Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Monday 14th November 2011 Lords Chamber

[Lord Noon]

My Lords, I wish to support the amendment moved by my noble friend Lord Patel of Bradford. I declare an interest as chair of the Noon Foundation, which has made significant donations to charitable organisations and others concerned with the care of those living with cancer and those in hospices or receiving palliative care in the community.

My noble friend has outlined many of the key issues faced by the charitable sector with respect to VAT exemptions. I do not want to repeat these arguments, but let me add further information on the scale of the services that we are discussing. The combined contribution of these services amounts to more than 26 million hours of care every year. In excess of 2,000 adult in-patient beds are provided by the voluntary sector and more than £1 million is raised in charitable donations every day.

Of course, these are voluntary sector services that rely on thousands of people who give up their time to ensure the work is done. In fact, the estimated value of the 100,000 volunteers is said to be more than £112 million each year. The value of this sector as a whole in providing hospices and palliative care is in the order of £3 worth of care for every £1 invested. This is an outstanding achievement that should make all of us very proud. It is also why we should be doing much more to protect the sector and ensure that it can operate and grow on a level playing field.

I am a businessman so I know something about VAT and the need for equality in financial arrangements when different providers are in the same market. I am perhaps less anxious than some about the use of competition as a driving force in healthcare. I believe that competition can be harnessed for good and that there are many benefits to be realised by opening up the healthcare sector to this kind of discipline. However, competition must be fair and the current arrangements on VAT between health services and the charitable sector are certainly not fair.

One of the charities that I have been most closely involved with, as a donor and a supporter, is Marie Curie Cancer Care. Marie Curie provides high-quality end-of-life nursing care throughout the UK and has more than 2,000 Marie Curie nurses, who care for half of all cancer patients who die at home. These nurses provide essential care for patients and their families at the most stressful time of their lives. I have met many of these nurses, and their dedication and passion is second to none. They not only provide essential practical support to people as they face the end of their lives but are an emotional support for the whole family.

In addition to a range of community and home nursing services, Marie Curie is one of the largest providers of hospice care outside the NHS in the country. It runs nine specialist hospices which deal with all the patients’ needs—physical, social and emotional—across in-patient and day-care services. These services are vital to those who use and need them but we should put them in this context: 65 per cent of people say that they would like the choice of being able to die in their own home, surrounded by family and friends, but the reality is that only 20 per cent manage to achieve this choice.

It is clear that we need more of these provisions, and the Health and Social Care Bill will help to extend them. The new arrangements for commissioning mean that other organisations can provide more health services. This will also mean that there will be much more competition from lower-quality commercial organisations, but we must support them to be able to do this. Part of that support must be to ensure that there is a level playing field in respect of VAT. We should not expect charities to take up an extra burden in providing these vital services by expecting them to take on costs that do not currently apply to the NHS. The amendment provides a way of achieving this social goal by placing a clear duty on the Government through the Secretary of State’s report to Parliament on the treatment of VAT provisions across the charitable sector. I hope the Minister agrees that it is an important move in the right direction and will support the amendment.

[Baroness Finlay of Llandaff]

My Lords, I declare all my interests in relation to hospice and palliative care services.

The amendment is particularly important because of the any qualified provider provision which seeks to bring in more charitable sector providers, working with NHS commissioners, to provide essential services where the NHS is not able to plug the gap. That is why there was a debate in the other place in May this year on the effect of VAT on hospices. However, it goes much wider than simply hospices.

The VAT gap means that the private sector can claim back VAT by passing on the cost to customers; the public sector pays VAT, which is then refunded by government; but the charitable sector can do neither—it fund raises. In the hospice world—I am grateful to Help the Hospices for the figures—an average hospital in the UK, supporting about 1,000 patients and spending £8 million on care, may receive about 30 per cent of its funding from the NHS but it will spend about £82,000 on irrecoverable VAT. So money has to be raised just to cover that VAT gap.

As the hospital takes on more and more responsibilities, the problems become greater. As we try to get hospices to work together on joint ventures and share services with other providers and other charities, one hospice has to recharge services to another—one voluntary sector provider to another—including VAT, and that cannot be recovered. It also cannot recover any VAT on the repair and construction costs of charitable buildings. As there is increasing use of its buildings and it needs to upgrade to meet more modern quality requirements, VAT becomes a problem because, for the hospital to provide the quality service that we need, it has to outlay on capital expenditure.

The other difficulty is that VAT is fairly complicated for charities and requires expertise to manage the VAT process for them, which of course also incurs a cost on them in terms of personnel, which again is irrecoverable.

This is an extremely important amendment and the principle behind it has to be tackled if the fundamental idea of any qualified provider is to work in practice in the long term and provide stable, quality clinical services.

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[Baroness Emerton]

My Lords, I have put my name to Amendment 47B. At Second Reading, I referred to why I thought it important that education and training be mentioned in the Bill, even though it was understood that work was already under way. Noble Lords who have spoken have underlined the importance of education and training being mentioned in statute now.

The Health and Social Care Bill proposes a comprehensive health service reliant on an effective workforce that is capable and competent to deliver a service that demonstrates improved patient outcomes. For this to happen, there needs to be an effective partnership between the NHS and universities. The introduction of local commissioning of services will also require local commissioning for education and training places for the agreed workforce plan at both local and national level. There must be multi-professional involvement if professional silos are to be avoided, both in relation to funding and the structures and governance arrangements that underpin the workforce. For too long, silos have been the problem in the funding arrangements for education, training and research.

Developments around the establishment of Health Education England are now being considered, but, as has already been said, progress is slow and is causing anxiety out in the field. The intent to move to an integrated health and social care service calls for these partnership arrangements to be made. There is a need to ensure the right balance of responsibility and accountability between Health Education England and the provider-led networks—employers/professions, the education sector and the whole workforce, plus patient and public representatives, working together. It is vital that this is a proper partnership and representation on the boards of local education and training boards, which can ensure effective multi-professional workforce planning. Representation of universities, medical schools and postgraduate deaneries, in relation to both non-medical and medical education, on the board of the local education training boards will ensure effective co-production of the healthcare workforce.

Universities should not be considered simply providers of education programmes but also co-producers of the workforce through this wider role of research, innovation, releasing social capital, and the globalisation of healthcare, which is integral to the development of advanced clinical care, service redesign and workforce planning. Universities should work in co-operation with the NHS to ensure the delivery of high-quality education and training and then be held to account by Health Education England. Ensuring that universities are a central part of the local education will facilitate effective partnerships, improved quality outcomes and a multi-professional approach.

The intent to move to this is very important and the establishment of budgets, which has already been mentioned, is also crucial. As already stated, silos should be avoided so that an integrated approach can be established to the education and training of the workforce. The challenge for the new education system will be whether it can truly ensure the co-product of a workforce that can deliver the new way that care can be delivered—one that will provide holistic care, especially adapting to the demographic changes, demanding more care in the community for the elderly, frail, vulnerable and for end-of-life care. Budgets will need to reflect the most cost-effective provision of care to enable hospital expenditure to be reduced.

Nursing, midwifery and other allied healthcare professions are committed to evidence-based practice and would warmly welcome the multi-professional involvement in education and training programmes as well as the benefit gained from multi-professional buildings and shared facilities. Not only would this be of benefit for the learning environments but it could be cost-effective in the use of expensive educational facilities, tutorial staffing and equipment. Could the Minister clarify some of these issues in his summing up?

[Baroness Finlay of Llandaff]

My Lords, I have an amendment in this grouping. It addresses the duty that I would like to see on clinical commissioning groups to promote education and training of the current and future NHS workforce. The reason for putting the future in is because of the undergraduates who are studying to become healthcare professionals. This is important because we know that primary care placements at undergraduate level have a significant influence on career choices and therefore on career progression. The quality of training and the quality of care given by the tutor who is their tutor in primary care is influenced by having undergraduates with them. That applies across all the disciplines that work in the community.

The other point is that general practitioners will need training in commissioning responsibilities in the future. Therefore, if we are to attract the brightest and best of our undergraduate clinical workforce to work in the community and eventually contribute in clinical commissioning groups, they need to have excellent exposure at an undergraduate level.

I also support the other amendments in the group so eloquently introduced by my noble friend Lord Kakkar. I strongly support the comments made by all the other noble Lords who have spoken. We need to have this duty at every level—at Secretary of State level, at Commissioning Board level and, as I have suggested, at clinical commissioning group level. The one area that we have not addressed and that is not in the amendments is the way that Monitor grants licenses. We might need to come on to that at a later stage when we discuss Monitor.

There is a particular need for planning medical education and training and having it planned nationally. It takes 15 years, on average, from start to finish to develop a specialist in highly technical, very complicated areas of medicine. There are about 32 small specialities, and in-depth local intelligence and intelligence within that speciality are needed to know both the numbers that are needed in the future and to horizon-scan and look at the type of training that will need to be delivered and whether things will change. A simple example is in surgery, to which reference has already been made, where keyhole surgery came about. My discipline, the development of palliative medicine as a distinct speciality, has completely altered the face of some of the care in both hospitals and the community, and it has a significant workforce which is still developing.

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[Lord Mawhinney]

I am a just a simple Belfast boy. Archbishop of York seems pretty good to me; most of the clergy I know can only fantasise.

The timing of this debate is important in that it reinforces the message that my noble friend got the last time this was debated in this Chamber. I hope that he will tell those who tabled the amendments that they are premature. If he does, he will need to tell them that he will take away the contents of this debate and the previous one and bring back, in whatever way the Government think is appropriate, a means to attach the principle of education and training to this Bill. He knows that I hope that he will do that, but I hope that he is encouraged that I share the views expressed that this is not yet the time.

The noble Lord, Lord Owen, has addressed particularly well the element of perplexity and perhaps confusion in the NHS about the Government’s intention. My noble friend and his colleagues keep going on about the Future Forum. I am sure that it is doing a fine job, and no word of criticism about it will cross my lips—except to say, as a simple Belfast boy, that in a democracy it seems to me that the role of this House is to try to persuade Ministers; it is not its role to try to persuade those who are going to try to persuade Ministers. The Future Forum may have an important role, but I would like us to discharge our role quite clearly. The noble Lord, Lord Owen, has the experience of having served in Cabinet, and I have been extremely fortunate and blessed to have had a similar experience. If my noble friend or the Secretary of State can go to the Dispatch Box and say, “I undertake that there will be legislation”, and specify the Session, we will all believe him. However, if that is not possible, it adds to the importance of bringing forward at least the principle to get this issue into this Bill.

