the efforts of the previous Government—to whom the noble Lord, Lord Patel, is quite right to pay tribute—to address the needs of people with mental illness by allocating more money for talking treatments, on which the coalition Government have substantially built, as the noble Lord said with reference to the legal friend of the noble and learned Lord, Lord Mackay, out there in the real world, mental illness and problems of mental health do not get the same attention and concern. As we said in the debate in November, many people think of mental illness as a subset of illness, like cancer, diabetes, or whatever, but it is not. It is a quite different aspect. When you fall ill with something physical, something happens to you but your personality and your self are not affected; but when you fall mentally ill, the very essence of your self is affected. That is a very different business. It frightens people. They often turn away from paying attention to it because they are so troubled by it. The provision required is different. Often, much more than is the case with other illnesses, a whole range of services has to come together to provide treatment and support.

Our concern in that debate—which was supported by noble Lords on all sides of the House; no one spoke against—was that all the efforts until now have been less than fully successful in building up the regard and esteem in which mental health and mental illness is held. So the proposition for the amendments was not a belief that there was a particular technical flaw in the Bill which meant that mental illness would not be addressed; we are very much aware that it is addressed in the Bill. That is not the problem. The problem is: how do we find a way continually to bring mental illness to the attention of commissioners? The noble Lord, Lord Patel said, as was said in the November debate, that in times of financial pressure and austerity, the tendency is to pull back financial commitment from those areas where there is least pressure. When people are physically ill, they can often nevertheless continue to exert pressure; but when people are mentally ill, they often do not give due regard to themselves, never mind press for the needs of others who are suffering from similar disorders.

Our concern is not about those three specific amendments but the principle. The noble and learned Lord, Lord Mackay of Clashfern, went away and produced a single amendment. The noble Earl was kind enough to give a considerable amount of time to me and the noble Baroness, Lady Hollins, to discuss the question. A concern was expressed by him and some people in the department that if one included this in one place, one would have to put it in every place because otherwise the implication would be that it applied only to the issue to which it refers directly. I have to say that the noble and learned Lord, Lord Mackay of Clashfern, was wholly unimpressed with that argument. As he is a former Lord Chancellor, I think one takes that pretty seriously.

The point is that we must find some way in which to make it absolutely clear beyond peradventure that concern for those who have mental health problems is every bit as great and the responsibility on commissioners is every bit as great to ensure the proper provision of services. One reason why this comes up as the very first amendment Report is that we want to ensure that in all aspects of health care, mental health care is attended to: no health without mental health and indeed, as the Royal College of Psychiatrists’ report said, no public health without public mental health.

It is regrettable that the Royal College of Psychiatrists, of which I am a member, has over the past few days been saying that the whole Bill should be set aside. That is not really a helpful way of engaging in these kinds of questions. The college knows perfectly well that the Bill is not going to be set aside—in fact, it would not be at all helpful if it were. I have seen these kinds of situations in other places, with people polarising in an unhelpful way. I appeal to the Minister, to the Royal College of Psychiatrists and to others who are interested and concerned in this field to find a way to get together again before the completion of the Bill to ensure that the concerns that we are expressing are reflected in a cast-iron fashion. It is a question not of these particular words or of this particular amendment but of receiving solid assurances so that we and those who care for people with mental illnesses, as well as those who suffer from such illnesses, can be confident about the new NHS.

[Lord Walton of Detchant]

My Lords, in rising briefly to support the amendment so ably proposed by my noble friend Lord Patel and supported by the noble Lord, Lord Alderdice, I ask the Minister one very simple question. In Clause 1(1)(a) the Bill talks about the,

“physical and mental health of the people of England”,

and says that the health service must be “designed to secure improvement” in that health. What on earth could the objection possibly be to inserting in paragraph (b) at line 6 the unexceptional words listed in the amendment? They simply stress the crucial importance of mental as well as physical illness. How on earth could this be construed as doing any damage whatever to the Bill? It is something that I hope very much the Government can be persuaded to accept.

