Health and Social Care Bill

Baroness Finlay of Llandaff Excerpts

Wednesday 12th October 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, no one could dispute that the NHS needs to change to meet its challenges, drive up quality to be universally good, and narrow health inequalities. The way to bring the benefits of research and innovation to people's health, whatever their condition, is for the NHS constantly to change and evolve. But if it is more fragmented by external ownership, any irreversible damage may not be evident for several years. The real concerns about this Bill are neither a resistance to change nor vested interests. They come from all quarters because there are so many changes to the NHS in the Bill and so many needed changes that are not in the Bill. The more we ask questions the more we are told that secondary legislation will sort out the detail.

The key risks with this Bill identified by the impact assessment include whether clinical commissioning groups have the capacity and capability to engage with and deliver clinical commissioning and to manage risk, and how the Commissioning Board will deal with the potential conflicts of interest for GPs as providers and commissioners of patient care. As my noble friend Lord Kakkar said, Nolan principles and oversight of primary care need to be on the face of the Bill. With excessive autonomy, how will we avoid a patchwork of services, with rarer conditions left out in the cold? Planning of services has always required a critical mass of population, but how will that planning happen now? Will public health, the Commissioning Board or the clinical commissioning groups have the final say?

A real concern is for patients of all ages with complex, long-term, but not very rare conditions. Rare conditions will be centrally commissioned; common conditions are to be dealt with by GPs. In children, for example, conditions such as cerebral palsy, diabetes, Down’s syndrome or survivors of leukaemia are rare for a GP but not rare in paediatric practice. It is this middle group that risks falling between the cracks. Their real needs are for excellent, small-volume services. The choice—the real choice—they want is to have a service rather than no service or one restricted by stealth. Allied health professionals can be key, but where do they feature as core professionals? In the Nottingham area, we have already seen restrictions so imposed that they cannot practise properly.

Clinicians are used to rationing; the ethical principle of justice embodies it. Clinicians are also inherently competitive. It is their professional pride, not money in their pockets, that can be harnessed to drive up quality. We face the Nicholson challenge of savings and yet the impact assessment questioned the ability of GPs to deliver potential financial savings as well as transactional costs. There is also a question about how much this Bill is going to cost.

The Minister said that improving quality is motivating this Bill. But the NHS Confederation has said the jury is out on whether the Bill will actually improve quality. With more than 8,000 separate contacts, how can the Commissioning Board possibly manage primary care from a distance and monitor the quality and value of the service? The patient voice is a powerful driver to improve quality and it must be strengthened. We all welcome that. Patients’ feedback on their experience of care can change practice, so feedback from patients on the way complaints are handled and collated must inform commissioning. However, it is unclear how the Commissioning Board will discharge its responsibilities for involving patients, the public, and public health in its plans and decisions.

Let me turn briefly to “any qualified provider”. The hospice movement has provided this par excellence, sitting outside the NHS yet increasingly integrating. Where hospices have delivered best is where they have collaborated and integrated with the NHS, rather than competing fiercely for funding. I need no convincing of not-for-profit providers. However, people must have the protection of recourse to the health ombudsman, whoever the provider is—not only if it is the NHS—and every provider must have adequate indemnity.

My noble friend Lord Mawson spoke of the stifling barriers to progress when systems are not integrated and simple patient data are not available. There is a tension between collaborative integration and the possessiveness that can come from commercial competition. We must use our patient data better, not make it more difficult for them to be transferred. The personal profit motive can distort; incentives not to refer patients to other clinicians can cause delayed diagnosis. They neither achieve better quality, nor save money overall in the long term. It is good general medicine that decreases inappropriate referrals and ensures the best use of secondary care, and that requires closer integration of primary and secondary care, not less. The Government need to confirm that such integration will continue and be fostered under the proposed changes. We will meet our workforce needs only if the provision of educational and training resources is embedded in the contract with any qualified provider and is part of every tariff.

The duty to facilitate research must be strengthened in the Bill. Research drives up quality of care as well as contributing a financial benefit to the UK; when money is tight we need research more than ever. Change and innovation are essential for our health services to keep abreast of improved outcomes, to promote independence and to meet patient need. Change and innovation are driven by research. That is why universities and hospitals need to integrate more, not less.