Those of us who are in favour of education and training but want to support the Government are not entirely clear whether we should be tempted by Amendments 47A, 47B or 133, and I have to say to the noble Baroness, Lady Finlay, that I am not tempted by her Amendment 199A. But at some point this House has to make a decision, so I hope that my noble friend will stand up, look the noble Lords who tabled these amendments in the eye and say, “Thank you, it’s been very helpful and I’ve heard what you’ve said. I’ll take it away and I’ll bring something back on Report, which I hope will satisfy the whole House”. In the mean time, I hope that noble Lords will not press their amendments.

[Baroness Finlay of Llandaff]

I hope that the noble Lord, Lord Mawhinney, will be tempted by this comment. If commissioning groups do not have a duty towards education and training, there is a real danger that they will commission services that are equal in quality but undertake no education and training and are therefore of a lower price as they do not incur the expenditure of having to have facilities, and so on, to provide education and training as well. In that case, we will deny the developing workforce expertise of quality placements in many parts of Britain as local commissioning will not take account of it.

[Baroness Thornton]

My Lords, at the risk of stating the obvious, the massive reorganisation of the NHS proposed in the Bill, combined with the need to make £20 billion of efficiency savings, without doubt, and with common agreement across many of the professions, threatens the quality and delivery of medical training, post-graduate training and workforce planning. That is why noble Lords have been exercised about this matter from the outset.

The concern is that responsibility for medical training will be given to healthcare providers who, as I understand it, have a history of allowing service and research to dominate the agenda at the expense of education. That brings with it risks of its own. Many trusts, as other noble Lords have said, have persistently failed to support education supervisors by recognising this activity in job plans and increasingly failed to support their staff in fulfilling important national roles related to standards setting and training. I think that most noble Lords who have spoken would agree that there is an insufficient mention of the safeguards that need to be put in place to protect the quality of medical training.

The noble Lord, Lord Kakkar, and my noble friend Lord Turnberg mentioned their concern about post-graduate deaneries. Indeed, that was a major stream of work for the Future Forum. I would like to say to the noble Lord, Lord Mawhinney, that as he made his remarks about the Future Forum I wrote in my notes that I do not understand why the Department of Health seems to have franchised that particular piece of policy-making out to the Future Forum. I think that the Future Forum was right in what it said about the dangers and risks involved in abolishing the strategic health authorities and its recommendation that it was mandatory and critical that alternative arrangements should be made.

We know that post-graduate deaneries are currently pivotal in quality-managing the delivery of medical training in trusts, but the planned replacements, being answerable to and funded by healthcare provider units, may lack the impartiality required to drive the quality agenda at a time when it is most needed because of the fiscal pressures and the associated threat to education quality. We all agree that effective management of the complexities of post-graduate medical training require professional leadership skills and experience, which take many years to develop. The noble Baroness, Lady Finlay, underlined that point in her remarks. My noble friend Lord Warner put his finger immediately on the crucial aspect—how will the money be safeguarded and how will we make sure that the funding that is necessary is in the right place, is accountable in the right place, and cannot be directed into places that we would not wish it to be? How will the Government make sure that that is what happens?

I was very struck by the briefing on this matter by the Royal College of Nursing. The noble Baroness, Lady Emerton, referred to this. The Royal College of Nursing expressed its concern that Medical Education England would dominate the new organisation, HEE. I think we would all agree with the RCN that:

“It is essential that nurse educators are treated as equals and the membership of HEE is representative and not led by the medical deaneries”.

The Royal College of Nursing also believes that there is an essential role for national planning in the delivery of these important functions. I think that there are great risks in the decentralisation of education and training in terms of quality, standards and safeguards. It is unclear how the skill networks or the LETBs will be held accountable for performance issues. It is not clear what authority Health Education England will have to enforce performance issues or how its overseeing of the skills network will take place.

There are some key questions for the Minister to address. The crucial one, which was mentioned by the noble Lord, Lord Owen, who used the expression “chasm in continuity”, is how long we will have to wait for legislation. We cannot be sure that the primary legislation that will be required in this area is going to come down the track in the next year. The Minister needs to recognise that it is too risky to leave this to chance and we have to put the appropriate duties and powers in the Bill to ensure the continuity that the noble Lord, Lord Owen, mentioned. On these Benches, we are very happy to discuss how to resolve that particular issue and how to ensure that medical education is safeguarded.

This is an important group of amendments. I am slightly worried by the statement of the noble Lord, Lord Ribeiro, that this is work in progress. The problem is that there is too much work in progress and there will be too much work in progress for the next few years. This is an area where we cannot take chances. We know from previous reorganisations, for which my Administration were responsible, that we have to be absolutely sure that we are safeguarding the education and training of future generations of workers in the National Health Service.

The most reverend Primate said that continuity and certainty are vital. I agree with him. Certainty in this area is vital. I look forward to hearing the Minister’s views, but I suspect that we have not heard the last of this subject.

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[Lord Warner]

My Lords, in the unavoidable absence of my noble friend Lord Rooker, he has asked me to move Amendment 50 standing in his name and those of a number of colleagues. This amendment is very simple in intent. It seeks to ensure that the national Commissioning Board has at least one member who is a public health specialist. Much of the work of the board and, indeed, of the clinical commissioning groups, is to commission services that arise from failures of public health, or the associated issue of the absence of clinical intervention at an early stage in a person’s condition. Later we will discuss a raft of amendments for strengthening the Bill’s provisions on public health itself. This group of amendments is concerned with the membership of the national Commissioning Board and the disclosure of information.

This amendment is intended to help the board in its deliberations. It is essential that it has ready access to public health expertise. I very much support Amendments 153ZA and 153B in this group, standing in the names of my noble friends Lord Hunt of Kings Heath and Lady Thornton, which seek to curb the administrative costs of clinical commissioning groups. I have degrouped my amendments on controlling the overheads and management costs of the board. I have also tabled amendments that try to curb clinical commissioning group management costs. I tabled these amendments because I wanted to ensure that we had a fuller discussion on the two linked issues of overheads and administrative costs at a later stage. I will not speak on that issue at length today but I want to flag up to the Minister that this is an extremely important issue in this very difficult financial climate. Rather unusually, we may need to put in a Bill establishing new bodies a curb on the extent to which they can grow their administrative budgets in the future. My noble friends are doing the House a service in giving us a chance to have a debate on this issue.

I return to Amendment 50. It may not be directed at the right place in the Bill—I leave the Minister to think about that—but its substance should be in the Bill. I hope that the Minister will reconsider the Government’s position on this issue. I beg to move.

[Baroness Finlay of Llandaff]

My Lords, I rise to speak to this amendment, which is also in my name, and to support the other amendments in this group. They have the effect of ensuring that public health considerations and public health expertise are given due weight in the new arrangements set out in the Bill.

Public health covers three main domains: health improvement; health protection; and health service delivery. Public health specialists are trained and skilled in interpreting data and information about populations, understanding health needs and securing the services required to meet those needs. That expertise is vital to having effective commissioning at every level, particularly that of the NHS Commissioning Board, which will have the overarching responsibility for commissioning health services, so as to ensure that the services are effective, appropriate, equitable, accessible and cost-effective. It therefore seems only sensible to make sure that that expertise is incorporated at board level.

The Commissioning Board exists to secure and improve the health of the population through the NHS services it commissions, and indeed through the services which are not NHS-provided, if I have understood this Bill correctly. To do this, the board would benefit from public health input. Public health specialists have an unparalleled overview of a community's need for health services and how they are best commissioned, including changing, adapting or even decommissioning services which could work better in other ways. The role of a public health specialist would also be to provide the essential expertise needed to commission preventive services, such as screening and immunisation, and to look at the evidence relating to those services. The board may need the courage to decommission some of those services as well, or to substantially alter the way that they are delivered.

It would be inappropriate to say that this is going to be too expensive, because a public health specialist should pay for themselves many times over with their presence on the board. It is only by having such an expert at board level that we can ensure their expertise is incorporated into decision-making, rather than only feeding into the process in an advisory capacity.

[Baroness Williams of Crosby]

My Lords, one of the most interesting aspects of the proposals in this Bill is the greater status to be given to public health. I think we all recognise that for some years public health has been something of a Cinderella in the medical establishment. To have public health lifted, as it should be, on to board representation seems to me absolutely central in our attempt to put greater accent on prevention, education and information; there are future amendments by some of my noble friends on some of those issues. I wish to say very briefly that I think that this amendment is absolutely right. It is crucial that public health recognition is given at board level, and I hope we can echo that in having it also represented in the clinical commissioning groups as they emerge.

One other question to raise in relation to public health, which we have been considering very carefully, is how we deal with chronic illness. Chronic illness is obviously not unrelated to lifestyles and life behaviour, so here again, raising the influence of public health in the attempt to bring about a healthier lifestyle among our fellow citizens and ourselves is absolutely essential. I therefore completely agree with what has been said by the noble Baroness, Lady Finlay, and the noble Lord, Lord Warner, in moving this amendment: that it is vital that public health be represented at the highest level.

Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Monday 14th November 2011 Lords Chamber

[Baroness Cumberlege]

Can I also ask the noble Lord, Lord Hunt, about his amendment, in which he proposes setting up another very strong bureaucracy? It is a corporate body, known as a clinical senate; I presume, because it has a proper officer, that it will have a range of officials. It is suggested that it should revalidate doctors within the area, but I am wondering how that would work with the GMC and others. It will maintain a whole system of clinical governance within clinical commissioning groups and also authorise some of the clinical commissioning groups.

I can understand the noble Lord’s wish for some strategic leadership. I have been a regional chairman—and I have to say that our medical advisory groups were really excellent compared to those of south-east Thames. We had really good ones. But I am anxious about this matter. I sense that this is simply a probing amendment, because the membership of what the noble Lord proposes would be extremely bureaucratic. I understood that these were advisory boards, and that it was to try to get some of the clinical input from the acute centre into the commissioning groups so that they understood perhaps more clearly what they were commissioning in terms of acute services.

I very much look forward to what my noble friend is going to tell us as to how he sees this issue. But I must say to the most right reverend Primate—I think I have got that right—that if he can manage the Anglican Church he really could manage the National Health Service.

[Baroness Finlay of Llandaff]

I wonder whether this is one of the occasions where the organigram that we were discussing previously in Committee might be helpful. I would be grateful if the Minister could tell us in his summing up when we might expect to see that diagram.

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

My Lords, we heartily endorse the important role that clinical advice will play in supporting the NHS Commissioning Board in fulfilling its duties and carrying out its functions effectively. We fully expect clinical networks and the new clinical senates to make a vital contribution to this.

