NHS: Specialised Services
Baroness Hollins Excerpts(12 years, 6 months ago)
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Baroness Hollins
My Lords, until 2008, I was deputy chair of the National Specialist Commissioning Advisory Group, which was a predecessor organisation to AGNSS.
There are some very rare conditions affecting mental health. Services meeting the criteria defined by the noble Baroness have been commissioned, such as: the children’s gender identity development service, for children struggling with the development of their gender identity; services for those with very severe obsessive compulsive and body dysmorphic disorders; secure mental health in-patient services for young people, including those with learning disabilities and those who pose a forensic risk; and services for young deaf people with acute mental health problems. Each of these disorders is low in overall national numbers, which makes it difficult to assess the suitability of proposed services and treatments. The proposal made in the draft mandate to the NHS Commissioning Board is that the board will commission those services that fall into the national specialised services definition set. I understand that 85 services are being considered, of which about 10 are mental health services. These include some services that were previously commissioned following recommendation by AGNSS, such as the services I have already briefly described.
My worry, and I seek ministerial reassurance on this, is that learning disability and mental health services will fall though the specialist commissioning gap. Some of these services are quite messy. They do not conform to the medical model of rare medical diseases that can be researched in the lab, even if they have a serious impact and are rare. Even moving these services to NICE would create a problem since the research investment needed to provide evidence-based treatment has been neglected until now.
If there is to be parity of esteem between mental and physical illness, people with severe mental illness and with learning disabilities need equal attention to their complex clinical conditions. For example, there is no new, well funded research into drugs to treat serious mental illness and no repurposing of drugs, and I am unaware of any investment into exploring, for example, the role of immunology in drug treatment for severe mental illness.
I would like the Minister to comment on the continuing need for such highly specialist commissioning skills that have been developed within AGNSS and its predecessor NSCAG. There is some concern, which I share, that the successful work of AGNSS will be lost, with the risk of forgetting important lessons learnt about national, highly specialised commissioning in the past few decades. The NHS constitution states that the NHS’s resources are to be used,
“for the benefit of the whole community”,
to,
“make sure that nobody is excluded or left behind”.
There are concerns about whether any group which replaces AGNSS would comprise sufficient expertise to assess the unique requirements of highly specialised services, as well as about how the strong relationships built by AGNSS with royal colleges, patients and others will remain within the national Commissioning Board.
For me, the most important message is that some highly specialist services are needed for a small number of people with severe mental illness and learning disabilities which may meet, or nearly meet, existing criteria. New criteria for highly specialist services must ensure parity for these groups. Can the Minister assure the House that the new commissioning arrangements for highly specialised services will indeed mind the gap for complex psychiatric conditions, including those affecting people with learning disabilities and deaf people, and that the skills that AGNSS has demonstrated, which are still needed to commission highly specialist services in the future, will be retained and further developed as suggested by the noble Baroness, Lady Jolly?
NHS: Mental Illness
Baroness Hollins Excerpts(12 years, 6 months ago)
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Earl Howe
I am very happy to take the advice of my noble friend, who is of course an expert in this area. Historically, it is true to say that access to talking therapies in the broadest sense has been very poor. That is why we have invested £400 million in rolling out the IAPT programme, which makes available a range of NICE-recommended therapies to a much larger cohort of people. However, I will take my noble friend’s point away and, if I can throw any light on the issue that he has raised, I will gladly write to him.
Baroness Hollins
My Lords, I, too, commend the report. What action would the Minister expect in response to two of the recommendations that relate to training? First, there is the recommendation that an automatic component of general practice training in future should include mental health. Only a minority of GPs currently receive any training in mental health. Secondly, with respect to the current recruitment crisis in psychiatry, it is recommended that we recognise that psychiatrists have an essential leadership role to play in mental health care.
Earl Howe
My Lords, as regards GPs, the Royal College of General Practitioners has identified improved care for people with mental health problems as a priority within its enhanced GP training programme, which forms part of the college’s proposals for a new evidence-based four-year programme of training.
As regards the workforce issues, I am aware that there is concern about recruitment into psychiatry. My department and the Royal College of Psychiatrists are looking into this matter. The royal college has established a task force to make recommendations to improve recruitment, and it is investigating the factors before medical school, during medical school, during foundation training and in core and higher psychiatric training so as to get to the bottom of the issue as best it can.
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 10 months ago)
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Baroness Finlay of Llandaff
I am grateful to the Minister for meeting me with the President and Vice President of the College of Emergency Medicine and for listening so attentively to the concerns raised. This amendment comes from those discussions and aims to resolve the potential lacuna around the commissioning and the provision of unscheduled urgent and emergency care at all times of day and night.
Emergency medicine departments—commonly known as A&E—see 15 million patients a year, of whom about a quarter are children. About 7.5 million patients arriving in A&E are not ambulant. Typically one-third of these on a stretcher need to be admitted, most frequently into an acute medical bed. The extent of seriously ill and injured attendees is illustrated by the fact that one in 50 will need high levels of care. A quarter of all intensive care admissions come through A&E and seriously ill patients go straight to coronary care and high dependency units from the resuscitation room in the emergency department.
The full spectrum of integrated services has to involve acute medicine, acute surgery and orthopaedics, paediatrics, obstetrics and gynaecology and is crucially underpinned by critical care and anaesthesia.
These very seriously ill patients need integrated services along the whole care pathway; care cannot be broken up. The full spectrum of back-up services with radiology and laboratory services needs to be there 24/7. The best outcomes—and we were talking just now about patient outcomes—for trauma and stroke victims are absolutely reliant on immediate cross-sectional imaging, ideally co-located in the emergency department.
There is a need for closer integration and improvement of the services needed to care for emergency department patients. For example, those with mental health problems, both acute suicidal ideation and acute psychosis, and those with drug and alcohol problems, need a comprehensive integrated psychiatry service, as they are a very vulnerable group. Improving primary care, both out of hours and alongside emergency departments, is essential if departments are to deliver the best care and not be overwhelmed. This will require close collaboration, integration and accurately informed commissioning.