[Lord Carlile of Berriew]

My Lords, I should like to say a word on behalf of those who have had to care for family members—often a young member of the family—who have suffered from severe mental illness. Those who have suffered that experience—and I am one—know how marooned they feel when they find that someone in their family has a serious mental illness. If somebody has a broken leg, you can locate the leg and take the medicine. If somebody has even cancer, it may not be curable but at least you have the knowledge of the location or locations of the cancer and the topical treatment that is to be applied to it.

The problem for families who experience in their midst mental illness is that no medicine can be applied topically to the place where the hurt or illness is taking place. The prognosis is uncertain, the mortality rate is depressingly high and usually at the hands of the sick person, and accessing good health service facilities is quite chancy, I am afraid. There is a real postcode lottery with mental health treatment. If, for example, you live in a remote rural area, only some therapies will be available and they may be the wrong therapies, particularly if the patient is a child or adolescent suffering from serious mental illness. Therefore, I simply say to the Minister who, as has already been said, cares deeply about these issues, that the adoption of this very simple amendment, as the noble Lord, Lord Walton, rightly described it, would send out such a telling message of support to families who have to care for people who suffer, perhaps temporarily, from mental illness that it would be seen as a declaration of purpose by this Government.

--- Later in debate ---

[Lord Willis of Knaresborough]

My Lords, I support government Amendments 61 and 104. As regards Amendment 2, which the noble Baroness has introduced, Clause 6 adequately describes the duties of the Secretary of State in relation to education and training. My noble friend the Minister has done an incredibly important job in recognising the real anxiety that existed at Second Reading about education and training. Indeed, we are grateful to the noble Lord, Lord Walton, for withdrawing his amendment at that time as that has enabled major discussions to take place on the issue.

Government Amendments 61 and 104 bring us to the heart of who will be driving much of the education and training—that is, the national Commissioning Board and the local commissioning groups. In fact, neither of these groups seems to have any responsibility for education and training, even though, as the noble Lord, Lord Turnberg, rightly says, they will be right at the heart of commissioning the healthcare required, whether it is in an NHS setting or a private, approved setting. That appears to be an omission in the Bill.

Although I have much sympathy with Amendment 109 of the noble Lord, Lord Turnberg, and he is right to point out that there is a requirement on private sector providers or, indeed, third sector providers, to engage in training, I hope that when the Minister winds up on this group of amendments he will point out the advantages to those providers of engaging in education and training. Indeed, he has privately assured many of us that they are more than willing to do so because they cannot become qualified providers unless they are engaged in cutting-edge training and education.

In Amendment 109, the noble Lord, Lord Turnberg, raised the important issue of the involvement of universities. It worries many of us that the universities which have been very much at the heart of education and training, particularly postgraduate education and training, appear to be sidelined in the new architecture of the Bill. Frankly, that is unacceptable. It should not be for local employers to decide whether or not they want a university to be involved; it should be a requirement for universities to be involved. We must not have a situation where universities are regarded as predators in relation to education and training, as they are fundamental to it. If research is a fundamental part of the architecture of the Bill and of improving patient care, frankly, it is absurd to have universities outside that remit. Therefore, I hope that when the Minister responds he will assure us that universities are part of the solution—as the noble Lord, Lord Turnberg, rightly said—and are not seen as part of the problem.

[Lord Walton of Detchant]

My Lords, I have just counted that in the course of the past few weeks and months I have attended 28 seminars, group discussions and personal meetings with Ministers, the Bill team and others. That was extremely useful. We have spent a lot of time discussing education and training. I pay warm tribute to the Minister—the noble Earl, Lord Howe—and his team and colleagues for the way in which they have responded and listened to many of the concerns which we have expressed about these problems. The Government have tabled a number of very helpful and constructive amendments. However, I seek to ascertain whether they meet all our concerns.

I know that the noble Lord, Lord Willis, will say that our earlier concerns about research and its role in the NHS have been completely met. I agree with him entirely. We are satisfied on that point. However, in relation to education and training, I said at Second Reading that since the health service began, undergraduate training of doctors, medical students and dental students had always been the financial responsibility of the universities, but that it had always been the responsibility of the NHS to provide the clinical facilities in hospitals and general practices of the United Kingdom for the training of those undergraduate students. Of course, in more recent years, the newer universities—the former polytechnics—have played a major role in the training of other healthcare professionals such as nurses, physiotherapists, occupational therapists, speech and language therapists and others. That commitment has been totally accepted.