The Government intend that doctors, nurses and other experts from across health and social care will form clinical senates to give expert advice to commissioners. They will do this principally, although not exclusively, in two situations: senates will have a role in the authorisation of clinical commissioning groups, as well as having a role in advising on significant service change on a large geographical scale. Existing clinical networks will also be taken forward and developed and will advise on how specific services can be better designed to provide integrated and effective care. The Government are committed both to retaining and strengthening clinical networks and to using them to help ensure that a range of professionals play an integral part in the clinical commissioning of patient care. The networks will include patient and carer representatives that exist in areas such as cancer care, so that they cover many more areas of specialist care. Networks will have a stronger role in commissioning, in support of the board and local clinical commissioning groups.

Although we fully agree with the noble Lord, Lord Patel, in highlighting the important role that both clinical networks and senates will play in the new system, I cannot support his Amendment 51, nor can I support Amendment 224A, tabled by the noble Lord, Lord Hunt. The reason why I cannot accept them is the same in each case: both of them would specify the roles of networks and senates in legislation. That would restrict the range of ways in which they can operate, which in turn would limit the value that is delivered for patients.

Clinical senates and networks will not be statutory organisations, and that is why they are not referred to in the Bill. That, surely, is a positive thing. It gives them much needed flexibility in how they operate, maximising benefits for patients while minimising bureaucracy. This flexibility will allow both senates and networks to act as enablers of the commissioning system, supporting commissioners by providing them with expert advice. They will not act as another layer of management or administration which hinders progress; instead, the board will host both clinical senates and networks, allowing any supporting functions which can appropriately be shared to be organised with the least administrative bureaucracy. The review of the current system of clinical networks is identifying the features that deliver the greatest benefits, allowing the new system to build on these in a streamlined way that effectively drives improved quality and outcomes.

The board will be subject to a duty, in the proposed new Section 13J within Clause 20, to obtain appropriate advice to enable it to discharge its functions effectively. We believe that this general duty is sufficient to ensure that it seeks appropriate advice, including, of course, clinical advice. In practice, clinical networks and clinical senates will form one way in which the board fulfils this duty.

Clinical commissioning groups are also under a similar duty to seek appropriate advice. Although the board will host senates and networks, clinical commissioning groups will be closely involved in their design and functioning, as well as benefiting from their advice. It is expected that the board will issue guidance about avoiding conflict of interest where this might arise. The exact number of clinical senates is yet to be determined but they are expected to be able to offer informed, strategic advice across a health economy, which might suggest having around 15 across the country. Clinical networks will be based on patient flows rather than NHS boundaries, so variations in size will continue, but representation will always be appropriate to the remit of each network.

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[Baroness Barker]

I shall speak to Amendment 92ZZA, which stands in my name and those of my noble friends. At this time of night, brevity is of the essence. This amendment addresses a crucial point.

The whole structure that the Bill sets up for the NHS depends on a number of things to work efficiently. It depends on the clarity of responsibilities and on different bodies having a clear understanding not only of their own role but of their role in relation to each other. One of the most important parts of the process underlying the structure is integrity. Although there has been much exaggeration about potential conflicts of interest in some of the things that I have seen, there is one—the one that I have highlighted in this amendment.

One commendable thing about this Bill is that in relation to acute care and hospitals we are stopping the process by which organisations—in this case acute trusts—are rewarded for the volume of the procedures they do rather than the quality of their outputs. It is important in commissioning that we stick to that same principle. There must be no possibility whatever that anybody who is involved in the commissioning of services stands to gain by the provision of those services, or their volume. That is why I have drafted this amendment. It may be imperfect in some way or another but its intention is to say that those commissioning decisions must be completely separate from the derivation of any benefit—or pecuniary benefit—as a result of that.

I have absolutely no problem whatever with people who either work for or are shareholders of commissioning support organisations advising CCGs on what to do. If they are, as we have been led to believe, experts in commissioning and clinical commissioning groups want to bring in their expert advice, that is absolutely fine. I do not have a problem with that at all, as it could be a much more efficient and effective way in which to do it. However, it would be unacceptable if those same people had any role whatever in the decision-making processes of the CCGs, either by being a member of a CCG board or by being a member of one of the CCG sub-committees. My amendment attempts to remove that potential conflict of interest. It is probably one that the Government had intended to remove, but they have not done so in the Bill as it stands, and so there is a loophole which needs to be closed in order that there is complete integrity about the process.

[Baroness Finlay of Llandaff]

My Lords, this group of amendments and this debate are incredibly important. The risk of conflict of interest relating to general practitioners is particularly high because they are independent contractors—they are not NHS employees and therefore are not answerable in the same structure as an NHS employee would be within an organisation. Independent contractor groups may be small or they may be as large as practices.

I have been a GP myself and have had to go through the business of partnership agreements. I know only too well from colleagues of mine how disastrous the break-ups in partnership agreements can be and the degree of animosity that can occur. When we talk about GPs being on commissioning groups, there is a real problem in terms of how much they are going to get paid for undertaking commissioning decisions. If they are commissioned from an organisation with which they have a link—because they are a GP with a special interest and they work in another organisation—what are they being paid for? The content of their general and medical services contract is not closely defined. If they have a special interest, which their practice then refers to one of the partners in the group who is providing a service as part of another provider group, there is a risk that people in that practice will be getting double-paid under the organisation of that arrangement.

To try to explore this, I telephoned Assura, a group which is providing dermatological services in an area. I tried to explore the situation with regard to their internal governance arrangements and commissioning arrangements if they have a GP working there and how those arrangements are monitored. I was reassured by what I was told by the person on the phone, who was most helpful. However, it did not take away my anxiety. This provider was being careful and making sure that clinical governance structures were in place, but I have not been able to understand where the controls are on a clinical commissioning group. Will they be only on people who are GP principals on it, or will they apply to all the doctors who are working in general practice? Where will the GPs sit if there are a small number of principals, a large number of salaried GPs in an area who are doing all the clinical work and who know what needs to be done, and a senior partner who is taking the profits out of the business which is the business of the general practice?

Where coterminosity links to this is that, if you have coterminosity between the commissioning group and other services—local authority services, education services and so on—you at least have another organisation, or two others, which will be seeing what is happening. If you take a complex family—perhaps a single parent with one child with developmental delays, another with complex conditions such as epilepsy, diabetes or whatever, and another child who might be being neglected—then, by having triangulation between local authority services, education services and those services being commissioned, the gaps in the commissioning process may emerge. However, if you do not have coterminosity, I can see each group saying, “It falls outside our area”, and the children or the patients will fall through the gaps. With regard to the commissioning group, poor decisions in commissioning or decisions which involve a conflict of interest may not be revealed for a very long time.

Therefore, I urge the Government to look closely at these amendments, particularly the one tabled by my noble friend Lord Kakkar on the Nolan principles, because, unless we tighten up on the processes that will monitor and provide governance over the way that members of the clinical commissioning group behave, we run a risk. I wish that I could share the optimism of the noble Baroness, Lady Barker, that the conflict of interest will lie only among those supporting commissioning decisions, but I do not.

NHS: Hinchingbrooke Hospital

Baroness Finlay of Llandaff Excerpts

Thursday 10th November 2011 Lords Chamber

[Earl Howe]

My Lords, we do not envisage any other solution of this kind in any other trust. Of course, close monitoring will be necessary, and the contract with Circle is very clear in this instance—it has to perform according to the specification. As I said earlier, if it does not turn the hospital around, the financial risk up to £5 million of deficit, cumulatively, lies with it. I believe that this is extremely advantageous for the taxpayer. On the clinical side, of course the CQC will be extremely concerned to ensure that quality of care is not just turned round but significantly improved.

[Baroness Finlay of Llandaff]

My Lords, can the Minister tell us how often Circle is reporting to the CQC on the clinical outcomes, given that there have been clinical problems at this hospital, how often it is reporting on the financial turnaround and to whom it is reporting?

[Earl Howe]

No, I cannot, but I shall write to the noble Baroness.

Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Wednesday 9th November 2011 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I want to say only a few words. I cannot agree with the noble Baroness, Lady Cumberlege, that members of the public do not trust their Members of Parliament. Unfortunately, there have been a few problems, but surely we have moved on from there. I have just been to a meeting with about 20 Members of Parliament of all parties, who are supporting their constituents over the children’s heart surgery unit in Leeds. They trust their Members of Parliament more than they trust the people doing the review.

[Baroness Finlay of Llandaff]

My Lords, I hesitate to join in this debate, because it has been fascinating and wide ranging, and I hesitate particularly to come in after the noble Lord, Lord Darzi of Denham. However, I would like to pull out two factors which are important here.

First of all, there are inherent tensions. Fears have already been expressed by the noble Lord, Lord Davies, in particular. One of the fears is whether we will have a National Health Service or a national health insurance, which will actually be an insurance programme. Those who belong to a GP and are part of a clinical commissioning group will then access those services which that clinical commissioning group determines to commission, irrespective of who the provider is, and there will actually no longer be a National Health Service.

That is linked to autonomy, because the worry in this clause—the second anxiety—is where the boundaries of that autonomy lie. This clause does not seem to stipulate any boundaries to the autonomy at all, nor indeed, whose autonomy overrules another’s. Will it be the Commissioning Board, or the clinical commissioning groups? Where is the hierarchy? Health services are actually a spectrum. You cannot divide the actions of one from another, because they have a knock-on effect. A clear and very simple example is that delayed diagnosis in primary care results in later presentation and more expenditure in secondary care, but more importantly, in poorer outcomes for the patient, who has effectively been withheld from accessing expertise for too long.

Behind all that is a worry, because general practice per se is not an NHS employed service. GPs are individual contractors whose general medical services contract is remarkably poorly defined. It may be that the autonomy of the Commissioning Board will allow it to define very clearly what is in general medical services and what is out. The whole concept of GMS suffered hugely when the 24-hour responsibility went and out-of-hours services came in. That fragmented, to a large extent, what GPs did.

It is completely mistaken to believe that liberating the NHS depends on these clauses in the Bill. I have my name to one of the amendments to delete one of the clauses, but I do not see, from the debate that we have had today, how deleting the clauses will stop the changes to liberate the NHS that everybody has been arguing for.

Unfortunately for patients—and the NHS service is there for patients—the NHS has indeed become risk averse in a culture where the managers have become frightened, for whatever reason, of speaking out, and of taking patient-oriented decisions, and have often put pressure on clinicians to not do what they have wanted to do. I fear that behind that, too, there has been peer pressure and a mistaken view that it is unprofessional to show that you care. There has been a view that, if you step out from the local culture to do what is right for the patient, even though it may not be right for the service or the system, that can result in severe disciplinary action against an individual. We see the extreme of that with people who whistleblow and speak out for services. However, I do not think that any of that will be affected whether the autonomy clauses are in or out of the Bill.

In the past, I have argued with the noble Baroness, Lady Cumberlege, that the NHS should not be a political football and that there should be some distance between political interference and the way that the service is delivered on the ground. However, I must admit that I had never imagined that we might be discussing what could potentially be complete fragmentation of the service.

