Emergency Services: Paramedics

Baroness Jolly Excerpts

Wednesday 15th May 2013 Lords Chamber

[Earl Howe]

My Lords, the issue here is that they were not unqualified, as I tried to convey. All ambulance trusts in the UK allow student paramedics to work unsupervised, but only after they have had nine months’ operational experience and have passed both a written exam and a clinical practice observation by a qualified assessor. In this case, the London Ambulance Service accepts that, despite their qualifications and experience, the crew did not act in accordance with their training.

[Baroness Jolly]

My Lords, there are also volunteer first responders, trained with a minimum skill set and working with ambulance trusts across England. Will my noble friend tell the House who keeps the information about their deployment and how they are monitored for quality outcomes?

[Earl Howe]

I think that my noble friend is referring to first responders, who should be integrated into the clinical governance structure of all ambulance trusts. The outcomes will be assessed for all calls regardless of who attended the calls in the first instance. A first responder is just that—further ambulance staff would always be sent to a call. In rural areas, these staff can often get there first and provide immediate help, so the use of those people is a matter for local decision.

NHS: 111 Telephone Service

Baroness Jolly Excerpts

Monday 13th May 2013 Lords Chamber

[Earl Howe]

I take the noble Lord’s point. That is why the 111 service has been created; there is no doubt that there was a very confusing landscape in which people did not know who to call out of hours, and they did not necessarily have the telephone number of the out of hours provider in their area. The 111 service is designed to simplify all that, and across the vast bulk of England people are getting a good, if not fantastic, service. Unfortunately, in two areas of the country, the south-east and the south-west, we are still seeing problems arising, and those are being gripped.

[Baroness Jolly]

My Lords, the out of hours services, the ambulance services, A&E and these 111 services need to work in a harmonious and co-ordinated way for the good not only of the patient but of the service as a whole. Will the Minister reassure the House that the 111 service will be part of the review of urgent and emergency services being led by Sir Bruce Keogh?

[Earl Howe]

I am very glad that my noble friend has raised that issue. Sir Bruce Keogh is indeed looking across the piece at urgent and emergency care services, and that will include the way in which 111 is working.

National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013

Baroness Jolly Excerpts

Wednesday 24th April 2013 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, the hour is late and many of us are extremely keen to hear from the Minister. He took a brave decision in withdrawing the original set of regulations, and now we have these laid before us. Many people have posed questions and I hope that he will address them all head-on in his summing up. The lead question that has been asked tonight is why there is a such disparity between the centre here and how it is interpreted out there. Therefore, what will the Government do to make sure that there is no panic about challenges, that this does not become a lawyers’ charter and that integration works in the best interests of patients? Clause 2 suggests that it should take precedence over Clause 5 and that integration is key, because it will secure the best services for patients today and those of tomorrow. We have education, research and training in the Act and these also need to be secured for long-term stability. I suggest that we now need to hear from the Minister.

[Baroness Jolly]

My Lords—

[Noble Lords]

Minister!

[Baroness Jolly]

My Lords, many noble friends have already addressed the main issues of the debate and I do not intend to delay the House for long. I will confine my remarks to guidance—currently in preparation by Monitor—the role of Monitor in the process, and what the effect would be if the Prayer to Annul by the noble Lord, Lord Hunt, were successful. When we had our first meeting with the Minister about our concerns, we expressed our anxiety about the language. Laws they may be, but they did not have to be impenetrable and we improved the situation with the second draft, in particular, Clause 2 and Clause 5. I thank my noble friend Lord Clement-Jones.

The key issue, which my noble friend Lord Howe picked up earlier, is that we insisted that the guidance needs to be absolutely clear and unambiguous. It is written by Monitor, but it is signed off by the Secretary of State. We said that it needed to be a product not just of Monitor’s work, but also of various stakeholders’.

It also needs to contain a worked series of case studies so that people could see how things pan out in certain situations. During the Recess, the Secretary of State and my honourable friend the Minister, Norman Lamb, met some of the stakeholders and I understand that further meetings are in hand. But, of course, there is an open consultation as well. This has meant that the guidance is not published with the regulations. That is seriously to be regretted. However, if the end result is a workable set of guidelines with real case studies, time is the price that has to be paid.

What of Monitor’s other role, that of regulating and policing contracts? Until 1 April, much of NHS commissioning covered by procurement law was undertaken by PCTs. That meant that a supplier could take a PCT to court if they lost a contract unlawfully, and seek compensation and damages. That could be a waste of time and taxpayers’ money, damaging in one way or another to patient care.