Emergency departments are the 24/7 final safety net for all other services in the healthcare system and they are the last open-access point of call. Escalation of a problem, failure in community care and inadequate out-of-hours primary care support all result in urgent presentation out of hours. Such patients often arrive at night, are unstable clinically and cannot be sent home again, as they are alone or unable to monitor the condition reliably. These 7 per cent to 8 per cent of attendees need to be observed for up to 24 hours in a clinical decision unit, where there is twice daily consultant input, either until they are stable enough to be sent home, or until deterioration indicates admission and ongoing management.
Emergency departments are busy places, providing 24/7 care, looking after patients with wide-ranging needs from resuscitation to reassurance, and interacting with many specialties to ensure the best care. The seriously ill initially need the close interaction of typically three to four specialties; any fragmentation threatens the quality of care.
Commissioning of services in emergency care is optimised by direct and close working between those specialists responsible for delivery and the local commissioners. Given the size and complexity of urgent and emergency care, this should mandate such a specialist on the local commissioning board.
The challenge to us with this Bill is to ensure that commissioning processes recognise that patient choice in emergency care is inappropriate, as every patient needs access to a quality service that is fully integrated with pre-hospital services such as out-of-hours primary care and ambulance services, and with all the back-up and specialist services that patients are moved to for ongoing management.
The national Commissioning Board must work very closely with the College of Emergency Medicine to ensure that commissioning guidance drives up the standards of weaker departments, that the integration of services is included in the commissioning and that the urgent and emergency service for a population has the full skill set to deal with the full range of undifferentiated clinical problems that arrive at the only open access point of care. It is key to local commissioning that specialists in urgent and emergency care are directly involved. Without that, we will replicate Mid Staffordshire, but it may not be evident until unnecessarily large numbers of lives are lost. I beg to move.
Baroness Hollins
My Lords, given the concerns among the medical profession which are still evident, I ask the noble Earl for reassurance that, for those services where commissioning is appropriate, competition will always be on the basis of quality, not price, and that providers will not be able to cherry-pick lucrative parts of the care pathway to the detriment of vulnerable patients, such as people with learning disability or severe mental illness—people that I am particularly concerned about as a psychiatrist. The health and well-being of these patients depends on the effective delivery and co-ordination of complex care pathways.
According to the Guardian, NHS Devon and Devon County Council have shortlisted bids to provide front-line services for children across the county, including some of the most sensitive care for highly vulnerable children and families, such as child protection, treatment for mentally ill children and adolescents, therapy and respite care for those with disabilities, health visiting, palliative nursing for dying children, and so on. On the shortlist for the £130 million three-year NHS contract are two private profit-making companies as well as the Devon Partnership NHS Trust, which has been bidding along with Barnardo’s and other local charities.
The contract will apparently be awarded, according to the criteria, to the most economically advantageous bid, which appears to be possible under current commissioning arrangements. I seek reassurance from the Minister that the new safeguards in the Bill also prevent such commissioning decisions risking the perceived risks raised by my noble friend with respect to the commissioning of integrated care pathways in emergency care. I am referring not just to the emergency care part of the pathway but to the whole care pathway, which inevitably requires stable working relationships across organisational boundaries.
Earl Howe
My Lords, this is an important topic. The noble Baronesses, Lady Finlay and Lady Hollins, have eloquently set out the important role that emergency care services play for all of us, and I could not agree more.
The Government are clear about the need to strive continuously for improved quality of urgent and emergency care. The move to clinical quality indicators for A&E and ambulance services will ensure a better reflection of the quality of the services that patients receive, rather than encouraging an isolated focus on time factors. Furthermore, the introduction of the NHS 111 service supports the commitment to develop a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care.
I hope that I can reassure the noble Baroness about how clinical commissioning groups will be supported in commissioning high quality emergency care. The NHS Commissioning Board will produce commissioning guidance, and also may produce guidance on the exercise of CCGs’ duty to obtain advice under new Section 14W. Both of these will reinforce the importance of effective and informed commissioning of emergency care. We have had many debates about clinical advice for commissioners during the course of our deliberations and, as I have previously mentioned, we anticipate that the clinical senates and networks that the Board will host will provide a resource of expertise, including in urgent and emergency care, on which CCGs can draw to inform their commissioning decisions. Equally, in order effectively to discharge their own duties with regard to obtaining appropriate advice, the NHS Commissioning Board would also need to take advice from a range of experts in order to assist them in producing such guidance. I understand that the College of Emergency Medicine has already engaged in useful conversations with the Commissioning Board Authority about how such engagement could work as it moves forward.
I reiterate the framework within the Bill for ensuring the accountability of CCGs in relation to the discharge of their duty under new Section 14W. CCGs must demonstrate, as part of authorisation, that they have the competence to carry out their functions effectively, and they will be held to account on that. As part of the authorisation process, the NHS Commissioning Board would need to be satisfied that a CCG can effectively commission the full range of services that its populations are likely to require, which of course would include urgent and emergency care services. It would also need to be satisfied that a CCG had the appropriate mechanisms in place to ensure that it could discharge its duty to obtain the appropriate level of advice in relation to these services. I also reassure the noble Baroness that the performance assessment of CCGs by the NHS Commissioning Board will look in particular at how they have discharged their duty to obtain advice.
The noble Baroness suggested that we should mandate that an emergency care specialist should have a seat on the CCGs’ governing body. As your Lordships are aware from our previous debates on membership following the NHS Future Forum report, we committed to use regulations to specify a minimum membership for CCG governing bodies. We plan to specify that each body should include at least two lay members, at least one registered nurse and at least one secondary care doctor. This secondary care doctor may well be an emergency care specialist, or a CCG may choose to add additional specialists to its body should it wish to do so—there is nothing in the Bill to prevent that. However, in terms of going further and specifying that an emergency care specialist must sit on these bodies, I am afraid I cannot go that far.