In the past I have said that the NHS must stop being a political football. But removing so much responsibility from the Secretary of State feels more like abandonment. The recommendation of the Constitution Committee is that the Secretary of State's role be put beyond legal doubt. The suggestion of my noble friend Lord Owen seems to provide a good way to address this and to be time efficient. At the very least I hope that the Minister will agree to review this as the Bill proceeds.

I have kept asking whether we need this Bill to bring about the changes to drive up quality of care, improve outcomes, empower the patient voice and decrease layers of bureaucracy. The answer I have consistently been given is that the vast majority of changes can happen without the Bill and indeed the most important ones are already happening. I doubt whether this House will throw out the Bill, but it must amend it properly. At a time when we need to make savings and focus evermore on patient care, these reforms risk being an ever-increasing distraction for clinicians and managers. It is a credit to NHS clinical services that they continue to develop despite the uncertainty. Their concern that the NHS will not exist in five years time is driving their vocal opposition. People’s health is not a commodity to be traded.

Health: Charities

Baroness Finlay of Llandaff Excerpts

Wednesday 12th October 2011 Lords Chamber

[Earl Howe]

My Lords, we greatly value the work that Connect and other charities carry out, working alongside people with aphasia and their families to develop communication and rebuild confidence. I can tell my noble friend that we understand that the current fiscal position is presenting voluntary organisations and charities such as Connect with challenging funding issues. But, in the end, we are looking at local services. Where local services are concerned, it is the responsibility of commissioners—currently primary care trusts and local authorities—to commission services based on their local population needs. They must ensure that the services that they secure for local people provide the best value for money and quality for patients. I am afraid that we cannot get away from the value-for-money question. It is important to emphasise that we are sending the message to local authorities and PCTs that the voluntary sector should not shoulder a disproportionate share of funding cuts.

[Baroness Finlay of Llandaff]

Will the Minister ensure that healthcare charities that provide clinical services have the same VAT exemption as NHS providers, to establish the level playing field at this time of financial stringency that the Minister spoke about in the preceding debate?

[Earl Howe]

The noble Baroness makes a good point and I shall ensure that it is passed on to my right honourable friend at the Treasury. She will understand of course that I cannot give her a categorical answer at this point.

NHS: Health Improvements

Baroness Finlay of Llandaff Excerpts

Wednesday 29th June 2011 Lords Chamber

[Earl Howe]

I absolutely agree with the noble Lord. The information agenda, which should run in parallel with our plans, is essential for delivering the improvement in outcomes that we all want to see. Part of that will involve new technology. As the noble Lord knows, work is under way on genomic medicine, which is extremely exciting. We have included in the amendments tabled to the Health and Social Care Bill in another place a duty on both the Secretary of State and clinical commissioning groups to promote research in the health service.

[Baroness Finlay of Llandaff]

My Lords, who will be the final arbiter in a decision if a commissioning board commissions a highly specialised treatment that may require patient testing locally and an infrastructure of local services, but the local commissioning group does not recognise the importance and potential good patient outcomes of this, and therefore does not adequately provide the infrastructure needed for the more highly specialised service?

[Earl Howe]

My Lords, the system ought to respond to the kind of situation that the noble Baroness has posited. If a service is specially commissioned by a board, that board and local commissioners will be required to work in concert. If they do not, there will be mechanisms to ensure that the healthcare needs of an area are aired at the local authority level—that is, through the joint health and well-being boards, whose job it will be to prioritise the commissioning of services in that area.

Drugs: Prescribed Drug Addiction and Withdrawal

Baroness Finlay of Llandaff Excerpts

Thursday 23rd June 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, how much advice is now being given to GPs over the prescribing of psychoactive substances? In the revisions of the NHS as proposed by the Government, will the pricing bureau which monitors GP prescriptions still have the same levers as it currently has in providing GPs with benchmarking of their prescribing of psychoactive substances?

[Earl Howe]

My Lords, I am not sure that I can answer the latter part of the noble Baroness’s question but GPs are clearly in an important position in this context. They are responsible for identifying patients who need help and for supporting them. I do not think that there is any reliable evidence that doctors are failing to comply with guidelines on the prescribing of benzodiazepines but I am aware that the Royal College of General Practitioners is updating its guidance at the moment. It is working hard to produce that very shortly.