I should like to run through some of the boundaries that I think are very important in discussing this matter, and I know that we will be debating this further in relation to the role of the Secretary of State. Like others in the Committee, I commend the Minister for the way in which he handled the debate on Clause 1 and for his very positive approach to the discussions that we all need to have on these clauses at the beginning of the Bill.

Do the people with the autonomy have the skills and capabilities to exercise that autonomy, and how will those skills and capabilities be measured? How will autonomy interact, when you are trying to drive forward collaboration and integration and trying to drive performance management, with a decent level of services and consistency to improve quality if one part of the system decides, for whatever reason, that it does not want to provide a particular service or part of it? Will there be a requirement on these autonomous bodies to publish the evidence of their performance, or would such a request be deemed to be burdensome and to be impeding their autonomy?

I was particularly struck by a line in the impact assessment, which states that the reforms will create,

“a statutory basis for the NHS Commissioning Board and consortia, to protect them from interference in commissioning decisions at both a local and national level. To ensure their autonomy, both board and consortia remain solely responsible for their commissioning decisions, and neither are obligated to gain approval from local councils or health and wellbeing boards”.

In other words, the K factor would not be able to function.

In the past, I have understood the concept of earned autonomy, where the power and ability to take decisions at a more local level come when there is proof that quality has been driven up. However, I fear that these clauses will not do that, and they may just give unfettered autonomy to organisations which may be ill equipped to cope with the range of responsibilities that will suddenly be thrust upon them.

[Baroness Tonge]

My Lords, I intend to be very brief because we have already had a long debate, but I am bursting to say something. We have heard very erudite and learned speeches, not least from my noble friend Lord Marks, who put the situation very clearly. However, I am a simple soul. I told your Lordships at Second Reading that I was a barefoot doctor trying to protect patients and my staff from the ravages of health service reorganisation, and I want to try to tell the Committee briefly how they see the combination of these two clauses.

If Clause 4 were adopted, that could lead to different sorts of health services all over the country. Provision would not be equal throughout the country and people would not like that. On the other hand, if Clause 1 were amended after discussion to make sure that the Secretary of State had a duty to provide certain services, that would rule out Clause 4—there would no longer be autonomy because, as I understand it, the Secretary of State would be able to say, “No, you must provide this tariff of services”.

--- Later in debate ---

To do that, we need not just to incentivise the NHS with funding but make it more attractive by driving through research. It is a well known fact that there is a very strong correlation between organisations that do research and the quality of healthcare that they provide. That is well established, and that is why it is extremely important to ensure, when the Commissioning Board may be inundated with different challenges—a significant amount of effort is going into this under the leadership of Dame Sally Davies—that we maintain and protect research funding in these turbulent times as the NHS refashions itself.

[Baroness Finlay of Llandaff]

In intervening in this interesting debate, I shall be very brief. I simply want the Minister to explain where the levers will be in the commissioning decisions to make sure that the principle of research that is being embedded across all the professions happens, given the multiplicity of providers and, as the noble Lord, Lord Turnberg, clearly outlined, the relative paucity of research in primary care but an increased push for more people to be cared for in the community across all the disciplines involved. A simple example of that is the problem that we now have with antibiotic resistance. There is potential overprescribing, but much of that prescribing is going on in primary care in the management of relatively simple conditions. If those are not researched into, we miss a fantastically important opportunity.

[Lord Kakkar]

My Lords, I support many of the amendments in the group. I do so as a biomedical research and clinical academic, therefore benefiting from many of the opportunities that the current systems for biomedical research in the National Health Service provide.

I start by congratulating Her Majesty's Government on having included for the Secretary of State for the first time in a health Bill responsibilities to promoting research. That is hugely important, because it allows us to secure what has been achieved to date in structures and funding going forward in the National Health Service.

There are, of course, anxieties, which we have heard in this important debate, which need to be addressed. Can the noble Earl provide clarification in three areas, notwithstanding the fact that the Bill already emphasises the responsibilities of the Secretary of State for Health? First, how is it is envisaged that the funding for biomedical research will be protected when that fund moves to the NHS Commissioning Board? Secondly, how will the clinical commissioning groups be responsible for promoting research in future, how will that be supervised by the NHS Commissioning Board, and will any form of instruction or performance measure be included in the supervision that the Commissioning Board provides for clinical commissioning groups?

Finally, how, within the proposed structure of the Commissioning Board, will there be encouragement and support for academic health science centres, as they currently exist, and in the future, potentially, academic health partnerships? They provide the opportunity both to drive forward opportunities for biomedical research to improve healthcare and the health gain for our population, and to drive forward the economic opportunities that attend the biomedical sciences industry in our country. However, they also drive forward opportunities for a broader population health gain through a focus on the tripartite mission of improved clinical care, education, training and research.

EU: Economy

Baroness Finlay of Llandaff Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Earl Howe]

I will, of course, look at that point. However, the NHS logo is considered to be the cornerstone of the NHS brand identity. The letters NHS and the logo type are trademarks managed by the branding team at the Department of Health on behalf of the Secretary of State for Health, who technically holds the trademark. They are extremely well recognised and trusted, and use of them is very carefully controlled indeed.

[Baroness Finlay of Llandaff]

Are the Government satisfied that the general practitioners in the focus of this Question were not subject to double payment—first, paid under the terms of their GMS contract for general medical services to patients on their list, and, secondly, then receiving private payments for giving the service that had already been paid for under the GMS contract?

[Earl Howe]

My Lords, I have already indicated that there must be a clear separation between NHS services provided by a general practitioner and its private services—or indeed services for which it is entitled to charge that fall outside its contract. The rule is that patients should be left in no doubt about which service they receive.

Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Wednesday 2nd November 2011 Lords Chamber

[Baroness Thornton]

I think that the noble Lord misheard me. I said that it was the first time that we had discussed this in the process of this Bill. I beg to move.

[Baroness Finlay of Llandaff]

My Lords, I shall speak especially to Amendments 10A, 10B and 11A, and address my remarks principally to Amendment 10A, whose aim is to avoid fragmentation and inequity through a loss of contiguous, coterminous and comprehensive area-based structures for healthcare resource allocation planning, commissioning and service co-ordination. The amendment would ensure that the sensible changes that were just agreed today over GP contracts for this year are carried forward into GP consortia arrangements. The Secretary of State, Andrew Lansley, himself discussed issues around area-based practice at the congress for the Royal College of General Practitioners last month, and had a fairly extensive and open discussion with the GPs there on this topic.

I move to the Bill as it stands. I hope that with some of the background discussions that have been happening, my amendment will not just be dismissed and will be quite seriously considered, because it might solve a problem.

In the Bill, the new commissioning consortia’s duty—

[Lord Mawhinney]

I am sorry, I may be the only person in the Committee who is thick enough not to understand what is going on, but I have to say that I do not. I asked the noble Baroness, Lady Thornton, to define something that she said she was in favour of, which was area-based entities, but she palmed that off on to the noble Baroness, Lady Finlay. I would be grateful if she would define what an area is. Is it a county, a city, a town or a village? Is it the north-east or the south-west? Who in the context of this Bill does she see as having responsibility for defining the area and addressing the issue in the area?

[Baroness Finlay of Llandaff]

I would be grateful if the noble Lord would bear with me for a couple of minutes while I go through a few paragraphs and try to explain how this clause poses some problems, because I agree that it is pretty complicated.

The new commissioning consortias’ duty in the Bill is to arrange for health services provision that applies to those enrolled patients registered with them. This contrasts with primary care trusts, and the other structures that will be disbanded when the new structures come in, because the population of the consortia will be drawn from the patient lists of member general practices rather than from residents living within a defined geographical area. That means that as clinical commissioning groups they will have the freedom to choose who they take on to their registers, regardless of where they live. As a consequence, the population for which a clinical commissioning group is responsible may not include all individuals and families living in the local area, so may not represent an area-based population. However, it may have some people whose primary residence is a long way away but who decide to register with a GP because that is where they work and where they are during the week.

It has been suggested that individuals and families who are not enrolled within a local commissioning group’s general practitioners may not be covered and would therefore need to be covered by a small number of more centralised clinical commissioning groups, which will effectively mop up those individuals and families who lack membership within a local clinical commissioning group. I would therefore be grateful if the Minister could confirm the arrangements for those patients, such as people who are homeless, and who may for whatever reason not be on a particular general practitioner’s list. Can he also explain to the Committee how these patients will be allocated to receive primary medical care services since that allocation duty currently falls to primary care trusts, which will not be there in the future? The services will be designated from the commissioning board, which is at quite some distance from patients who do not have a GP and from individual GPs.

The combination of removing geographical responsibility for the provision of healthcare, together with the removal of practice boundaries, creates a number of risks: an inability to plan for local services; a risk of worsening health inequalities and social segregation; and fragmentation between social care and healthcare—the former being based on local authority boundaries and the latter then being based on a potentially England-wide catchment area, depending on who registered with a GP. Allocating resources based on the GP-registered list rather than any geographical population will mean that there would not be coterminosity with public health—or, importantly, with local authority services, which are responsible for much social care and for the safeguarding of children and vulnerable adults. A lot of those responsibilities for safeguarding held by a local authority relate to the geographical area of a local authority.

With GPs potentially competing for patients across the whole country there could be fragmentation, especially if someone registers near their place of work as when they are ill they are likely either to be at home or to return home, which may be many miles away. They may need services at home, particularly medical and nursing care, if the condition is sufficiently serious to require them. Yet the GP with whom they are registered for primary medical services would then be at a distance that would make home visiting impossible.

In April of this year the Health Select Committee emphasised the importance of aligning care to geographical boundaries, making this point:

“Aligning geographic boundaries between local NHS commissioning bodies and social care authorities has often been found to promote efficient working between the two agencies. There will in the first instance be more local NHS commissioning bodies than social care authorities; the Committee therefore encourages NHS commissioning bodies to form groups which reflect local social care boundaries for the purpose of promoting close working across the institutional boundary. History suggests that some such groups will find the opportunities created by co-terminosity encourage more extensive integration of their activities”.

To paraphrase that, I hope that my amendment is in line with the recommendation of the Health Select Committee.

The local authority will take over many functions of current PCTs, especially over safeguarding, as I said. This is important, particularly for children who are unable to transfer their own care. Different children from the same family who are at particular risk and on an at-risk register will potentially be registered in different places by abusive parents who deliberately want to ensure that they limit, or almost exclude themselves from, surveillance. I am sure I do not need to remind the House that the tragedy of Baby P was an example of a parent who avoided surveillance and, tragically, avoided it far too effectively.