The NHS Future Forum’s report states that it would be unhelpful for CCGs’ governing bodies to be representative of every group. We agree with that. The prime purpose of a governing body should be to make sure that CCGs have the right systems in place to do their job well. It is these systems that will ensure that they involve the appropriate range of health and care professionals in commissioning. Requiring a bigger group of professionals on the governing body itself would not mean that a broader range were involved in designing patient services; it would just lead to governing bodies that were too large and slow to do their job well.
Turning now to the noble Baroness’s points about integration and competition in the context of emergency care, I agree with her about the importance of integration, and the Bill contains strong provisions to encourage and enable the delivery of integrated services. I reassure her again that choice and competition will not prevent the delivery of integrated services where these are in patients’ interests. Additionally, it will of course be for commissioners to decide where to make use of choice and competition in order to best meet their patients’ needs, and it is clear that this would not always be appropriate. Emergency care is a good example of a service where we would not expect to see competition.
I take this opportunity to respond to related concerns from the noble Baroness, Lady Hollins, who asked about the basis for competition. The Bill is clear that competition will not be pursued as an end in itself and that competition will always be on quality, not price. We made amendments in another place to ensure that this would be the case by removing the ability of Monitor and the board to set maximum prices rather than fixed prices. I hope that that answers the noble Baroness’s question on this point.
The duty on CCGs to obtain advice is deliberately wide-ranging in scope purposefully so as to ensure that it covers the full spectrum of services that CCGs will commission. I draw noble Lords’ attention to the language of new Section 14W: the advice must be drawn from people,
“who (taken together) have a broad range of professional expertise in … the prevention, diagnosis or treatment of illness, and … the protection or improvement of public health”.
That is very inclusive and it echoes the approach taken in Section 3 of the NHS Act, which the Bill amends, to establish the fundamental commissioning responsibilities of CCGs.
Noble Lords will wish to note that the interpretation—
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 10 months ago)
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Baroness Young of Old Scone
My Lords, I support the amendment of the noble Baroness, Lady Emerton, from two perspectives. One is as the chief executive of Diabetes UK, where we increasingly hear stories from patients about the care that they receive in hospitals. One in 15 of all patients in hospitals at the moment has diabetes. They may not be there as a result of their diabetes but they have it—it is, of course, a serious condition. There is strong evidence that poor care in hospitals exacerbates that condition rather than improves it. I shall just mention two issues: people lose control of their own insulin and glucose management and they develop pressure problems—particularly foot and leg problems, which can dramatically escalate and lead to amputation.
Patients increasingly tell us that one of the major problems that they face in receiving care as an in-patient is that readings, checks and procedures are undertaken by healthcare support workers who are insufficiently trained and knowledgeable to alert qualified staff to take action. Just yesterday, the All-Party Parliamentary Group on Diabetes heard the distressing story of a gentleman who had been admitted to hospital and who went into a hypo through insufficient management of his glucose levels as he lay in a hospital bed. The healthcare support worker said, “I thought you were a bit strange when I gave you your lunch”. If people with diabetes “go a bit strange”, any qualified nurse will know instinctively that this is serious and needs to be dealt with. It is unforgivable that patients in a healthcare establishment have worse control over their diabetes than when they are in their own homes. I am not laying that at the feet of healthcare support workers entirely but, increasingly, the care given to people in beds, day in and day out, is given by people who need to be accredited and qualified.
The second perspective from which I want to speak is as the ill-fated chairman of the Care Quality Commission who set up the regulator for health and social care. I confess that one of my great regrets, when I resigned from that post, was not to be able to take forward work that I saw as absolutely vital. It had become abundantly clear to me, from the regulatory work in healthcare, that the key to quality was very dependent on the quality of nursing care. It is absolutely central to quality as a whole for people in healthcare. What has also become clear to me—and the evidence is borne out in many cases of poor care—is that it is not published standards or agreed levels of care that are important but the knowledge, education and skill of the nurses and healthcare support workers who are providing that care. It is about how they feel about the job and about their commitment to the job—not just seeing it as another job but seeing that improving things for patients is at the centre of what they do.
Had I stayed as chairman of the Care Quality Commission, I was intending—and I had already begun discussions with the Royal College of Nursing and others —to mount a major campaign to ensure that the nursing process, and with it, at its heart, the healthcare support worker, was improved and that formal registration and regulation of healthcare support workers was introduced. The Minister may well say that these improvements can be tackled through a voluntary register but, from my experience, I do not believe that this is the case. This is so important that a formal statutory register is absolutely required.
Baroness Hollins
My Lords, I support the amendment. I note that one of the reasons given for not considering statutory regulation for this group is that there is a very high turnover of staff in this grade. This seems to me to be a symptom of an unsatisfactory situation and perhaps points to the poor job satisfaction and lack of prospects for healthcare workers. My noble friend has pointed to the problems with skill mix. I think that she was really talking about skill mix across the whole range of mental and physical healthcare settings and not just physical healthcare. Within that, she would have included people with learning disabilities.
It seems to me that there must be some minimum requirements for training and supervision. I know that the Government suggest that it is the responsibility of the employer, and perhaps also of the commissioner, to ensure that the service which is provided reaches minimum standards. Perhaps that requires that, in order for commissioners to contract with an employer, a service has to have been appropriately accredited. A service which has been accredited has of course been accredited for the whole service, not just for the work of individual staff, who are subject to their own regulatory authority.
This morning, I revisited the Royal College of Psychiatrists’ accreditation standards for adult in-patient wards for people with learning disabilities—I should remind noble Lords that I am a past president of the Royal College of Psychiatrists and a psychiatrist myself. The college’s general standards very helpfully include attending to recruitment and retention of staff, training, supervision, management of complaints and so on. It is helpful to think about the relationship between the necessary accreditation of services and the need to attend to the training and aspirations of all those staff who work in such services: retention and job satisfaction are key to this.
Baroness Pitkeathley
My Lords, I join with others in paying tribute to the noble Baroness, Lady Emerton, for her tenacity and commitment in keeping the issue of healthcare assistants before your Lordships’ House. She may not be my noble friend in the political sense, but she has been my friend in the professional sense for many years.