Health: Transmissible Spongiform Encephalopathies

Baroness Finlay of Llandaff Excerpts

Monday 13th June 2011 Lords Chamber

[Baroness Finlay of Llandaff]

In making decisions about funding, do the Government recognise that the research into prions and TSEs may be only the tip of the iceberg, and that prions may be implicated in a whole range of other protein-folding abnormalities, including Alzheimer’s and amyloid disease? In asking that question, I must declare an interest, because research in the field is carried out in my own university, Cardiff University.

[Earl Howe]

My Lords, I am aware of emerging findings in that sense. We welcome, of course, any significant findings from research, and my department has indeed part-funded some of the studies that the noble Baroness may have been referring to. Future funding applications for new studies will be considered, as they always are, on a case-by-case basis. These decisions are dependent on, among other things, existing research in progress and the availability of funding. However, this is an interesting area.

NHS: Waiting Times

Baroness Finlay of Llandaff Excerpts

Tuesday 3rd May 2011 Lords Chamber

[Earl Howe]

My Lords, that does concern me. I do not think anyone could endorse the practice of patients remaining on trolleys. I hope my noble friend was seen and tended to in a timely manner, but what she describes does not sound to me as though it conforms with good clinical practice. However, I stress to her that the figures I have show that nationally hospitals as a whole are adhering to the new standards that have been set.

[Baroness Finlay of Llandaff]

My Lords, do the Government recognise that, until the shortfall of 1,280 A&E consultants is met, the quality indicators will not be met because they require consultant sign-off? They must not be interpreted as rigid targets because of the variability of clinical scenarios that present. Indeed, the Primary Care Foundation report showed that this consultant shortfall must be met because only 15 to 25 per cent of attendances could be seen by co-located primary care. That figure is much lower than other people had previously estimated.

[Earl Howe]

My Lords, the noble Baroness is right to raise the question of consultant numbers. I simply say that one of the clinical indicators that we have set for A&E is that there should be consultant sign-off. That in itself should encourage consultant capacity over time.

NHS Reform

Baroness Finlay of Llandaff Excerpts

Monday 4th April 2011 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness will know that her own party’s plans included a 30 per cent reduction in administrative and managerial costs throughout the health service. We agree with that and we have got on with it. It is right that, when a Government come in and announce their intentions, as we did, expectations should be managed, as we are doing, and uncertainties should be allayed. The way to do that is to get on with the process.

[Baroness Finlay of Llandaff]

Can the Minister tell us how the clinical governance arrangements in primary care will be safeguarded during a time of transition, particularly because clinical decision-making can be adversely affected when people are concentrating on many management restructures?

[Earl Howe]

My Lords, we are clear that the essential functions of the primary care trusts should continue. That includes monitoring clinical governance within primary care. Having said that, I am sure that the noble Baroness will agree that clinical governance in the primary care context has not been all that it might be, which is why we believe that the new arrangements will considerably strengthen that governance.

Health: Multiple Sclerosis

Baroness Finlay of Llandaff Excerpts

Wednesday 2nd February 2011 Lords Chamber

[Earl Howe]

In recent years the number of specialist MS nurses has increased—I understand that the number has almost doubled—partly as a result of the risk-sharing scheme introduced in 2002. However, we hear anecdotal reports that the numbers are dwindling, which is a matter of concern. Under the new NHS architecture, which will be characterised by clinically-led commissioning responding to the health needs of the local area, we will see that the workforce planning that will emerge will lead to the training of more of these specialist nurses.

[Baroness Finlay of Llandaff]

During the current transition phase of the NHS as we move towards the new arrangements, what appeal mechanisms are there for patients who wish to be considered for disease-modifying drugs to be referred for neurological assessment where their general practitioner is not doing so or where they cannot find out who is the person to approve payment?

[Earl Howe]

My Lords, at the moment, the appeal process is to the primary care trust. Under the Government's proposals, the appeal will be, in the first instance, to the GP-led consortium and, thereafter, if appropriate, to the NHS commissioning board.

NHS: Front-line and Specialised Services

Baroness Finlay of Llandaff Excerpts

Thursday 13th January 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I am delighted to follow the noble Baroness, Lady Jolly. I welcome her and congratulate her on having made a superb short maiden speech in the time available. She has shown a deep affection and critical praise of the NHS. She brings to us experience from engineering and maths, and the critical thinking from that, as well as extensive personal, administrative and provision experience in the NHS and the voluntary sector. I am sure the Liberal Democrats celebrate her being on their Benches, and we must celebrate her addition to this House.