However, postgraduate training of doctors, as the noble Lords, Lord Turnberg and Lord Willis, have said—those who are training to become physicians, surgeons, psychiatrists, and specialists in any branch of medicine—is the financial responsibility of the National Health Service and has been from the very beginning of the NHS. At the same time, the NHS has employed postgraduate deans who have been very helpful and responsible in helping to provide that training. It has also been monitored throughout by the royal colleges and faculties that have provided the content and curricula for the training of these groups of specialists. It is crucial that that interrelationship of all these bodies be enshrined in the Bill, even when Health Education England comes into being. I am mildly surprised that all the amendments grouped with Amendment 2 deal with education and training, but so too do Amendments 13, 16, 62 and 106 that are equally important and crucial to this whole programme.

I therefore ask the Minister whether he is satisfied that in the amendments that the Government have tabled, or in regulations that he can assure us will follow, the responsibilities of the universities and other institutions of higher education will be enshrined and clarified. Is he satisfied that through the postgraduate deans and the clinical senates—wherever they are housed, or whether they are housed with the National Commissioning Board and its outreach into parts of the country—the responsibilities of the royal colleges and faculties will also be enshrined, and the postgraduate deans will thereby continue to supervise the programmes? Is he satisfied—and this is crucial—that independent foundation trusts and any qualified providers that are providing NHS services will be required to accept responsibilities for the training and education of healthcare professionals, just as NHS hospitals, general practices and other NHS institutions are?

It is crucial that these issues are confirmed, and I trust that the noble Earl will be able to tell us that in the government amendments, and in regulations that may follow, all our anxieties about these major issues will be accepted and covered to the benefit of the healthcare workforce and the National Health Service overall.

[The Earl of Listowel]

My Lords, I rise briefly to pay tribute to the noble Earl, Lord Howe, and his colleagues for giving this most important issue such great attention since the Bill arrived in this House.

I wish to look at the experience in social work, where there has been great deterioration in the attention given to the professional development of social workers. I remember reading a letter from the noble Lord, Lord Hunt, when he sat on the Front Bench a few years ago, acknowledging the fact that newly qualified social workers were being placed in situations where they had too large a case load and were not being properly supervised. Fortunately, some steps have been taken to address this, but there is clearly still a long way to go on supervision of social workers, and the culture and state of morale of social workers has for many years been eroded by the lack of attention to their professional development. There was a time when there was good professional development; so it can happen, and it could happen in the medical professions.

Perhaps I may draw attention to the experience of teachers in Finland. This is particularly relevant to the Minister’s and the Government’s desire to increase autonomy within the health service and devolve responsibility down to the professionals closest to the front line. About 20 years ago, Finland reviewed its education system and decided to emphasise the professional development of its teachers. It decided to select its teachers very carefully, and now all practising teachers have a masters qualification before practising with children. Only one out of 10 applicants for teacher training places is accepted: there is huge competition to get on those courses. A few years ago, when PISA started publishing league tables of education system performance across the world, the Finns came out top of the numeracy, literacy and science tables, not just in one year but in successive years. Teachers are given a huge amount of respect within their society, very good professional training and development, and are well recruited. There is no inspection of the education system—teachers are so well trusted to do the best for children.

I pay tribute to the noble Earl and colleagues for giving this the best possible attention in the course of proceedings in your Lordships' House.

Health: End-of-life Care

Lord Walton of Detchant Excerpts

Monday 16th January 2012 Lords Chamber

[Earl Howe]

My Lords, the department does not hold information about the degree of adherence to advance decisions, but I can tell the noble Baroness that there are a number of systems available in the NHS that enable patients to record their preferences for care at the end of life and the choices that they would like to make, including saying where, if possible, they want to be when they die. We know that there is widespread use in the NHS of the Preferred Priorities for Care tool that supports decisions about preferences.