I am sorry, therefore, to disagree with her on this particular issue. Indeed, it seems that I am a lone voice disagreeing with her. I certainly want to emphasise that I do not disagree about the problem with regard to healthcare assistants which has been so thoroughly and persuasively set out by her and other noble Lords. But the Council for Healthcare Regulatory Excellence, the organisation which I chair, disagrees with her, as she knows, about statutory regulation being the solution to these problems. The CHRE has had the opportunity of speaking to many of your Lordships in two seminars organised by the Minister, so I do not need to take up time here repeating the arguments. I will say only that mechanisms already exist to deal with the difficulties which your Lordships have set out. These include ensuring that those supervising healthcare assistants take their supervisory responsibilities seriously. The Nursing and Midwifery Council is providing strong direction on this with its codes. Employers are required to ensure safe systems of work, which include giving support to healthcare professionals in delegating and supervising effectively. There is also the vetting and barring scheme, whose aim is to prevent unsuitable people from entering or remaining in the workforce.
Add to this the expense and relative slowness of statutory regulation and it seems to add up to a case showing that the increased public protection that we are all seeking can be achieved by applying existing mechanisms more firmly. We should consider other ways of making this large group of workers, low paid as they are and with a 30 per cent turnover, as we have been reminded every year, feel more acknowledged and valued. There may well be a role for a professional association with a voluntary register, but principally we must use existing processes effectively before we embark on statutory regulation.
With regard to voluntary registers, which have been mentioned so much this morning, or accredited registers, as proposed by the Bill, much work has already been done by the CHRE. We are using the term “assured registration” to distinguish it from the old notion of voluntary registers and to describe the process of organisations assuring the individuals on their register and then the CHRE accrediting the organisations and their registers, thus creating accredited registers. I remind your Lordships that the whole purpose of such a scheme is to enhance consumer protection. The standards to be met by organisations which hold accredited voluntary registers will include standards of competence, education and training, registration of complaints and information provision. I certainly do not want to argue that this is the same as statutory regulation, but for many professions it offers further safeguards for patients and public, and that is what we are all seeking.
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 10 months ago)
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Lord Newton of Braintree
My Lords, perhaps I may intervene briefly, if only to avoid withdrawal symptoms from not having spoken on any day this week. I want to support my noble friend Lord Clement-Jones on the general proposition without wishing in any way to threaten mayhem if we do not get a satisfactory reply. The House is well aware, as I have referred to it on a number of occasions, that last year I went through what turned out to be the trauma of trying to engage in what was technically a takeover, although we presented it as a merger, with the neighbouring health trust. That involved Suffolk Mental Health and Norfolk Mental Health. We finally achieved it on New Year's Day, so I am, so to speak, out of work.
There was a real problem. One got the feeling that the people on the competition and collaboration panel, or whatever it was called, which overlaps quite heavily with the Competition Commission, saw us in much the same category—how can I put this without upsetting anyone?—as two rival sellers of washing detergents. They did not recognise that health is not like that. There were health issues, patient safety issues and quality of service issues that needed to trump the competition issues. I know that we have been told that that will happen, but it is very important to make sure that the machinery will ensure that it happens and that the health issues trump those narrower competition issues. All I seek from the Minister is an assurance that, one way or another, that will be the case.
Baroness Hollins
My Lords, I would like some reassurance that the regulation of competition will improve on the current situation in some circumstances. I do not know whether these amendments, or any existing provision in the Bill, will achieve that. I have a couple of examples about which I feel uncomfortable.
First, I am keen to know whether adequate safeguards are in place for the kind of situation that occurred in Surrey, to ensure that the range of providers envisaged by the Government will be able to compete on a level playing field. I remember the wise words of the economist Fritz Schumacher that sometimes “small is beautiful”. Can the Minister tell the House on what basis it was decided that a £10 million bond would be required as surety from bidders for the NHS contract tendered last year for community services in south-west and north-west Surrey? The winning tender was a private company and the loser was Social Enterprise UK, which is currently providing services to central Surrey but which did not have the £10 million in the bank. That organisation is providing high-quality community services which have been acclaimed by the noble Lord's own department. At the end of its three-year contract, will it simply be taken over by the large private company which has more money in the bank?
My second question relates to the culture within the NHS and medical practice. Since the NHS began over 60 years ago, most doctors have worked primarily in the NHS and used their clinical skills first and foremost for NHS patients. There have been special contractual arrangements in place to ensure that NHS specialists with a private practice do not neglect their NHS patients. I think it is fair to say that specialists with a thriving private practice usually put their extra energy into their private practice. They are not the ones who contribute to managing and developing NHS services, and nor do they usually make much contribution to research.
Let me give the House one example of how the culture within medicine is being encouraged to change. The presidents of many if not all of the medical royal colleges have been invited to a champagne reception and dinner at a posh London venue in a couple of weeks’ time. The invitation comes from a firm of solicitors and the Royal Bank of Scotland, and it states:
“Against the backdrop of challenging economic conditions and massive pressure on the public purse, we are keen to explore how other professions might be able to support your membership and the healthcare sector generally”.
This seems to be a new phase in encouraging and supporting doctors to turn their attention to setting up in private practice, in chambers and in other private healthcare organisations. That is a departure from our history. Is this the direction that the Government hope the medical profession will move in? What safeguards does the Bill contain with respect to competition to protect the NHS?
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 11 months ago)
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Baroness Howarth of Breckland
My Lords, I wish to add my voice to the need for clarification, as raised by the noble Baroness, Lady Finlay, between the services provided by the national and regional boards for rare diseases and conditions. I declare an interest as a patron and trustee of an organisation that deals with children with hypoplastic left heart syndrome and some similar conditions of right heart defects.
As the Minister will know, a recent Safe and Sustainable review has been looking at how those services should be delivered. Obviously the complex surgical procedures need to be carried out in specialist hospitals, but the aftercare very often takes place locally. The Safe and Sustainable review having stalled during the discussion about this Bill, parents are extraordinarily concerned about how that will be taken forward. I say this as an example but it is true of all families who have children or adult relatives with rare conditions that they want to be absolutely assured that the right service is commissioned at the right level, and need to know how that assessment is going to be made. At the moment it is extraordinarily unclear and I think that is why the noble Baroness, Lady Finlay, has tabled her amendment and the other issues have been raised.