The other difficulty is that there are families who have very complex lifestyles, with different members registered at different distances, particularly if they are mobile families. This will make it very hard to obtain an overall picture of the health, education and safeguarding services if these are not coterminous. Where local authority, education authority and health provision are coterminous, there is a much better chance of a good transfer of important data on the welfare of these children who are at risk.

Public health is a major and very welcome focus of the Government. This amendment is also necessary to ensure that the NHS will adequately address those issues of health improvement such as smoking cessation, screening for disease, immunisation and so on, where treating people as a population rather than a collection of separate individuals is more effective. Public health can achieve optimal population health outcomes only if there are area-based organisational structures and frameworks in the health system. That becomes particularly important in more rural areas, as it ensures optimising efficiency, accountability and effectively integrated care.

The amendment also supports the Secretary of State’s responsibility for issues of health protection, such as the control of an epidemic of infectious disease. Such an epidemic cannot be dealt with just by treating individuals. It requires an area-based approach, using vaccinations, population monitoring and so on to ensure disease containment. Additionally, without coterminous working of health and local authority, planning of capacity becomes harder.

General practice can certainly do much to improve its quality of service in some areas, particularly access to primary care through extended hours, out-of-hours coverage of the population and decreasing the dangers that are encountered with the lone-worker GP who does not have contact with other colleagues. General practice could go towards federated models of practice; that is not incompatible with the spirit of this amendment. However, all these improvements need geographical areas to function properly and drive up quality of care.

Epidemiological research has been a strength of the UK, building on registers of a precisely defined denominator of patients, categorised by age, sex and so on, and known to be living in a particular environment. Weakening it by multiple registration will break the link of geography with health and may impede the aim of driving up quality. It will certainly impede our ability to carry out effective quality-based research on improving health in the future.

Another area that I want to address briefly is that of the medical examiners in relation to coronial jurisdictions. Their work depends on them being geographically area-based and seeing the death certificates of all the general practitioners within that area as they come through. There is a concern that if there is wide fragmentation it may be more difficult to pick up trends that should not be there.

Amendments 10B and 11A seek to delete “or” and insert “and” to make subsection (1) of proposed new Section 1A of the 2006 Act refer to the prevention, diagnosis and treatment of illness, and then go on to public health. I suggest that these amendments are logical as they would ensure that the Secretary of State has a duty to improve all three of those aspects in relation to illness. The measure also emphasises the importance of public health in conjunction with the prevention, diagnosis and treatment of illness. I stress that “illness” includes both mental and physical illness.

[Lord Walton of Detchant]

My Lords, my noble friend has, as always, been extraordinarily persuasive in her detailed argument in support of her Amendment 10A. I apologise to her and to the Committee for not having discussed it in detail with her beforehand. The intention underlying the amendment is in every way admirable. Amendment 10B, to which she spoke more briefly, deserves a great deal of attention and would greatly improve Clause 2 of the Bill. My only concern with her remarks about area-based populations relates to the definition that would be attached to the clause. New Section 1A(1), as inserted by Clause 2, is defective in my opinion in that it refers to,

“securing continuous improvement in the quality of services provided to individuals”.

The provision of services in the National Health Service does not relate simply to the treatment and improvement of the health of individuals. As the term “public health” implies, it deals also with the improvement of the health of communities. After all, public health doctors were called community physicians until quite recently. In many ways I would have preferred to see the clause include, after the word “individuals”, “and/or communities” to make that position entirely clear. I warmly support the principles underlying my noble friend’s amendment but the wording requires a little attention as throughout my professional career I have been very familiar with the hazards that arise in attempting to draft and redraft documents in committees, large and small. I do believe that this matter needs to be given attention by the Minister.

--- Later in debate ---

[Baroness Tonge]

My Lords, most of the points I wanted to raise have already been raised so I will not repeat them. I congratulate the noble Baroness, Lady Finlay, on her comprehensive overview of her amendments. What concerns me most is those patients who fall through the net of the new general practice commissioning groups. If it is not area-based and there is not a primary care trust responsible for allocating those patients, where will people who do not speak English very well, asylum-seekers, the homeless, mentioned by the noble Baroness, and Travellers go? What about those patients whom I remember well, whom most GP practices did not want on their lists at all and who were rotated around general practices in order that they got medical treatment? What will happen to all those patients? There are many of them and some of them have severe disabilities and some are severely mentally ill. They fall into all sorts of groups. I am extremely concerned that without an area base or a responsibility on a PCT or a commissioning group to deal with patients in a particular geographical area, those patients will suffer hugely.

I want to make one final point. The other service that will suffer hugely is our accident and emergency departments, because if those people do not have GPs, that is where they will go. I was a casualty officer in central London for a whole year, once upon a time, and I virtually ran a general practice there then for patients who were unattached to general practices. That problem will increase, and I hope that the Minister will address that in his comments.

[Baroness Finlay of Llandaff]

My Lords, it may help the Committee if I explain how the GP contract is being renegotiated; I hope that I get this right. Instead of a GP contract covering a rigidly defined area, as now, there will be an outer ring as well. If patients move a bit further away but stay within that outer ring area, instead of being forced to change their GP, they will be able to remain with their current GP. Therefore, I think that the problem of choice, to which the noble Baroness, Lady Cumberlege, alluded, should in large part be solved by the negotiations that the Government have just had with GPs. There is of course a difficulty in defining any area but to date the areas have been defined by GPs, and they will still have to define the outer area or outer ring to which it is practical for them travel to carry out home visits and so on.

As I understand it, a decision has not yet been taken on what will happen with people who, like most of your Lordships, are classified as temporary residents. Many of us live a long way from here and, if we need to see a GP, we register as a temporary resident with one somewhere in Westminster. I am not sure how those arrangements will work in the future but they have served us reasonably well until now. The danger in relation to allocation relates precisely to those patients to whom the noble Baroness, Lady Tonge, referred—those who have been thrown off GP lists or cannot get themselves signed on to a GP list for whatever reason but still have healthcare needs. If those needs are not met, that will impact on the very social fabric of our society. I hope that I have clarified some of the points.

[Baroness Hussein-Ece]

I should like to ask a couple of questions to clarify where the debate is going. As my noble friend Lady Tonge said, for a number of years some groups have found it almost impossible to get a GP. It is almost a case of GPs selecting the people they want on their lists; it is an unwritten code. That is why asylum-seeking families, refugee families and others with very high needs will always find it difficult to get a GP, and I want to ask the noble Baroness, Lady Finlay, how her amendment will assist that.

Equally, as has already been mentioned, areas of high need have in my experience always been in inner cities, where it has been difficult for some people to register with a GP. We know that attendance at A&E departments has become extremely high in some areas—almost unsustainably so—and I want to ask how the amendment will address that too.

There are also families who are placed by local authorities in temporary accommodation in other areas. Currently, a local authority is responsible for such a family—for example, social services or family support may be involved with the children. However, if that family is placed in another borough way out of the catchment area, I am not sure who their GP will be. Perhaps the Minister can respond to that as well and say how that would work with a local authority having responsibility for a family placed well outside the area. Would that family still be able to get support by going on to a GP list in the new area? Would that connection be made? Over the years we have worked very hard to make sure that social care, healthcare and local authorities all work together in partnership. Perhaps we could have an explanation of how it is going to work when families with very high needs are spread around.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, I thank the Minister most sincerely. Apart from anything else, he has explained the BMA agreement far better than I did in my attempted few sentences. I hope that that has provided some reassurance to the House.

I am grateful to him for explaining the problem with the wording in Amendments 10B and 11A, and I accept that he has assured us of the totality of the Secretary of State’s duties overall in relation to the two proposed subsections. I thank him for explaining, in relation to the other amendment in this group, that the mandate set by the Secretary of State is one to which the Commissioning Board must have regard. That was precisely why I was concerned about also having “areas” because the Commissioning Board will be contracting with GPs themselves for their clinical services, which is separate from the role of the clinical commissioning group. So I have a little nagging doubt and that is why I put this right at the front of the Bill. I am sure we are going to return to the word “area” as we work our way through the Bill.

For the moment, however, I am grateful for the noble Earl’s explanations. I also thank all noble Lords who have contributed to the debate, particularly the noble Lord, Lord Warner, for what I think was a flash of brightness in the fog when he asked for a diagram that will set this out geographically for us. That will be most helpful.

NHS Commissioning Board Authority (Establishment and Constitution) Order 2011

Baroness Finlay of Llandaff Excerpts

Tuesday 1st November 2011 Lords Chamber

[Lord Willis of Knaresborough]

Perhaps I might say first to my noble friend that I support and appreciate the idea of bringing forward a special health authority to shadow the new Commissioning Board. That is right and proper but, like other noble Lords, I think the idea of doing that is a little confusing before we have had a chance to examine this proposal in Committee, and to test it against the large number of amendments which are coming in to tease out what role the Commissioning Board will ultimately perform and what its form and functions will be.

I do not want to add to the questions asked by my noble friend Lady Barker, the noble Baroness, Lady Thornton, and the noble Lord, Lord Warner, all of which I am sure the Minister will get to in his response, but I particularly want to raise one issue with my noble friend. It is the question of research; he will not be surprised that I have raised that. In another place, the Government conceded that research ought to be put into the Bill and that it will be a duty not only of the Secretary of State but of the Commissioning Board and commissioning groups to promote research. At the moment, research within the NHS is of course promoted by the Chief Medical Officer of health, who has responsibilities for the National Institute for Medical Research. To be fair, I think that Sally Davies carries that job out very well indeed. She has done a remarkable job since the Cooksey report and the setting-up of OSCHR with the identifying of resources within the NHS for research. We are starting to see the fruits of that work; indeed, during the passage of the health Bill I hope to be able to speed up the process of getting a special health authority for research and, ultimately, a new research authority.

However, will this shadow authority have a duty to commission research? In which case, will that budget be within the £80 billion to £100 billion identified by noble Lords? Will it in fact take over the duties currently held by the Chief Medical Officer, Sally Davies, or will she continue to retain them and report to the Commissioning Board? In short, where will NHS research reside and who will have authority for it in making the decisions within the new arrangements?

[Baroness Finlay of Llandaff]

My Lords, I too would like to ask a question in relation to conflict of interest. As the noble Baroness, Lady Barker, has said, it seems that conflict of interest is much more likely to be in the non-financial sphere than the financial sphere. Would members of the board be expected to declare it, perhaps particularly in relation to their own health and that of members of the family who may be affected by commissioning decisions? Also, who will the Commissioning Board be required to take advice from in its commissioning decisions and who will it be required to work with? Will education and training, just as with research, actually become a core duty of the Commissioning Board at the outset or will it come along later? I note that it is said that this is a transition process and that the Commissioning Board will ultimately have responsibility for primary medical services. However, I would be grateful if the Minister could explain at what point that transition will occur, whether it will be phased across the country gradually or happen all in one go, and what plans are being made for the potential risks that can occur with such a major transition of funding from the current system, with the whole of primary medical services being taken over by the Commissioning Board.