We have also supported the piloting of electronic palliative care co-ordination systems to ensure that a person’s wishes and preferences for care are taken into account and to improve communication between the professions and organisations. The Information Standards Board is currently considering a proposed standard setting out a core data set to support the implementation of those systems.

[Lord Walton of Detchant]

My Lords, what evidence do the Government have regarding the number of elderly people in the population who have taken advantage, as I have, of signing an advance directive and lodging it with my general practitioner to specify what forms of treatment I would and would not wish to have if I became incompetent? What is the present position of the legal right of an individual to specify while competent a proxy who could fulfil a similar role if the individual in turn became incompetent?

[Earl Howe]

Unfortunately, my Lords, we do not hold information about how many advance decisions have been made out or pursued; those statistics are not collected centrally. However, I am aware that lasting powers of attorney, which the noble Lord will know came in under the Mental Capacity Act, are growing in popularity and number. The numbers are rising, although I do not have those statistics in my brief. We are encouraged by the fact that people are now aware that they can delegate to a loved one—a family friend or whoever—to take decisions in their best interests should they lose capacity later on.

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, I shall be brief because most of what I would hope to say has already been said by the noble Lord, Lord Hunt, by my noble friend Lady Meacher, and by the noble Baroness, Lady Pitkeathley. This Bill, in Clause 209, will abolish the General Social Care Council and place social worker and social care assistant regulation in the Health Professions Council, which is to be renamed the Health and Care Professions Council. This is highly undesirable for a profession that faces enormous challenges and which has only had its own regulator for just over two years. Is it possible for the Government to turn back from the brink? To take the regulation, education and performance standards of social workers and social care assistants—100,000 of them—into a body such as the Health Professions Council is likely to overload considerably the administrative procedures and activities of that council.

If this change is inevitable, the amendments that have been tabled by the noble Lord, Lord Hunt, and others are worthy of very serious consideration. They would give social care and social workers a very special and identifiable voice in the Health Professions Council. Is it really appropriate that this mass of social workers should be regulated by a body that already regulates art therapists, biomedical scientists, chiropodists, clinical scientists, dieticians, occupational therapists, physiotherapists, and many others—people who all work primarily in the health field? I quoted many of the bodies regulated by the Health Professions Council earlier today. It seems that putting the social care profession under this council is going to make it a very uncomfortable bedfellow.

I wholly appreciate the Government’s wish to have a bonfire of the quangos, and I understand why they wish to reduce the number of regulatory authorities, but there is no doubt that their last mechanism for doing this, when they brought together three major bodies and cumulated them into the Care Quality Commission, has been struggling to fulfil its responsibilities. It is functioning very effectively, but it has had a massive task in taking on all the additional responsibilities that have fallen to the Care Quality Commission since that merger. I fear that the same problems might well emerge in relation to this proposed merger, about which I therefore feel very uncertain and somewhat uncomfortable. I only wish that the Government felt able to think again.

[Lord Newton of Braintree]

My Lords, prompted only by the debate, I ask one simple question of my noble friend on the Front Bench. What assurance can she give me, in the light of the concerns that have been expressed, that this move will not end up with the same problems that we have had with the CQC, which was asked to take on too much, too fast, and proved incapable of doing it effectively?

--- Later in debate ---

[Baroness Northover]

I am more than happy to write to the noble Baroness. In the discussions that I have had with various organisations, including the HPC, that is not the conclusion that I come away with. I hope that she is reassured.

[Lord Walton of Detchant]

I apologise for interrupting and I do not wish to prolong the debate but the noble Baroness was kind enough to refer to my presence at the General Medical Council, which ended in 1989. Things have changed a little since that time. Of course, the GMC was concerned primarily with standards of education and ensuring that those who were properly educated and qualified were fit to practise in the first instance. Secondly, it was concerned with fitness to practise and with individuals in the profession who deviated from proper standards of practice as defined by the standards committee. It was concerned with the ethics of the profession and with ongoing and further education as well as with many other responsibilities. My understanding was that all those matters were within the ambit of the General Social Care Council in relation to its responsibilities. When the General Social Care Council transfers to the Health Professions Council, can we be assured that all those responsibilities that fall to the General Social Care Council, which is very young and only just finding its way, will be taken on board?