All I am seeking is that clarification, partly because I have got to go and tell the parents this weekend at their AGM.
Baroness Hollins
My Lords, I have been reflecting on the amendment tabled by my noble friend Lady Finlay. I declare an interest as one of my daughters has one of the conditions that she mentioned in her speech.
This lacuna must be addressed because the discretionary powers of clinical commissioning groups to apply the appropriateness test provide no assurance for those with these rare diseases. Today’s debate shows that it is essential that this is addressed in the Bill. I hope that the Minister will be able to suggest a way in which perhaps a government amendment might be able to address this lacuna.
Lord Hunt of Kings Heath
My Lords, this is a very interesting group of amendments. They do not entirely fit together but all of them raise important points.
I very much support the noble Baroness, Lady Cumberlege, in her comments about HealthWatch. This is my mea culpa moment about the demise of community health councils. It is clear that having a statutory body with the right to be heard and listened to is very important at local level. Of course, I would link the noble Baroness’s amendment with the desire for HealthWatch England to be wholly independent of CQC, which is another important ingredient in ensuring that the patient voice is heard as effectively as possible.
We support Amendment 96. There has been a persuasive argument about the need to ensure that services for patients with less common conditions are commissioned effectively. We debated these issues on Monday. We know that primary care trusts have often found it difficult to give proper attention to these services. With clinical commissioning groups, this will become even more problematic. I hope that the noble Baroness will be able to pursue that.
I entirely support the noble Baroness, Lady Williams, on Amendment 75. This is a very important statement of principle. I understand the points made by the noble Lords, Lord Mawhinney and Lord Newton. I am sure that this matter will be put to the vote. The whole point about Third Reading is that it can be used for parliamentary counsel to tidy up the wording of such amendments. I do not think that we should let minor technical difficulties get in the way of passing an amendment which has a very important principle. It may be that the noble Earl, Lord Howe, will agree to it. Let us hope so.
My amendments relate to the corporate governance of clinical commissioning groups. On Monday, I developed my arguments when we discussed conflict of interest issues. I do not want to go over the same ground again, save to say that clinical commissioning groups will have a crucial role to play in the new system. They are to be handed billions of pounds by the NHS Commissioning Board to commission services. Essentially, a clinical commissioning group is not an NHS board as we know it. It is a group of small business people—GPs—who will be able to benefit financially from the decisions of that board. I cannot conceive that the Government could be going down this route if they did not want more resource spent in primary care. That must be one of the end results of the Bill. The Government want to spend more money in primary care and to reduce expenditure in acute hospital services, which is a very fair aim. But that means that the board of clinical commissioning groups will be spending public money and placing it in the hands of GPs who also sit round the board of the clinical commissioning group.
The conflict of interest amendment in the name of the noble Baroness, Lady Barker, which the noble Earl accepted, was very weak and does not provide the kind of assurance that we require. I have to say to him that there will be trouble in the future with clinical commissioning groups in this area. The proper safeguard would be for clinical commissioning groups to have a proper board. Proper boards in the public sector usually ensure that there are a majority of non-executives, people who are appointed independently, who can make sure that the public interest is protected. We have the extraordinary proposal that we are guaranteed only two non-executives on the board of clinical commissioning groups. We are not even guaranteed that one of them will be the chair of that clinical commissioning group. Looking over all the corporate governance difficulties in this country in the past 20 years, can noble Lords imagine that any of those inquiries would endorse the kind of governance arrangements that the Government are putting forward for clinical commissioning groups? I say to the noble Earl, Lord Howe, that I just wonder how long it will be before the first group of members is prosecuted for corruption. This is an open invitation for corrupt action. The Government show no signs of understanding or realising what difficulties they will put the whole service in by these proposals.
I have put forward a number of amendments to put in place proper corporate governance protection. I also believe that the constitution of clinical commissioning groups should be subject to approval by your Lordships’ House. In relation to primary care trusts, orders go through. I do not see why the same thing should not happen to clinical commissioning groups. I also endorse everything said by the noble Lord, Lord Patel, about quality payments. It is absolutely abominable that quality payments could be made to clinical commissioning groups where those payments end up in the pockets of individual GPs. That money ought to go into the commissioning of services. Again we see the conflict of interest. There is so much potential for conflict of interest between commissioning decisions in the public interest and commissioning decisions which are to the financial advantage of the members of the clinical commissioning group.
Finally, Amendment 118 would remove the quality premiums altogether. This is very much a probing amendment. I am content to support the noble Lord, Lord Patel, in his argument that, if quality payments are to be made, they should simply be put back into the commissioning pot.
Baroness Finlay of Llandaff
My Lords, this is a clear example of an iatrogenic condition, very often originating in primary care. When patients have presented with insomnia, instead of being taken through the more complex and time-consuming aspects of sleep hygiene and possibly talking therapies to discover the cause of their insomnia, a prescription has been given all too quickly and readily. If we are looking at responsibility falling back to clinicians in primary care, it seems inordinately sensible that the clinical commissioning group should consider its responsibility to provide support to patients who end up with an iatrogenic problem.
I can see that the Government may feel that this is a very specific amendment targeted at a very specific area, but the guidance that needs to go out to clinical commissioning groups on their responsibility for the behaviour of all those prescribing on their patch may well deal with some of the principles behind this amendment and ensure that the necessary services are provided to patients who, completely inadvertently, fall foul of taking the drugs that they were prescribed and as they were told to take them.
Baroness Hollins
My Lords, I pay tribute to the work of my noble friend Lord Sandwich, who has done so much to raise awareness of the often unmet needs of people whose addiction originated in a legal prescription. There is some progress in training doctors—for example, in undergraduate medical education with a new national curriculum on substance misuse. This guidance provides learning objectives on rational prescribing and iatrogenic addiction. The fact that such a curriculum is only just being introduced shows the need for the attention of clinical commissioning groups to be brought to this issue.