I speak as a clinician in the NHS, and declare all those interests in so doing. The Government have inherited much from the previous Government. They have inherited the problem of the PFI burden, with high interest rates that will increase the burden on hospitals. This will not go away during reorganisation. They have also inherited, as the noble Baroness, Lady Jolly, has illustrated, very high levels of satisfaction with the NHS as we know it. In 2009, indeed, 64 per cent of the population declared themselves to be satisfied or very satisfied. Even among Conservative voters, the figure was 61 per cent.

The public out there fear the loss of the NHS. They fear the escalating costs that they see in US healthcare. A major concern is the concept of “any willing provider” and its effect on primary and secondary care. The competition engendered by this concept seems to work against collaboration. In private-provider competition there seem to be three main problems. The first one, identified in the US, is fraud. The biggest department in the FBI is that which investigates fraud in healthcare, yet we have US providers advising us. I find that worrying. The second problem concerns the role of Monitor. Will Monitor promote competition? The US system and others show that health outcomes are better where collaboration is higher. I ask the Minister why collaboration between primary and secondary care is not the key marker rather than a pre-requirement to competition. The third problem relates to European law. Current law on services of general intent allow subsidiarity for publicly provided healthcare, but if it is privately provided it will become subject to general interest regulations. If the reorganisation fails, can the service effectively be renationalised?

I turn briefly to financial failure. Current legislation allows for a failing foundation trust to be brought back into public administration, but that will be repealed. What will happen if a GP consortium runs out of money? Will the patients be left with less or no care? I understand that there is to be a central levy to allow for failure. I ask the Minister how it was calculated, and whether the Government are confident that it will be enough to continue care provision, particularly if faced with multiple failures at the end of the financial year. If a GP consortium fails, will it be taken over by the private sector, as is happening with hospitals?

The NHS is there for patients. The phrase “nothing about me without me” is both clever and wholly appropriate, referring to clear simple terms of informed consent, but when transposed to choices in healthcare provider it can become distorted rhetoric. The choices that people have to make relate to decisions across all parts of care: whether to remain at home when ill; whether to have a gastrostomy, as swallowing fails in neurological disease; or whether to try physiotherapy to defer joint replacement surgery. There are decisions about immunisation versus infection risks and about how to manage psychotic disease relapse.

These decisions depend on services being integrated, not operating in isolation or in competition. They require excellence in clinical standards, not just “any willing provider”. The problem is that private providers can cherry-pick services to provide in neat packages, but most patients do not fit neat packages. Choice in packages requires a surplus to choose from, but we cannot afford that. Those with complex co-morbidities are optimally managed by a service leading their care and collaborating with others, avoiding duplication and minimising the risk of patients falling into a gap.

How will secondary care integration with primary care be promoted and long-term planning secured? Patients want choice to be seen by the right person at the right time. Pathfinder consortia may be achieving this in the short term, but if Monitor is to ensure competition, how will such collaboration continue? To ensure data on fair competition, will commercial confidentiality clauses be overturned by statute? How will outcome data be collated? Will they be meaningfully interpreted to account for those with multiple co-morbidities?

I ask the Minister these questions because we are embarking on a reorganisation that will cost up to £3 billion. There is a genuine fear that an integrated NHS is being dismantled under the influence of for-profit organisations.

NHS: Reorganisation

Baroness Finlay of Llandaff Excerpts

Thursday 16th December 2010 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, like others, I thank the noble Lord, Lord Touhig, for securing this debate at this significant time. Having watched the Health Select Committee questioning yesterday of the Secretary of State for Health, Andrew Lansley, I was left with more concerns than I had previously. As always, the devil is in the detail and the detail is where the problems lie.

The importance placed on the patient voice is welcome, but the new local HealthWatch organisations should have powers to call for an inquiry when there are concerns. Of course, there should be no decision about a patient without the patient being involved in and informed of what is going on. There must be respect for the individual, and provision of care that enhances dignity should be at the heart of every clinician, patient encounter. Attitudes in some areas certainly need to change, both in primary and secondary care, if we are really to have the patient’s concerns at heart. Let us push forward with those measures.