After 1 April, PCTs, which could be ordered to do anything by the Department of Health, were replaced by CCGs, which could not. If we want to continue to keep the NHS out of the courts, something needs to have the same power over CCGs in relation to procurement as the Department of Health had over PCTs. That something is Monitor.

However, Monitor is not a body under the control of the department. Instead, it is directly under the control of Parliament. Instead of the department being able to tell Monitor to continue to enforce the PRCC—principles and rules for co-operation and competition—Parliament must do it for Monitor. Thus we arrive at the furore around the Section 75 regulations—Parliament’s way of telling Monitor to enforce the PRCC within the NHS. The regulations, like the PRCC, reflect the overarching requirements of EU procurement law.

I now come to a point that was picked up by the noble Baroness, Lady Hollins. In the general debate until today, much has been made of the opinion of this or that lawyer. Often, any one lawyer gives an opinion that reflects the view of whoever instructs them. We end up with as many views and opinions as we have lawyers. Therefore, with due respect to noble members of that profession, we need to inform our own opinions on this debate.

Without these regulations, all we have is EU competition and procurement law and the courts. There is no direction about the nature of services to be commissioned, and CCGs are completely unprotected and unsupported. What the regulations are not is a signal that the NHS is up for sale. The NHS will still be free to all at the point of need.

The purpose of these regulations is twofold. First, they are a legally binding tool, along with detailed guidance, to be used by the CCGs and NHS England when commissioning the best possible services for their patients and facilitating an integration of those services—services which put patients first. The regulations enforce that patient care is about competition and they outlaw cherry picking and vested interests. Secondly, to put it bluntly, they are to keep the NHS out of the courts. When we decide whether to support this Motion or not, those two conditions are precisely what we would do well to keep in mind.

[Baroness Masham of Ilton]

My Lords—

NHS: ECMO Machines

Baroness Jolly Excerpts

Monday 22nd April 2013 Lords Chamber

[Earl Howe]

I shall certainly take that idea away with me, but I think that there is broad consensus among the medical community that the key to success with ECMO is getting the patients connected to the equipment quickly. Although it is a moving scenario, all the evidence so far suggests that ECMO confers no benefit if some hours have elapsed since the cardiac arrest.

[Baroness Jolly]

My Lords, services that need ECMO machines would currently, in the new world, be commissioned by NHS England. Will my noble friend explain to the House what role, if any, the department now has in commissioning such services?

[Earl Howe]

My Lords, the department itself no longer has a role in commissioning highly specialised services. NHS England is implementing a single operating model for the commissioning of 143 specialised services. That replaces the previous arrangement whereby 10 regional organisations were responsible for commissioning specialised services and, to be frank, there were wide variations in the standard of those services. The new operating model represents a significant change to the previous system and should result in better outcomes.

Mid Staffordshire Foundation Trust Inquiry

Baroness Jolly Excerpts

Tuesday 26th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, I thank my noble friend the Minister for repeating the Statement. I am sure that many noble Lords will welcome, in due course, a full and spirited debate on this issue. Will my noble friend clarify which of the recommendations that are being adopted will require primary legislation, what the timescale might be and what the mechanism might be for that?

We welcome my noble friend’s remarks on the duty of candour but, as with all these things, the devil is in the detail. My question is about the chief inspector regime in general. We are going to have a chief inspector of hospitals so it would seem sensible to have a chief inspector of social care. Will we then need a chief inspector for public health and another one for mental health? Is that the way to have all the bases covered?

[Earl Howe]

My Lords, it is a little early to say what legislation we will need, but I can tell my noble friend that we can deal with the duty of candour by secondary legislation. It may be that many of the follow-up actions to Francis can be done without any legislation at all. However, primary legislation would appear to be the obvious route when statutory roles are to be changed.

With regard to the chief inspectors, the only firm decisions we have taken so far are to appoint a chief inspector of hospitals and a chief inspector of social care. We are looking at the merits of a chief inspector of primary care but we need to make sure that there is a genuine issue that needs to be addressed by way of a chief inspector role rather than leaving the CQC to perform its role in the normal way. Further details will be forthcoming at an appropriate time.

NHS: Out of Hours Service

Baroness Jolly Excerpts

Tuesday 26th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, in some parts of the country confidence has been lost in out-of-hours services. The NHS Commissioning Board takes over next week, so what can it do in terms of commissioning smartly to regain the public’s confidence in these services?

[Earl Howe]

We have known that out-of-hours care has been in need of reform for some considerable time. The much strengthened commissioning arrangements that we have put in place, including the national quality requirements that I mentioned earlier, will enable that to happen.