There seems to be a special responsibility on the National Health Service to provide better care for people affected by medical prescribing practice, and I hope that the Minister will be able to suggest how such a responsibility could be emphasised in the Bill.
Baroness Thornton
My Lords, I intend to make only two remarks. We have a great deal to get through tonight, so I shall exercise great self-discipline. I think that I will come in at under a minute and a half.
The noble Earl needs to be commended for his determination and hard work in this area. We think that it is an important issue. This is a growing problem and the noble Earl makes very reasonable requests, for which he has widespread support. I agree with the noble Baroness, Lady Masham, in that I fear this problem may get worse before it gets better, but I hope that the Minister will have good news for us about it.
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 11 months ago)
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Lord Faulks
Before the noble Lord sits down, could he confirm that, since the Compensation Act 2006, an apology is no longer deemed to be an admission of liability?
Baroness Hollins
My Lords, I support the amendment, particularly because it draws attention to the point that often patients experience prolonged psychological harm after an incident, something that is not well understood across the whole of the medical field. Such psychological harm is often overlooked. However, there is plenty of evidence that an honest and prompt apology can do so much to help the person and their family going forward. It is fair to say that delaying a response is very much like denying a response. The timeliness of a response is critical.
Lord Turnberg
My Lords, As someone who taught medical students for many years that it is very important to be absolutely open and candid with your patients, and that, if something has gone wrong, to explain it in full to the patients and their relatives—explaining that that is not necessarily an admission of guilt in some way—I am very keen on the sort of sentiment that is being expressed in this amendment. I am particularly keen on the GMC imposing on doctors the duty of being open. I am all behind the sentiments of this amendment. I have some anxiety, though, about how this can be put into law. How can you legislate for someone to be candid? How will it work? How do you know that someone has been candid or not? There is a great deal of subtlety about this candour and about putting it into law as a duty on every occasion. I am slightly apprehensive about the amendment, even though I support everything about the principle.
Lord Owen
My Lords, I rise to speak because I am a little troubled. It looks as though the Minister will object to this amendment. Of course, we are speaking in advance of knowing what he is going to do but I should like to give two or three reasons why I very much hope that he accepts the amendment.
First, using the term “social care” in the Bill means that expectations will rise. Those expectations have not been fulfilled and, to be honest, they could not have been. Nevertheless, it was a good idea to try to point to the fact that this was about more than NHS care or healthcare. We all know—it has been said many times in our debates—that there is no way that we can look at the narrow definition of the health service; it has to be broader.
The other powerful argument which I thought the noble Baroness was going to make is that this is a cultural change, and that needs to be re-emphasised at every stage as part of an educative process. Let us take the national Commissioning Board. This is a new body and the person who has been appointed to chair it is an academic lawyer—a person of great distinction. I am not objecting to the fact that it may be somebody with not very long experience of the health service. Nevertheless, a lot of hopes are vested in that Commissioning Board and to draw attention to it in a more declaratory way in this Bill is very important. It needs to know and see in clear terms in the Bill that this is part of its remit. I take great notice of what has been said about the reluctance of local authorities to respond to this. Were we having a debate involving local authority services, I would raise that, too. For a very long time I have believed that in the 1948 Act a great mistake was made in not pooling together local authority health services and welfare and social services in a comprehensive package. As everybody knows, there was a very deep debate inside the then Labour Government between Herbert Morrison and Aneurin Bevan.
There is also another debate about decentralisation and centralisation. That has been with us all these years. In the very early 1960s I wrote a book about a unified health service. When I was a Minister, there was a great deal of animosity within the medical profession at the thought of working closely with local authorities. It is amazing how that has changed. There is now a readiness in the medical profession in particular—nurses have always done it—to work across these things. I shall make no more points, but I hope that the Minister will accept this amendment. With all the reservations that have been put down, nobody should believe that this legislation will have a very big impact on social care anyhow, but pointing it in the right direction at this moment would be helpful.
Baroness Hollins
The amendments have particular relevance to mental health and learning disability services. In speaking in this debate, I declare an interest as a past president of the Royal College of Psychiatrists. I shall focus my comments on commissioning integrated care.
I remember that in the early 1980s, when I was newly a consultant, we had jointly commissioned services. They worked effectively and provided a very accessible way of developing integrated services. I shall talk briefly about the work that the Royal College of Psychiatrists has already done to support integrated commissioning since the Bill was first mooted. The joint commissioning panel on mental health was launched in April 2011. It is led by the Royal College of Psychiatrists and the Royal College of General Practitioners. It is a collaboration of 15 other leading organisations, service users and carers with an interest in mental health, learning disabilities and well-being across health and social care. It draws on expertise from across the statutory, voluntary and private sectors.
It has already produced guides on primary mental health care and liaison mental health services, which is relevant to the comments of my noble friend Lady Young about integrated care for people with diabetes. My interest here is integrating mental health care into the diabetes pathway. The panel is working on both commissioning guidance: on what is needed; and on practical commissioning tools—how to do it. The practical how-to-do-it tools have been developed with strategic health authorities, thus providing important support to the emerging and new NHS structures. They will be ready in 2013.
The joint commissioning panel on mental health is an example of an existing strong and practical partnership, which brings together the whole mental health sector with government to develop and implement integrated high-quality care and interventions. Incidentally, it is hard to understand why professional organisations leading this work were excluded from the Prime Minister’s recent summit on implementation, given this real focus on that issue. Mental health can so easily be forgotten along with other complex services when physicians, surgeons and politicians are debating health rather than mental and physical health. I am interested to know the Minister’s views on whether this cultural change needs to be in legislation. Some of the experience gained in jointly commissioning mental health services provides very good learning for services traditionally seen as providing stand-alone health episodes—good learning that could be used to develop integrated services in other areas of healthcare.