However, my two areas of concern are, first, the “any willing provider” approach and, secondly, the wholesale disbanding of PCTs and the effect on patients of the consequent destabilisation of secondary care. As has already been mentioned by the noble Lord, Lord Hunt of Kings Heath, Chris Ham writes today that,

“what is not yet clear is whether the incentives in the new system and regulatory framework will allow integrated services to grow, rather than stand in the way of their evolution. … We would disagree with the assertion that structural changes will help to meet the productivity challenge and the ambitions of the government’s QIPP agenda. While proposals are being phased in more carefully over four years, we share the concerns set out by the Health Select Committee yesterday, that they will still act as a distraction from delivering the enormous productivity improvements required across the system”.

The “any willing provider” requirement risks fragmentation and cherry-picking, which would leave NHS organisations to struggle to provide for those with multiple co-morbidities and complex needs. The Royal College of General Practitioners and the Royal College of Physicians—I declare that I am a fellow of both—and the King’s Fund and the BMA, of which I declare that I am a member, have all alerted us to the dangers. All support using private and voluntary sector providers to fill the gaps—hospices are a prime example—and to support defined roles. However, hospitals need a critical mass of activity to be efficient. Without that, how will good seven-day cover be achieved?

The Government’s response recognises the fluctuations in need that occur in any one area. Neonatal cots, winter beds and so on are obvious examples. How will flexible provision be achieved if foundation trusts are destabilised by being stripped of their profitable elements by the cherry-picking of private sector providers? Clinicians can tell of many examples of patients suffering when providers are in direct competition and not in collaboration.

The tariffs look crude and contain perverse incentives. For example, specialties that have invested in IT teleconferencing follow-up will not be paid. Clinical leadership in primary and secondary care, underpinned by good management, is overdue, but such leadership must be around pathways of care for patients. That means that secondary care needs to be at the table with primary care, because people do not know what they do not know—advances in different branches of medicine are moving forward so fast that GPs cannot possibly be up to speed with everything. In areas where there are good GPs and good relationships between GPs and secondary care providers, cross-fertilisation will happen but in many areas such relationships are not in place.

What will drive up standards of primary care at local level to ensure that patients with long-term conditions are supported in their own homes? To speak of unscheduled care is to gloss over the reality of out-of-hours work. With only 30 per cent of the week adequately covered, how will the reforms specifically address the needs of patients who want to stay in their own homes? All too often, such patients are put in an ambulance and land in A&E if secondary care provision is not integral to the process of determining pathways of care.

The US model seems to underpin much of the thinking, yet we all know that healthcare per capita in the US is vastly more expensive than that of the NHS despite there being 40 million US citizens without any adequate care. Will the profits from services organised by American systems go to the US? That is not the John Lewis Partnership model, which would reinvest in the NHS.

I turn to PCTs. To have evolution not revolution, why did the Government not put GPs in the driving seat by putting a majority of GPs on the boards of merged PCTs, which could have had a lay chairman? The PCTs could have retained the skills of managers in responding to particular local needs and could have used primary and secondary care working arrangements to make joint plans. If patients can register with any GP anywhere, how will care be provided in the patient’s home when he or she is sicker, older and frailer? Who will want to take on a patient who poses a lot of work? If a GP can jump between consortia, how will stability of commissioning be achieved? Without some baseline stability, quality will not be driven up. We have all seen short-term projects wither. Sir David Nicholson has today exhorted trusts to maintain quality standards. To do that requires stability, not the fragmentation of services.

Many of the partnership agreements between PCTs and local authorities are legal agreements under the Health Act 1999. How will the more than 134 statutory functions of PCTs be discharged? Those include safeguarding children and commissioning for vulnerable groups, prison services and so on. Local authorities are already struggling, so I have no confidence that they will be able to take all this on too. Where will pooled budgets and joint commissioning sit? Will the consortia disband those arrangements, or will they have to respect them and build on them?

With estimates of one in four GPs having a commercial conflict of interest, how will the new model ensure probity in healthcare delivery, given that tendering, done properly, can cost around £500,000? How will the £20 billion saving be found with this massive reorganisation? Redundancies in PCTs are already costing money and losing organisational memory. Staff are then re-employed by private providers. That takes people away from the core task of quality assurance of patient care. The Mid Staffs trust is a glaring reminder of that.

The process seems to be storming ahead, with the detail being clarified as we go. We will be faced with legislation when, as the Health Committee suggested yesterday, the train has left the station at a dangerous speed before we have even had time to scrutinise the Bill.