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

My Lords, I welcome this, the second in a series of debates tabled by the noble Baroness, Lady Thornton, scrutinising various pieces of secondary legislation which together are intended to provide continuity and security to NHS staff, as well as maintaining the continuity and quality of NHS services, and delivering the £20 billion efficiency challenge.

This second debate provides an opportunity for me to set out the need for a proposed new preparatory body to ensure the most effective transition to a new system for commissioning NHS services. As noble Lords will know from our debates on the Health and Social Care Bill, a key part of the Government’s agenda is to turn the NHS into a more patient-centred organisation, with a clearer focus on improving patient outcomes, and designed around the needs of the local population.

The Government intend to create a more autonomous and accountable NHS, with greater clarity about the roles and responsibilities of different organisations for provision of commissioning. A stronger, more effective commissioning system is necessary to support the improvement in health outcomes that we all want to see. An autonomous but accountable NHS Commissioning Board is a key component in the realisation of this objective.

The NHS Commissioning Board will be rigorously held to account by Ministers and Parliament as a whole for delivering improved patient outcomes instead of top-down process targets. While it will be free from interference on a daily basis from Ministers, it will have clear duties set out in primary legislation, and will be held to account for objectives set by the Government through an annually refreshed mandate, giving it a clear long-term direction.

The board will allocate resources to clinical commissioning groups and support them to commission services on behalf of their populations, according to evidence-based quality standards. It will directly commission services in six areas: specialised services, primary care, specialised dental services, military health, prison health and some aspects of public health. It will develop a high-quality market for commissioning support, while minimising redundancy costs, living with reduced running costs and retaining the best of NHS talent. This means that the board will be at the centre of delivering improved, patient-centred services while cutting waste and bureaucracy.

It is essential that we get this right. With this in mind, the NHS Future Forum has recommended that,

“the NHS Commissioning Board should be established as soon as possible to ensure focused leadership for improving quality and safety as well as meeting the financial challenge during the transition”.

This shows that there is a recognised need to begin work now to ensure that the transition arrangements to the new system allow the NHS Commissioning Board to undertake its full responsibilities from the day it is established.

The NHS Commissioning Board Authority, as established in the statutory instruments that we are debating tonight—as well as the functions which were not laid before this House, but noble Lords may have seen earlier this week—is a preparatory vehicle, which will allow the organisation to recruit a leadership team; establish robust governance processes; develop an open and supportive ethos and culture; and begin to develop some of the key relationships with other organisations in the system. It will take on only limited functions, delegated by the Secretary of State for Health, with regard to the health system during the course of 2012.

The authority will ensure that the NHS Commissioning Board is able to function as intended as soon as it is established as an executive non-departmental public body, subject to the passage of the Bill. The authority will help the NHS to manage some of the challenges of the transition from the current system to the new one. Through establishing a body at arm’s length from the department, we can ensure robust accountability and governance arrangements.

There will be a letter from the Secretary of State setting a series of objectives that the special health authority will be expected to deliver. In addition, there will be a framework agreement defining the relationship between the Department of Health and the authority. This provides a level of transparency that would not have been present had this preparatory phase been handled wholly in-house. The authority will have an accounting officer who will be accountable to the department, and the Public Accounts Committee, giving Parliament and the Secretary of State for Health clear access to officers responsible for the major decision-making within the board.

Establishing an arm’s-length body also allows us to recruit a strong leadership team, who can provide strategic input and challenge. Wherever possible, we have drafted the establishment legislation for the special health authority to reflect the legislation that noble Lords have been scrutinising in this House. This has been done to build in continuity wherever possible, particularly around the balance of the board. Officials have sought and received the approval of the Appointments Commissioner to roll over the key non-executive director appointments to provide continuity of leadership as the body moves from being a preparatory one to an operational one, subject again to the passage of the Bill. The preparatory arrangements will ensure that the culture of national and local accountability is embedded in the board from an early stage, and does not see the centrally administered, top-down, performance-managed culture merely transferred into the board on the date of establishment, by transferring all staff and working practices on day one.

We have taken our administrative responsibilities extremely seriously during this process. We have been careful to balance appropriately the need for transparent and accountable preparatory arrangements, while ensuring that we still respect Parliament’s role in scrutinising the legislation for which these regulations prepare. Establishing a special health authority at this stage does not pre-empt the Bill’s progress through this House. It is intended as a short-term measure. The Secretary of State for Health can abolish the authority, subject to consultation with staff and parliamentary scrutiny. We are working to ensure that the costs of establishing the body are kept to a minimum, and the body will employ only staff whose roles are considered business-critical to its preparatory functions. The Government are committed to creating an NHS that is able to shape health services that are patient-centred and locally accountable. The NHS Commissioning Board Authority is a key step in this process.

I shall now address the specific questions raised by noble Lords in this debate. I was very grateful to my noble friend Lady Barker for reminding the House of the legislation passed under the previous Administration in relation to the establishment of the CQC. That is not an unreasonable comparator to the present situation. The orders before us do not pre-empt the outcome of the scrutiny of the Health and Social Care Bill. There are good reasons for establishing the authority now. They are, in sum, to ensure strong governance around the organisation’s preparations; to identify and induct a strong, independent board who could lead the NHS Commissioning Board, subject to the passage of the Bill; and to provide an important signal to the NHS about the future.

I say to my noble friend Lord Willis that this legislation is not subject to the successful passage of the Bill. It is a supporting measure, which could be reversed or amended as necessary, subject to consultations with affected staff. The functions of the authority, which are outlined in directions issued by the Government, could be updated as the Bill progresses.

The NHS Commissioning Board Authority was established as a special health authority yesterday. As I say, it will have a preparatory role and will be replaced by an executive non-departmental public body by October 2012, subject to the passage of the Bill. It is expected to be fully operational by 1 April 2013.

The noble Baroness, Lady Thornton, asked me about consultation on the setting up of the special health authority. Section 28 of the NHS Act 2006 is the basis for establishing special health authorities. The Act requires consultation with staff, which was carried out. It does not require consultation with others. As stated in the government response to the Future Forum report, the authority—the preparatory body, in other words—will continue operating until the provisions of the Bill relating to the establishment of the board are brought into force some time between July and October 2012. Only at this point will the full executive non-departmental public body be established with responsibility for establishing and authorising clinical commissioning groups. This would be followed in April 2013 by the executive non-departmental public body taking on its full suite of statutory responsibilities. The special health authority would therefore only have a preparatory role; it is currently envisaged that it will exist for a maximum of one year. The noble Baroness, Lady Thornton, asked a number of questions about the powers of the special health authority: how many would be employed; how many would be recruited and at what cost.

In order to prepare for the establishment of the board, we have established this authority with the purpose of developing the details around the processes and relationships required to carry out the board’s functions, developing the business model, and making such other practical arrangements that are necessary and appropriate for the effective running of the board on its establishment, including developing HR and governance models. I would simply say to the noble Baroness, Lady Finlay, and indeed my noble friend Lord Willis that that encapsulates the functions of the authority. The functions of the board are of course subject to the passage of the Bill and not dealt with in the orders that we are currently considering.

As regards staff, the publication of the NHS Commissioning Board People Transition Policy in July 2011 gave staff in relevant bodies, including PCTs, SHAs and arm’s-length bodies in the Department of Health, a description of how the NHS Commissioning Board would manage the transfer of functions and staff from other organisations. While further detailed work will need to be undertaken during the preparatory phase on the detail of transition, the People Transition Policy was able to set out how transfers will be managed and appointments will be made. The chair, as the noble Baroness mentioned, has been appointed—Professor Malcolm Grant. Other non-executive board members are recruited by the Appointments Commission; however, the department has used the intelligence gathered by the recruitment company to aid this process. The chair will lead the recruitment of other board members.

Recruitment to the NHS Commissioning Board is being managed in two phases. This phased appointment process will allow the senior leadership team to help take the NHS Commissioning Board forward, together with their support teams and some key transition and priority roles, while more of the work on the detailed structure is carried out. The immediate priorities for appointments as part of the first phase for recruitment are: first, the senior team and their support staff; secondly, the transition functions; thirdly, functions that have early deadlines; and, fourthly, transfers from organisations that may not be sustainable until October 2012.

The noble Lord, Lord Warner, asked about induction training of non-executives and the chair. An induction process has been developed for the chair by the authority transition team. It will also be adapted for the non-executive directors. The noble Lord also asked a series of questions about the budget of the board during its first year; what it will be responsible for in terms of that budget and about the number of non-executive directors.

The preparatory NHS Commissioning Board Authority has access to a transition budget of up to £6 million during the financial year 2011-12 to establish itself and to undertake consultation and analysis to design its future functions. This excludes staff costs and capital expenditure on estates and infrastructure—

Accidents: Costs

Baroness Finlay of Llandaff Excerpts

Monday 31st October 2011 Lords Chamber

[Earl Howe]

There is no question but that accidents in the home and in leisure contexts are a serious issue. It so happens that the UK has a very good record compared with some other European countries, but we can never be complacent on this. Some very tragic accidents occur, particularly to children, that we must bear down upon. Again I pay tribute to the work of RoSPA to prevent accidents with looped blind cords, which can often be a hazard to children. NICE has published accident guidelines relevant to home and leisure situations and also guides focusing on home safety and road design. It is that realm of public health that we hope NICE will focus on more and more as the years go by.

[Baroness Finlay of Llandaff]

My Lords, I declare an interest as the chair of the All-Party Parliamentary Group on Gas Safety inquiry into carbon monoxide poisoning, whose report is being published today. Do the Government recognise that carbon monoxide poisoning currently costs the country about £178 million in total; that the protection of putting up a carbon monoxide alarm in each home in Britain for a year would cost less per home than a cup of coffee at a motorway service station; and that lives would be saved if carbon monoxide alarms were readily available? If the Government considered removing VAT from them, it would give a very strong message that everybody must protect themselves.

[Earl Howe]

My Lords, the noble Baroness has highlighted a very serious and important problem. She will know that in the European Union context the Commission has focused very strongly on products that may prove unsafe if sold wrongly or if manufactured or fitted wrongly. The kinds of safety incidents that she refers to could well fall into that category and work is ongoing in that area. However, I take on board the figures that she has so graphically supplied and will feed them back to my department.

Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Tuesday 25th October 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, it has been said that if you do not know where you have come from, you do not know where you are going. It is important for us to remember what we are talking about: a nationalised healthcare provision that arose originally because there were people who could access no healthcare. We have a situation in this country that is the envy of the world: if you are seriously ill, by and large you will get treated well and, most of the time, to standards of international excellence irrespective of who you are, your financial means, your social standing or anything. That does not apply in other parts of the world.