The Earl of Listowel
In rising briefly in support of the amendments, I pay tribute to the Government for their contribution in this area already. This is a personal view, but in my experience the best professionals will find a way through against all odds and against the system to work together in partnership to improve outcomes. What the Government have been doing with the social work workforce in terms of raising the threshold of entry to social work, the additional support for newly qualified social workers and the review by Professor Eileen Munro on child and family social workers is a welcome part to this. I hear again and again from people on the front line that an obstacle to integration is continual structural change. When disciplines have stability and can grow together they can learn to work in partnership effectively. Finally, I welcome the building of capacity in the social work workforce, which will assist with the question of better integrated working.
Health: Smear Tests
Baroness Hollins Excerpts(12 years, 11 months ago)
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Earl Howe
My Lords, inoculation is not being offered to boys as part of the national programme. As I am sure the noble Lord knows, the aim of the programme has always been to prevent cervical cancer in women. Clearly, the best way to do that is to vaccinate girls and young women. However, these vaccines can be purchased privately and health professionals should exercise their clinical judgment when prescribing products for specific indications.
Baroness Hollins
My Lords, will the Minister explain what efforts are being made to ensure that uptake of both vaccination and cervical screening is good among girls and women with learning disabilities, particularly given their low awareness of the risk of cervical cancer and the high rate of sexual abuse among this population?
Earl Howe
My Lords, as ever, the noble Baroness raises an extremely important point about those with learning disabilities. I will need to write to her because my brief does not contain an explicit reference to them. However, I feel sure that the work to which I referred earlier—the strategic trial—will incorporate work to embrace all sections of the female population. I will write to the noble Baroness about that.
Health and Social Care Bill
Baroness Hollins Excerpts(12 years, 11 months ago)
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Baroness Hollins
Baroness Hollins
My Lords, I rise to speak to Amendment 26A and the others in this group on behalf of my noble friend Lord Ramsbotham, who was unable to stay until this hour tonight. My noble friend was first going to explain, and apologise to the House, that the amendments, as handed to the Public Bill Office, included the word “communication”, which somehow turned into “communization” during the printing process. My noble friend was then going to thank the noble Earl for his letter, which he received on Friday, and invite him to confirm to the House what he said in that letter about the healthy child programme. The letter said that the programme,
“provides regular opportunities after birth for the parents and the health visitor to review together a child’s development, health and wellbeing including any concerns about speech and language skills”.
My noble friend was very glad to note that the Department of Health and the Department for Education and Skills are working together to ensure that the two-year to two and a half-year review that is part of that becomes an integrated review covering both health and education, which he assumes is to be compulsory. He also noted the work that was being done within the public health outcomes framework to inform decisions on services and support. However, accepting all that, he noted that, in her final report, the communication champion recommended that the Government should fund local professional development for early-years practitioners to enable them to assess and support children's communication and language development within the revised early-years foundation stage framework that is part of the public health outcomes framework. There is a possible shortfall, so my noble friend would like to ask the Minister whether that includes training of health visitors, who will make initial assessments, and a halt to the reduction of speech and language therapists, whose numbers were reduced by 3 per cent in 2010-11. Their follow-up is crucial to successful post-assessment development support. Equally crucial is that health and well-being boards understand that speech and language development not only underpins literacy development but is at the heart of the Government's proposed revisions to the early-years foundation stage framework. My noble friend seeks the Minister's additional assurance that assessment and follow-on action are properly integrated.
Speaking now for myself in support of these amendments, I have had personal experience in my family of a child needing the specialist help of speech and language therapy to be able to acquire sufficient language for day-to-day communication. The battle to provide adequate speech therapy for pre-school and indeed for primary schoolchildren has been ongoing for many years. I know that my noble friend Lord Ramsbotham was not proposing to test the opinion of the House, but I beg to move this amendment tabled in his name.
Baroness Northover
I would refer the noble Baroness to the public health outcomes framework and the way that this will be included in that. The framework is very widely drawn and I hope that the Opposition will generally welcome that. It builds on the work that they themselves did and I hope that they recognise that.
I think that I have covered most of the issues that were flagged up. I reiterate that we appreciate enormously the commitment that noble Lords have paid to this area. We know how important it is; it sets the foundation for what happens later for many of these children. On the basis of that, I hope that the noble Baroness will be willing to withdraw the amendment.
Baroness Hollins
My Lords, I know that my noble friend was extremely grateful for the letter from the noble Earl, Lord Howe, on this matter. Communication is fundamental and screening is critical. We know that early intervention is effective. I am disappointed that the Minister did not confirm whether there would be a halt to the reduction of speech and language therapists. I beg leave to withdraw the amendment.
Baroness Hollins
Baroness Hollins
My Lords, I shall speak also to Amendments 55 and 238. My noble friend Lord Rix sincerely regrets that he could not stay this evening as his wife is unwell.
The three amendments tabled by my noble friend to this Bill have been placed together in this one group. I welcome this opportunity to speak to them. Noble Lords will be aware that these issues were raised during the Committee stage of the Bill. My noble friend recently met the Minister to discuss the matters that I am about to raise in relation to people with a learning disability. It is appropriate for me to declare an interest as a psychiatrist specialising in learning disability and also because my son has a learning disability.
To be fair to the Government, it could be argued that the broader issues which these amendments attempt to resolve could have been addressed by the National Health Service many years ago. However, my noble friend and I are using the opportunity presented by this Bill in an attempt to tackle them now. The first amendment, Amendment 37, aims to ensure that health services for those with the most complex needs are commissioned by the NHS Commissioning Board. Concerns were expressed about this issue in Committee. We seek assurances that health services for those with the most complex needs, particularly people with profound and multiple learning disabilities and people with complex needs whose behaviour challenges services, will be commissioned centrally by the NHS board. This amendment would ensure that the NHS Commissioning Board has oversight in this area, including the co-ordination and commissioning of specialist services or facilities for this particular group of disabled people. Any assurances that the Minister may be in a position to provide on this matter would be welcome.