UK: Ageing Population

Baroness Jolly Excerpts

Tuesday 19th March 2013 Lords Chamber

[Earl Howe]

My Lords, I very much agree with the noble Baroness. It is our ambition that people should receive high-quality, integrated, person-centred services that deliver the best outcomes to the service user. Making the service as a whole more efficient is the other benefit of integrating service. There is no single definitive model of integration. Some localities are further advanced than others in thinking about new ways of delivering it. We are developing the concept of pioneers to support the rapid dissemination and uptake of lessons learnt across the country, but we want to encourage local experimentation as much as we can to allow local areas to provide integrated care at scale and pace.

[Baroness Jolly]

My Lords, there are several common themes between the report from the noble Lord, Lord Filkin, and his group, and that of the scrutiny committee of the draft Care and Support Bill, which was published today. One of those themes is the funding of personal care, which has to be shared between the individual and the state. As recommended by the Dilnot commission, will the Government invest in an awareness campaign to inform people of this situation and the importance of planning ahead?

[Earl Howe]

I am sure my noble friend is right that there is a job of work to do to inform people about the new arrangements that we are bringing in to implement the Dilnot recommendations. My right honourable friend the Chancellor’s announcement at the weekend confirms that we will introduce a cap on care costs and extend the means test upper capital threshold at the earlier date than previously announced, namely on April 2016. The reason for the change in date is to bring it into line with changes to single-tier pensions. We will need to disseminate this information sooner than we would otherwise have done.

NHS: Mid Staffordshire NHS Foundation Trust

Baroness Jolly Excerpts

Monday 11th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, I, too, thank the noble Lord, Lord Patel, for bringing this important issue to the attention of this House, and for so eloquently outlining all the areas of concern shared by all noble Lords.

The negligent treatment of patients at the Mid Staffordshire hospital is inexcusable. To an extent, we are all culpable, as we let a culture develop across the NHS that fails to keep the patient central. I know that, as noble Lords have said, this is not the same everywhere, but there are certainly quarters in some hospitals where one can identify this still. We are now obliged to build a system to prevent its repetition. Given the time restrictions, I will limit my comments to a specific viewpoint. I am taking the perspective of the patient.

Our systems should be more proactive in seeking out patient perspectives and more responsive in addressing their complaints. At Mid Staffs, the patients were speaking out about the abusive environment and many warning signs were apparent, yet no one was listening, these signs went unnoticed and any criticism was oppressed. Not only was the abuse suffered intolerable but it is unacceptable that this inquiry would not have happened without significant public pressure over several years. The inability of the hospital and the Government to act swiftly when presented with these conditions of appalling care must be reflected upon.

Putting patients and their needs at the core of our health service is one step that we can take towards correcting this. Many changes need to take place. We must stop designing our patient safety systems on what fits well with our institutions. Instead, the core of how we protect patients should be built around the patients themselves. Three areas of focus are needed to make this happen.

We need to ensure that patients, families and carers are empowered to speak out when they receive negligent care. I support the swift adoption of the recommendations to create an accessible complaints system. I note the point made by the noble Lord, Lord Turnberg, that we should not need a complaints system, and I hope to goodness that we will soon be in a position in which we will not need one, but until that time I believe that we do. Every patient should know how they can have a voice and should be secure in knowing that there will be recourse for any problems that they raise. I ask my noble friend the Minister to commit to a complaints system that is responsive and responsible, that all patients are aware of, and where complaints are thoroughly investigated and will be received by the board. Will the Minister confirm that such a system could be implemented anywhere that NHS money is spent: private, not-for-profit and NHS trusts alike?

Patients should automatically be given all information regarding the level of care that they have received, including information about any lapses in the quality of care or mistakes made. I therefore welcome the recommendation of the establishment of a statutory duty of candour. Health workers, be they senior consultants or junior nursing assistants, must feel that they can talk with their patients if something goes wrong. This creates an open dialogue between patients and their carers and ensures that mistakes are addressed in an open, well informed manner. Will the Minister confirm that there will be a statutory duty of candour?

In addition, patient organisations must be listened to and action taken. Local Healthwatches should use the tools they have been given to work on behalf of patients to make sure that negligent care is caught early and corrected. They need to ensure that Healthwatch England and the CQC are informed immediately where systemic abuse and intolerable care are identified.

Even if every one of the 290 Francis recommendations were to be instituted immediately, a more fundamental culture change must happen throughout health and social care facilities. Noble Lords have already referred to this cultural issue. Solutions, as seen through the perspective of patients themselves, should be core to the strategy. Through efforts to give patients information about their care, empowering them to speak out and then listening to their voice, we will be able to help prevent these tragedies in care repeating themselves.