Those of us who have spent any time in the US will have seen what happens to some people who are not covered. I will never forget a young black man I saw with a terrible cardiac condition. All the money had run out and he was dying in a hospital because there was no further treatment. I was a medical student then and it made me resolve never to practise privately, which I never have, and to do all I could to further the principles of the NHS.

I suggest that there is much merit in considering a preamble, as the noble Lord, Lord Mawhinney, has just outlined. This brief debate has shown that the wording of this preamble is not right—I am sure that the noble Baroness, Lady Thornton, will not be moving it today—but that there would be merit in taking it away and coming back to it at a later stage. Perhaps I am wrong and she intends to move it; I did not have that discussion with her beforehand. However, I suggest that there is much here to commend.

We have a country that is very worried about its NHS, which is much beloved because it is the universal insurance policy that everyone needs if things go terribly wrong and they lose their health. The NHS Constitution was universally welcomed because it set out simple principles. There is much merit in enshrining that at the front of the Bill partly because, as it is written now, it concurs with the NHS and the direction of travel, accepting lots of change, that we want to see. There is anxiety that this could be amended in future.

We have had scandals about bad patient care. We have heard about bad staff attitudes, things not being done properly and personal interest overriding the interests of the patient population. There is much to be said for looking at putting in the Bill the vocational role of patient care and the duty to the health of the nation for those who are well to prevent ill health where we can, maximise the potential of those who are ill and restore them as much as possible to quality living. In the delivery of that, everyone, wherever they are coming from, whether they are a state sector employee or a private commercial venture, should adhere to the Nolan principles. That very essence of how we care for each other in our society sets the moral tone for the whole of our society. The Nolan principles are, if you like, the minimum that we should require across the board.

There is the question of transparency and openness. Questions have already been raised during this debate about potential conflicts of interest for those commissioning who may also be providing. There is a need for transparency about financial transactions and other personal career interests that might be there—about family members working in different parts of the service, about where people’s thinking might be biased and distorted, and about where there may be a wish to cover up one thing or another for different motives but where transparency would serve the greater good better. Linked to that, of course, is openness.

There is much merit in stating up-front on the Bill where we want to go. Where the NHS has come from, starting before its foundation and then as it evolved, has served us better than the alternatives. We want to drive up care and we want to change. Much can be changed and made more efficient. Nobody is advocating fossilising the services we have, but the principles about what we are trying to do need to be in the Bill.

[Lord Mackay of Clashfern]

My Lords, in 1946, the then Government promoted the National Health Service. They did so in the National Health Service Act 1946. Section 1 of that Act states:

“It shall be the duty of the Minister of Health (hereafter in this Act referred to as ‘the Minister’) to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act”.

Section 1(2) states:

“The services so provided shall be free of charge, except where any provision of this Act expressly provides for the making and recovery of charges”.

These are plain, clear, concise words which completely incorporate the fundamental principles of the National Health Service, as they have done since 1946. What is more, these provisions are enforceable at law, as the decision quoted by the Constitution Committee shows. They are enforceable in law, clearly, easily, without difficulty.

The previous Labour Administration had many skilled Ministers in the Department of Health to my certain knowledge and I pay my warmest tribute to them. One of them was the noble Lord, Lord Darzi, and during his watch in this House the National Health Service constitution was promoted. As some of my noble friends have said, that was agreed by all parties. The noble Lord, on behalf of the Government, declined to put that in a statute. I questioned that, because if we are dealing with the constitution of the service, one would think that it should go into the statute that is the fundamental part of setting up the service.

The Act of Parliament incorporated a duty such as referred to in the first part of this amendment, to have regard to the constitution. Everyone in the health service had to have regard to the constitution. The Government declined to put that into legislation. When I asked the noble Lord, Lord Darzi, why that was, he explained that he did not wish the constitution of the NHS to become a plaything for lawyers.

Noble Lords will understand that that reason was not particularly attractive to me. On the other hand, the sense of what he was saying certainly was, and I accept that it was wise and is still wise. The obligation to have regard to the constitution is fundamental and remains. However, I do not believe that it is possible for us to provide a simpler, clearer and more effective preamble to the National Health Service Act at any time than that which was thought of by the founding fathers of the National Health Service in 1946.

I should point out that this is not strictly a preamble at all; it is a first clause in the Bill. However appropriate some of these sentiments may have been for a resolution at a party conference, they are not suitable for an Act of Parliament, in my respectful submission, because the provisions in an Act of Parliament should be enforceable. When we have such a clear constitution of the NHS and such a fine example in what was provided by the founding fathers, which is enforceable, I respectfully suggest that it is unwise to muddy the waters now. I embrace all the sentiments expressed in this draft amendment and hope that we will have them in mind as we go through our later deliberations. All the sentiments are very acceptable, with the exception of the one about the market, which I find a little difficult. However, I will not elaborate on that now.

I am extremely grateful to the noble Baroness, Lady Thornton, and the noble Lords, Lord Hennessy and Lord Owen, for discussing this matter with me yesterday. I greatly profited from that discussion. It took me back to the beginning of 1946 when I was a second-year student at university. I remember that one of the difficulties envisaged in the founding of the health service was the fact that family doctors—GPs—did not wish to be employed by the Government. Therefore, the constitution provided that the Secretary of State had to provide the service—he did that from time to time at the beginning in hospitals and so on—or secure the provision of the service. “Secure the provision” was, of course, the one operative for GPs. That has served us well. As far as I am concerned, the proposed constitution, however one appreciates the principles that it expresses, is neither as clear or precise nor as readily enforceable as what we have. I respectfully suggest to the noble Baroness that she might wish to consider that aspect.

--- Later in debate ---

[Lord Patel]

My Lords, my name is added to this amendment along with that of the noble Lord, Lord Walton of Detchant. He has alluded to the need to include this amendment in the Bill. I consider that not only do we need it but that it is not strong enough. We may have to consider making it stronger. I say this because it is important to indicate on the face of the Bill that the Secretary of State has the responsibility to promote and secure a high-level of education in the whole of the workforce that delivers healthcare. I use the example of medical education and training but that applies equally to the training of nurses and other health professionals who are also regulated.

The current system of medical education and training—a model that is copied by many other countries and is widely respected—has evolved over many years. It is not something that was planned overnight and then executed. It has delivered well trained doctors who have improved healthcare. The system is complex and its essential relationships with different organisations and responsibilities are well documented. Only about 18 months ago, legislation was introduced which further changed the regulatory mechanisms for the training of doctors and nurses by making the General Medical Council the sole regulator of doctors’ training from entry to medical school to the day they retire, including postgraduate training, continuing professional development and revalidation. If we tinker with this, we run the risk of fragmenting it and making it inconsistent.

As my noble friend has already mentioned, under the GMC we have postgraduate deans, the royal colleges, the deaneries, undergraduate deaneries and the local hospitals where doctors are trained. These work together in a complex relationship to deliver high-quality medical education and training. The Department of Health has issued a consultation document, Liberating the NHS: Developing the Healthcare Workforce. Some of its proposals have caused a great deal of concern. If those proposals are implemented we run the risk of damaging what has been built up over many years. Adopting a localised approach to education, training and workforce planning to meet the short-term needs of employers will destroy the national training for a national workforce that has been developed over a long time.

There are many other concerns; for instance, the lack of clarity over the role of Health Education England. How will it hold education providers and commissioners to account? There are serious concerns about the continuing role of postgraduate deans, a very important group of people in the delivery and quality assurance of medical education and training. Uncertainties about the role of postgraduate deans are already leading to concerns about managing the recruitment of doctors into training in 2012. There is a lack of information about what part local skills networks will play and about the risk of serious damage occurring to workforce planning, and a lack of clarity about their governance and accountability. The training of doctors also includes training in research methodologies, as the noble Lord, Lord Walton, mentioned. Development of academic doctors is crucial. We already have a problem with recruitment to academic medicine. Therefore, training in research methodologies, postgraduate research and higher degrees in research is crucial. None of these is included in the Bill. They are not included because, we are told, there will be a second Bill. It might even be called the social care and health Bill as opposed to the Health and Social Care Bill. However, we are waiting for the responses from Future Forum, which is considering this. Then we will have the Government’s response, despite the fact that they have indicated that all the proposals in Liberating the NHS: Developing the Healthcare Workforce will need to be implemented by April 2012—the time is rather short. Perhaps the Minister will indicate when we are likely to see this Bill related to education and training. If there is not a satisfactory answer, we may have to consider putting a framework for medical education and training in this Bill.

[Baroness Finlay of Llandaff]

My Lords, I have two amendments in this group, but noble Lords who have looked at them will have noticed that they are almost identical. One of them has inverted commas in it. At this point, I ask the Committee to discount Amendment 8B because the inverted commas do not mean a great deal. However, I would like to take a moment out to pay tribute to those in the Public Bill Office, where this drafting error occurred, and I know exactly why. They have had unending patience, have been infinitely polite to everybody who has gone up there and have provided impartial advice when under enormous pressure. So if this is the only mistake they have made with my amendments, they have done amazingly well.

I would now like to quote from the report from Future Forum by Steve Field. In it he pointed out:

“The professional development of all staff providing NHS funded services is critical to the delivery of safe, high-quality care but is not being taken seriously enough”.

I am glad to see that the Government have also decided to put down an amendment providing that we should state on the face of this Bill the importance of education and training.

Amendment 8A is almost exactly the same as Amendment 6 except that it adds the words, “a nationally co-ordinated system”. The reason is that currently, the standards are set by deaneries, the royal colleges, the universities and the regulators. At the other end from the high-profile degrees and specialist competencies from the royal colleges, there are qualifications such as the NVQs, which have been used for training healthcare assistants. There has recently been much debate about the standard of healthcare assistants, but I think there is a foundation there that could be built on to raise standards across the board. However, it needs to be nationally co-ordinated rather than have lots of odd little bits of training in one particular area, because otherwise when staff transfer, the organisation of management of another area believes that they are adequately trained, when actually there is no national benchmark for that competency. That is why I put in the words “nationally co-ordinated”.

I turn to the amendment put down by the Government. I hope that the Minister will explain how those deaneries and those national co-ordinating bodies that set standards will link in. Will the national Commissioning Board and the clinical commissioning groups have to consider education and training in everything that they do? If they do, the deaneries will have a national planning function in conjunction with the royal colleges and specialist societies which set specific competency standards. I also wonder whether this government amendment, which talks about the health service in England, takes consideration of the NHS in Wales and Northern Ireland. If it does, how would that happen and, if it does not, what arrangements have been made with the devolved Administrations?