--- Later in debate ---

[Lord Walton of Detchant]

My Lords, I shall be brief but, as always, my noble friend Lady Masham was very persuasive. I have always felt, as indeed she does, that there is a powerful case to be made for the statutory regulation of healthcare assistants not only in hospitals but in homes, particularly old people’s homes. As we heard during the debate on the amendment tabled by my noble friend Lady Emerton, the Government are entirely persuaded that at present the regulation of such individuals could not be done by statute. I must say that I feel uncomfortable about that.

Is there any means by which the Government can suggest a mechanism whereby, perhaps in consultation with the Care Quality Commission, the terms of voluntary registration of healthcare assistants could be based on a set of agreed principles which were accepted generally by all the professions concerned? As it exists at the moment, voluntary registration is not adequate or strong enough and needs to be strengthened. Therefore, while I support in principle the ideas put forward by my noble friend Lady Masham, I think that for the present we will have to be satisfied with voluntary registration, which should be strengthened by whatever mechanism can be introduced.

[Baroness Barker]

My Lords, I have a great deal of sympathy with what the noble Lord, Lord Walton, has said. If noble Lords look at A Vision for Adult Social Care, a document published by the Government last year, they will see that the principles underpinning health and social care have been set out perhaps more clearly than they have been for some considerable time. I do not think the problem is that the principles are not there or are not known; it is that the training that brings those principles to life for a practitioner is not there.

I am torn on this issue. I listened to the noble Baroness, Lady Pitkeathley, and I was persuaded by what she said. I know of organisations which use staff who are not registered but who are exceptionally well trained and have very high standards. If the Government are reluctant—I am sure that my noble friend will again say that they are—to go down the path of full registration, I would understand that position if my noble friend would give a commitment to the development of training. That would go a long way to meeting the point to which I think all noble Lords are trying to get; namely, that the training of people involved in the direct care of those who, usually, have long-term conditions is of a high-enough quality. That is the most helpful thing that my noble friend might be able to say.

National Institute for Health and Clinical Excellence

Lord Walton of Detchant Excerpts

Wednesday 14th December 2011 Lords Chamber

[Earl Howe]

My Lords, I need to put on record that I have every confidence in the senior leadership of NICE. The current chair and chief executive have overseen NICE’s development into an organisation of global repute that provides robust, independent guidance on a range of issues. Continuity of leadership can be a very good thing, and I believe that it is in this case, where the leadership is of the highest calibre. I would also say that significant improvements have been made to the timeliness of NICE appraisal guidance on new drugs. NICE is now able to issue draft or final guidance for a significant majority of the drugs that it appraises within six months of a drug being licensed. That is extremely good, considering the complexity of some of these assessments.

[Lord Walton of Detchant]

My Lords, does the Minister accept that the Statement by the Government last week on life sciences is one of the most welcome Statements relating to the life sciences that we have heard in this Chamber for many years? NICE has had a very proud record. It is required not only to assess the value and importance in medicine of drugs and new procedures but to consider their cost effectiveness. While there are certain situations in which it can rightly be criticised, it has made an immense contribution to the development of new procedures and the introduction of new drugs in the NHS. It is actually envied in other countries, not least in the United States, which wishes that it had a similar mechanism.

[Earl Howe]

My Lords, I fully agree with the noble Lord, who puts the case very well. That is why NICE will be at the heart of our work to improve quality in the NHS. We are re-establishing it, as the noble Lord knows, in the Health and Social Care Bill, extending its role to social care and embedding the role of NICE quality standards in statute. Of course, it will still be there to provide independent advice to support clinicians in the way that we know it has over the last few years.

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Tuesday 13th December 2011 Lords Chamber

[Lord Walton of Detchant]

Is it not the case that procedures can be more easily and more cheaply carried out in the private sector in many instances than in the National Health Service because the costs in the National Health Service must take into account all the other responsibilities of the NHS, including responsibilities for education and training and many other things in which the private sector is not at present involved?