Care Services: Elderly People

Baroness Jolly Excerpts

Wednesday 6th March 2013 Grand Committee

[Baroness Jolly]

My Lords, I start by thanking the noble Lord, Lord Turnberg, for bringing this important issue to the attention of this Committee. He has adequately covered areas of the economy, so I shall leave that. Care in the community is a critical component of our current health system and an even more critical component of our future health system, and we must ensure continued support for those who require and provide this vital service.

Today I wish to touch on a few distinct aspects of this issue. First, I want to highlight the growing demand for care in the community for the elderly population. As we are all certainly aware, the elderly population are particularly vulnerable to conditions that require long-term care which, if left untreated, can lead to a revolving door of hospital care for the elderly, which is both unhealthy and costly. Building on this, I want to draw attention to the ways in which the newly established clinical commissioning groups can work to improve the quality of care in the community as well as to encourage the use of this type of care. Finally, I will pose three questions to the Minister that reflect my concerns and hopes for the future of care in the community for elderly individuals.

Older people already represent the largest cohort of patients in the NHS, accounting for 60% of hospital admissions. Hospital days are dangerous for elderly people and expensive. Patients are susceptible to infections in the ward and often fail to eat properly while staying in the hospital. Moreover, these stays can encourage a loss of independence, which leads to added problems on discharge. Home healthcare is proven to deliver better outcomes for patients. There is evidence that it can lead to lower costs and reduce admissions to hospital. Home-based models of care have proven to be effective for patients with multiple diagnoses and comorbidities with a high risk of hospitalisation. According to Department of Health statistics, during September and October 2011 some 128,517 hospital bed days were lost as the result of the delayed discharge of people who could have been cared for in the community had the right support had been available.

In order to provide care in the community that is of the same quality as a hospital environment, CCGs must ensure collaboration between acute care, community care and social care. This was clearly called for in the Health and Social Care Act 2012, and we expect CCGs and local authorities to be actively pursuing this practice. It is particularly important for elderly patients as long-term conditions associated with old age are particularly complex to treat and often involve several different types of health and social care intervention. These services are provided over months and years by a range of organisations in the public, private and voluntary sectors, and it is hard to split them into single episodes. Pathway design is a critical and urgent task for CCGs to engage in.

In order to delay acute care for our elderly citizens, we must also refocus our energy on prevention. Joint strategic needs assessments must emphasise the value of preventive care for the elderly, including simple things: measures to decrease falls, improve nutrition to prevent diabetes and encourage community-based programmes such as Dementia Friends. Here the involvement of the voluntary sector can often be critical.

Part of the prevention agenda is about combating loneliness. Isolation is associated with poor physical and mental health in older people, both conditions that undermine the health we seek to provide our citizens. Local providers work together to address this issue and must not fall short in this critical area of care, because it is care. Social isolation affects about 1 million older people and has a severe impact on people’s quality of life in old age. Mentoring projects, befriending schemes and computer classes form part of a solution built to engage an elderly population in their community.

The patient must be at the centre of every health and care system we create. The location and community in which we choose to spend our later years deeply affects our quality of life. By supporting people to remain in their homes for as long as they wish, we provide an invaluable service to those patients we serve. In light of these remarks, I ask the Minister to confirm the following three expectations that relate to CCGs. CCGs will be expected to work alongside local authorities on integrated care pathways for the older population in the community, which might or might not involve shared budgets. CCGs will be expected to enhance preventive services in the community to reduce unnecessary hospitalisations. They will also be expected to embrace a campaign against isolation in the community, working with local authorities, especially among the elderly who wish to stay in their homes.

Health and Social Care Act

Baroness Jolly Excerpts

Tuesday 5th March 2013 Lords Chamber

[Baroness Jolly]

My Lords, I thank my noble friend for meeting Members from these Benches on this issue nearly two weeks ago. Will he confirm for the House that, in line with assurances given during the course of the Bill last year, the regulations will promote integration of services in the best interest of patients?

[Earl Howe]

I think that everybody was agreed during the passage of the Health and Social Care Bill that we wish to encourage integration in the way that services are commissioned. Integration in this context should be taken as a term that reflects the experience of the patient. The patient has to feel that he or she is on a seamless pathway of care. That care may be provided by a number of agencies, if necessary, whether in the NHS or social care, but the patient’s experience should not be disjointed. Therefore, as my noble friend will remember, numerous provisions were inserted into what is now the Act to ensure that commissioning should be on that basis. Nothing in these regulations interferes with that, but it is very much in our minds to make it crystal clear that integration of services is one of the main factors which commissioners should take into account.