I should also ask whether the Secretary of State has a comprehensive duty. Will the national Commissioning Board and clinical commissioning groups have a duty to include education and training when deciding contracts and making commissioning decisions? If they do not do build in education and training right across the piece, will an appeal go to the Secretary of State?

In proposed new subsection (1) of the Government’s amendment, there is mention of,

“provision of services as part of the health service”.

Given the nature of the health service as we see it developing, am I right to understand that that would include all private providers, all voluntary sector providers and all public health and health protection arrangements? Am I right that any provider which does not then provide education and training would need to prove why they were exempt from providing it, if they have a contract for a specific service?

We heard earlier about the independent treatment centres and the sense that they had milked off some healthcare services but had not undertaken training and education. We hear now about specialist trainees in some of the disciplines. Orthopaedics is a clear example whereby a lot of shoulder and knee surgery is not being done in their training environment, so the trainees are not adequately exposed to the range of operations. Indeed, an orthopaedic surgeon contacted me about how she was crowded out in theatre by trainees desperate to watch her carry out a shoulder operation simply because they had not seen that operation done—whereas previously they had broader experience.

If the clinical care of patients is contracted out to private sector or voluntary sector providers, the clinical experience associated with providing that care, if it is high quality, will provide a fantastic education and training opportunity. If we are truly developing a healthcare workforce that will be comprehensive for the needs of the nation, it does not matter who owns the building or the service where that patient is being treated. If that is really high quality, there is much to be learnt. In all the years when I have asked patients if they minded students, postgraduates or whoever being present, there have been only two occasions when patients have said that they would prefer them not to be there—and they were for very understandable reasons. Everyone understands the need to educate and train, and the majority of patients understand that if the person looking after them is also teaching they are being held to account by the group that they are teaching.

Those are some of my questions to the Minister when he comes to speak to his amendment. I ask the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath, whether they see the use of the word “comprehensive” as a duty on the national Commissioning Board and clinical commissioning groups, and whether, when they talk about delivering NHS services, they are intending that private providers and public health are included.

My final point is: whichever of these amendments is agreed—and I have a sneaking suspicion that mine will not be top of the polls; but that is the way it tumbles—the different providers, whoever they are, need to contribute to the cost of education and training. I suggest that when determining a tariff, those who do not contribute to education and training on a particular part that they are providing should not receive the full tariff because they will be ducking out of part of the ongoing responsibility to secure the nation’s health.

--- Later in debate ---

[Lord Ribeiro]

My Lords, I thank the noble Lords, Lord Walton of Detchant and Lord Patel, for introducing this amendment. It highlights not only the importance of education and training in advance of the report that we will receive later in the autumn from the Future Forum group, but the fact that the Government have responded with an amendment of their own. That identifies the importance of bringing it on to the face of the Bill, so much so that it is right at the very beginning of Part 1. It is one of six duties that the Secretary of State now has to perform. That is very important.

It is quite understandable in a Chamber such as this one, full of doctors, that we tend to overemphasise the importance of medical education. As the noble Lord, Lord Turnberg, rightly said, nursing will be discussed later. However, it is not just about nursing. My wife is a physiotherapist—there are physiotherapists, radiographers and other healthcare workers as well. That is why the Government’s amendment talks about education and training without qualifying exactly which areas we are discussing. It is important that we bear that in mind.

The noble Baroness, Lady Finlay, I think, referred earlier to the independent sector treatment centres and the lack of training in that area. I must declare an interest as a past president of the Royal College of Surgeons. I had countless negotiations with the Department of Health to put into place a requirement for independent sector treatment centres to be able to train. The big issue was that all the surgeons and the ISTCs were overseas doctors. No UK doctors were allowed to train. We asked for a way in which we could introduce NHS consultants into what was effectively spare elective capacity. I fundamentally believe that we must separate emergency and elective surgery to produce the best-quality care for patients.

As a consultant, I would regularly do an out-patients’ clinic at Basildon hospital on Mondays. If I was also on call, as I sometimes was, I could be told that there was a patient in the emergency department who needed urgent treatment. That would ruin my out-patients’ clinic because I would have to go to theatre and sort out that patient. Our last assessment showed that 64 per cent of the general surgeons in Great Britain and Ireland have a responsibility to be on call while they are doing elective work. If you have that degree of commitment to doing two things, you cannot provide the best possible care for your patients. If NHS consultants could structure their work so that it was possible to work in a centre which was perhaps in the hospital—there are a few hospitals, including one in Nottingham, with elective centres within the hospital—or perhaps outside, they would be able to take their registrar and SHO to the independent sector and they would be able learn how to carry out the surgery.

[Baroness Finlay of Llandaff]

Perhaps I may ask for clarification from the noble Lord. I am not sure whether he is advocating that the duty in the government amendment should or should not be on every provider, whichever sector it is in. I tried to make it clear that I felt that the duty to provide education should be on everyone who provides patient services. I was hoping that the Minister would clarify that that was what was in the Government’s mind, so that history—what had happened before—could not be replicated.

[Lord Ribeiro]

I accept that point, although it might be difficult to implement when you consider the third sector and the voluntary sector, which may not be in a position to undertake education and training. That is a point to bear in mind.

[Baroness Finlay of Llandaff]

Forgive me but, as someone who works hugely in the voluntary sector and is a patron of many of the healthcare providers, perhaps I may point out that they carry out a great deal of education. An example is Marie Curie running NVQ courses for care assistants across the whole country. They are trying to drive up the standard of care given by people who are absolutely not at the medical end but whose care is critical to the quality of service that patients receive.

[Lord Ribeiro]

The noble Baroness makes her case but there is a wide spectrum of medical provision, and the question is whether this could be applied to every single provider. I am not clear about that but perhaps the Minister will be able to address it.

Returning to the question of training, I believe that through the Bill there is an opportunity, perhaps when the contracts for some of the independent sector treatment centres are up for renewal, to give some serious thought to whether these centres could provide the extra capacity that the NHS desperately needs if it is to go forward with the functional separation of emergency and elective care. I am of course talking about surgery and I recognise that that is a special case. None the less, we come from a history of one type of surgical provision to the situation in this Bill. If we are talking about quality as the indicator of the outcomes that we are looking for, it may well be possible to achieve this by utilising the ISTCs for NHS consultants. I shall give way if the noble Lord wishes to speak.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, perhaps I may briefly intervene to try better to clarify my concerns. I am not asking that small providers should have to account for all the education they provide. Let me give a specific example. If you have a hospice home care team, it is very appropriate that they should take nurses under training on placement. They can go out with the specialist nurses and learn about provision in the community. It will not cost the hospice anything, but the hospice management might feel that having students around is difficult because of regulatory functions and so on. All I am saying is this: if the management says that it will not take on students to learn about its excellent clinical service, it must justify why it is closing that educational door.

Similarly, if a group of physiotherapy providers dealing with back pain has an NHS contract, it would seem appropriate that it should take on physiotherapy students in order that they can observe and learn ways of managing back pain, which is what the group is primarily dealing with. Those students will get very good training. If the group says, “We do not want to take students”, then I suggest that it would be appropriate to point out in the contractual process that it needs to justify why it is refusing to provide education. Also, perhaps that group should not receive the full tariff because other providers will want to share their expertise for the greater good.

[Lord Alderdice]

My Lords, as I say, I understand the sentiments that the noble Baroness is trying to convey, but one has to be careful about generalising from one’s own experience, which might not necessarily fit everywhere. For example, a noble Lord said earlier that in a lifetime of clinical work, only a couple of patients had ever said that they did not want a trainee sitting in. I am afraid that psychiatry and the psychological services are a wholly different ball game. Whenever we were setting up for trainees, we had to warn them in advance that one in every three patients would not allow them to sit in on an assessment because of its personal nature. When you are living in a smallish community, as mine is, where people know people who know people, these things are much more of an issue.

It you make demands of some of the NGOs and smaller community services—demands that may be completely appropriate in a larger setting such as hospice care—that is quite a different thing. I accept absolutely what the noble Baroness is saying, but please let us not make a rule for everybody which may detract from some provision that is entirely appropriate.

--- Later in debate ---

[The Earl of Listowel]

I thank the noble Lord. I can see the difference and I thank him for that helpful correction.

[Baroness Finlay of Llandaff]

Before the Minister resumes his speech—I am sorry to do this, but I would like clarification. From what he has said, I understood that under this amendment the Secretary of State will not have a comprehensive duty, so that if Health Education England finds that the National Commissioning Board and the clinical commissioning groups are not making provision for education within the commissioning process that they set in place, the appeal would not go to the Secretary of State. I am not sure who the educational providers would appeal to if Health Education England found that it could not function because the commissioning process was not allowing for education.

[Earl Howe]

Perhaps I may just clarify some of this. The wording of the government amendment could not be clearer:

“The Secretary of State must exercise the functions … so as to secure that there is an effective system for the planning and delivery of education and training”.

That means that he is ultimately accountable. Of course, he will be answering questions in front of the Select Committee or Parliament: that is a given in relation to education and training, as it is for anything else. The role of Ministers in Parliament will not change. Ministers will still answer letters, Written Questions and so on. Whatever system we put in place, the government amendment makes the Secretary of State’s ultimate accountability and responsibility for ensuring an effective system absolutely clear. However, many of the questions that have been asked—I was very grateful to the noble Earl, Lord Listowel, for what he said—are about how the system will work, and that is a matter on which we are still listening to stakeholders.

Health: Cardiology

Baroness Finlay of Llandaff Excerpts

Monday 24th October 2011 Lords Chamber

[Earl Howe]

My Lords, I cannot rule anything out, because, as I emphasised, this is a matter for the NHS. In the final analysis, however, this could be a decision that falls on to the desk of the Secretary of State, so it would be unwise of me to be drawn into commenting in too much detail on particular centres of surgery. All I can say about the service at Leeds is that it received a very low score as an outcome of the assessment by the independent expert panel. It was ranked 10th out of 11 centres; that is one above the service at the John Radcliffe Hospital which, as noble Lords will know, was suspended over safety fears in February 2010.

[Baroness Finlay of Llandaff]

Does the Minister accept that the lessons to be learned from Bristol represent an important critical mass for highly specialised services, and that a hub-and-spokes model allows families to access really high-quality, high-tech services, leaving the lower-tech services to be delivered nearer to home? That requires integration at all levels across providers, but the concern with the NHS reforms is that that integration will be threatened.

[Earl Howe]

I hope to persuade the noble Baroness in our debates on the Health and Social Care Bill that her fears on the Bill and its provisions in regard to integration are not well founded. However, I agree with her remarks in the first part of her question. It is very important that surgeons have sufficient clinical work to maintain and develop their skills and to train the next generation of surgeons. The need for change in this area is widely supported, and it is only by taking a national perspective that the optimum configuration of services can be effectively assessed.