The second amendment tabled in the name of my noble friend, Amendment 55, concerns the importance of collecting data on the experience and outcomes encountered by all patients in the NHS. Where a patient has a disability, it would also ensure a breakdown of disability by impairment type. In Committee, the Minister informed the House that his department is working with the NHS information centre to explore the extent to which indicators in the NHS outcomes framework can be disaggregated to show impairment types, which we would both welcome. However, if the information is not collected at source, clearly there will be limits to which this can be achieved. The Minister also stated that the Government's NHS information strategy aims to cover this issue too, when it is published later this year. Any additional assurances that the Minister is willing to give about what steps the Government will take to ensure that data are collected at source would be welcome.
The third and final amendment, Amendment 238, concerns the provision of independent advocacy services for people who are in the process of making a complaint against the NHS. For those who are unfortunate enough to encounter it, the NHS complaints system is flawed and ineffective. We welcome the Government's proposal for local authorities to make appropriate provision to support people in the complaints process through the use of advocacy services. However, there is a risk that advocacy support could be started and then halted some time before any conclusion to an ongoing complaint has been made. In Committee, the Minister emphasised that local authorities would have the discretion to provide independent advocacy services, consistent with their legal obligations, as they deem appropriate. My noble friend is particularly concerned that such discretion could leave many families without the on-going advocacy support that they need. Is the Minister able to provide my noble friend with any comforting words on that matter? I beg to move.
Baroness Thornton
My Lords, it is important that the Minister can give us some satisfaction in answer to the remarks made by the noble Baroness, Lady Hollins, particularly in view of the tireless pursuit of these issues by the noble Lord, Lord Rix. This small suite of amendments aims to start at the top as it talks about the Secretary of State’s power to require the board to commission services including for those with profound and multiple learning disabilities. It then puts a duty on the board to reduce inequalities, which will involve collecting data on the experiences and outcomes of patients with these disabilities. It also sets out that there should be no upper limit on the length and type of advocacy support that must be provided by local authorities. Therefore, it aims to provide a suite of amendments that address the whole system and the interventions that will be necessary to provide the right framework under the new regime for some of the most vulnerable people in our country.
It was interesting that, on a more general matter concerning children and the Bill, the NHS Confederation deputy policy director, Jo Webber, said recently that the Government's plan to recruit 4,200 extra health visitors by 2015 was leading to a loss of staff in other vital roles in some areas. For example, many established and successful children's health teams are being rearranged or in some cases disbanded simply to employ more health visitors. Ms Webber’s report claimed that the Government should replace the health visitor target with one that focused on the outcomes for children rather than on the numbers of staff in place. That was a very wise remark.
I turn to the children with the most complex difficulties and the question of how under this framework they will receive appropriate assessment and treatment that will address their individual needs. At best, there will be problems with the transition to the new system, and if there are gaps in the service for vulnerable children and learning-disabled patients who perhaps have GPs with limited experience, and doubts about how GP consortia will react to the situation, that is an issue of great concern. Historically, there has been an imbalance whereby people with learning disabilities have lost out when compared with those, for example, with mental health problems—who have also lost out. Therefore, how this group of children and young people are catered for will be a way of testing whether these things will work at all.
Baroness Hollins
My Lords, I am grateful to the Minister for emphasising the Government’s wish to improve outcomes for the group concerned in these amendments. I am pleased that current plans are to define these services through regulations. On behalf of my noble friend Lord Rix, I thank the Minister for their recent meeting at which I understand these issues were discussed in depth. I know my noble friend was very pleased to have that opportunity. I would like to pay tribute to him for his careful and persistent work to improve access to healthcare for people with learning disabilities. I shall look forward to seeing the information strategy in April and seeing just how far the information is going to be able to identify the needs that my noble friend and I are concerned about. I beg leave to withdraw the amendment.
Health and Social Care Bill
Baroness Hollins Excerpts(13 years, 1 month ago)
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Baroness Hollins
My Lords, I would like to add to what my noble friend Lady Murphy has said by commenting on a couple of amendments in this group which concern the need for the tariff to be able to reflect and adapt to the requirements of people with complex needs. I am thinking particularly about people with learning disabilities who may need additional time to be devoted to them because of their conceptual or communication difficulties, or other disabled people who may require reasonable adjustments to be made in order for them to use a service. I think also of people with mental health problems using hospital services such as maternity services. The provision of maternity care is hugely complicated by the presence of people with an enduring mental illness. The need for the tariff accurately to reflect and encompass these needs poses quite a challenge.
Baroness Tonge
My Lords, I rise to ask a question rather than to make comments. I am rather confused about how tariffs work. I am thinking particularly of sexual and reproductive health services. Therefore, I support Amendment 292A tabled by the noble Baroness, Lady Gould.
Sexual and reproductive health services are currently provided by general practitioners and clinics directly commissioned by primary care trusts. They can be family planning clinics, youth counselling clinics or genitourinary medicine clinics. Under the new system, GPs will presumably carry on providing sexual and reproductive health services and abortion counselling services, although I am unclear exactly how they will be remunerated in the future. Those GP services are very variable. Some GPs provide a superb service while others provide a very bad one. Some do not provide certain services at all so it is common for patients to go to clinics in their area which have been provided by the primary care trust.
Under the new health service, local authorities will commission and provide sexual and reproductive health services and abortion counselling services as well as HIV prevention services, but not the treatment, although I do not want to go into that now. They will be responsible for those sexual and reproductive health services. However, I am puzzled by the following matter. Currently, if a patient does not like their GP or finds that the GP does not provide the service they want, they can go to a local clinic. However, because of political or religious arguments within a local authority it may have made those services a very low priority, or perhaps does not provide them at all. It seems to me that there is nothing to compel local authorities to provide certain public health services. If a patient cannot get the relevant services from a GP or does not like them, and cannot go a local clinic because one is not available, can they go to a clinic in another local authority where they are not resident? This could be a problem for many patients all over the country, particularly young people who tend to go to different areas for their services where perhaps they are not known or the doctor does not know them. So I am very concerned.
Could the Minister please say how these services will be affected if no national tariff is set on public health services? How do we know that local authorities will not only provide services for sexual and reproductive health but accept people from other local authorities for treatment? It is a very important question for many people in this country.