NHS Commissioning Board: Mandate
Baroness Jolly Excerpts(12 years ago)
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Earl Howe
My Lords, I am grateful to the noble Lord for his welcome to the overall structure of the mandate and its content. I do not believe that there is an inconsistency between those two paragraphs. We have had a number of debates about specialised healthcare. I can confirm to him what I have said in the past: it will be the responsibility of the NHS Commissioning Board to commission services in relation to highly specialised conditions and, on top of that, those specialised conditions that are currently commissioned by the regional specialised commissioning groups. It is services for not only very rare conditions but slightly less rare conditions that the board will commission. That is a positive step that has been welcomed by the specialised healthcare community. We will spell out in regulations exactly what conditions are specialised conditions.
Paragraph 9.3 states that the way in which the board is held to account should be directly analogous to the way in which other commissioners in the health service are held to account. In other words, the board cannot expect not to be held to account by the department in a similar fashion. I hope that with that clarification, the noble Lord will be reassured.
Baroness Jolly
My Lords, I note that the mandate no longer sets quantifiable levels of ambition. The Minister explained how progress might be measured. There will be overarching indicators and improvement areas that will all match or mirror the five parts of the outcomes framework. Will my noble friend the Minister explain to the House how frequently progress is likely to be reported, and how it will be monitored by parliamentarians?
Earl Howe
I am grateful to my noble friend. The board will have to publish its progress against the objectives in the mandate. The Government will publish an annual assessment of its progress. We have set an objective for the board to demonstrate progress against all the indicators in the NHS outcomes framework. We will use a range of evidence to assess the board’s performance, including asking CCGs and other stakeholders for their feedback. This will be important, because it will provide the board and everybody else with a much more rounded view of how the health service is doing. The information will be publicly available, so everyone will be able to judge for themselves whether the NHS has achieved these stretching goals. In year, Ministers will hold the board to account. In particular, the Secretary of State will hold formal accountability meetings with the chair of the board every two months. Minutes of those meetings will be published. The meetings will be an opportunity to review performance and discuss issues as they arise, and as is right and proper.
Health: Obesity
Baroness Jolly Excerpts(12 years ago)
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The Minister of State, Ministry of Justice (Lord McNally)
I suggest that we hear from the noble Lord, Lord McColl.
Mental Health (Approval Functions) Bill
Baroness Jolly Excerpts(12 years ago)
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Baroness Jolly
My Lords, I will keep my remarks short given the need to progress the Bill through its remaining stages in this sitting. I was briefed over the weekend and I am happy to give it my support. The most important thing is that the patients affected by the legislation are the most vulnerable, posing a danger to themselves or to others. They need, as do the public, a solution to this dilemma, and it needs to be found as quickly as possible. Doctors need that resolving too. For the past 10 years, they have been practising competently in blissful ignorance of their situation, assuming that they are approved.
The Bill is retrospective and, like others, I regret that, but I am totally convinced of the need for it and confident that appropriate advice has been taken. However, some questions still arise. Can the Minister confirm that the intention of Clause 1 is to give power not only retrospectively but with effect from today? Can we be confident that people who think that they are approved today actually are and do not need to undergo any validation or approvals? Further, can we be confident that until 1 April 2013 there is a process in place for people wishing to be approved? If that is the case, and given the demise of SHAs, can the Minister please tell the House what the process will be for registering doctors with effect from April next year and how the preparations for this transfer of responsibility are being progressed?
I am pleased that there will be an independent review of what went wrong in these SHAs leading to this state of affairs. I understand that this will extend only to this narrow issue but it begs another question. Where is the definitive list of SHA roles and responsibilities and who is the guardian of that list? Can we be confident that there are no other areas where action has not been taken by some or all of the SHAs? Can we be equally confident that they will not be lost in the process of transition away from the world of SHAs and PCTs towards that of the national Commissioning Board and CCGs?
Finally, I return to the patients. When the Statement was debated earlier this week the noble Baroness, Lady Pitkeathley, who is not in her place today, brought up communication with patients. The noble Earl has just outlined what is going to happen. However, can he update the House on the timescale? I repeat that I am happy to support this Bill. However, it raises many questions about associated issues and I would be grateful if my noble friend the Minister were able to help clarify these matters.
Winterbourne View
Baroness Jolly Excerpts(12 years ago)
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Earl Howe
My Lords, I am absolutely in agreement with the noble Lord, Lord Laming, that it is really important that people are held to account for making change happen. We have indicated what we think that change should be, and that is why we have developed a concordat with key partners to get them to commit to the actions they will take. We also plan to strengthen the learning disability programme board, in particular to make sure that key delivery partners—such as the NHS Commissioning Board, the CQC, ADAS and the Local Government Association—are core members. The board will review progress on implementing the action set out in the final departmental report and the concordat. We have tried to address the issue that the noble Lord homed-in on—which is speed of action—but the core of his point was that there are too many people currently in specialist in-patient learning disability services, including assessment and treatment units, and that they are staying there for too long. This is often due to crises which are preventable or which can be managed if people are given the right support in their own homes and in community settings. That is the agenda that faces us.
Baroness Jolly
My Lords, what action can be taken against partners that fail to comply with the concordat?
Earl Howe
My Lords, I think that part of this involves defining roles and responsibilities. There is no single answer to my noble friend’s question. However, the transparency of the delivery of care, measuring outcomes and measuring the quality of commissioning in local areas are all important. It is also important to ensure that systems are in place to expose poor practice when it occurs. The problem with Winterbourne View is that, for too long, people did not know that those dreadful things were happening. Therefore, levers such as the introduction of local Healthwatch, the promotion of the new elements of the NHS constitution and ensuring that the CQC focuses its attention on where risk may most strongly lie, all have to be considered in the mix. I can tell my noble friend that this very subject will be covered in the report that my department will be publishing by the end of next month.
Mental Health Act
Baroness Jolly Excerpts(12 years ago)
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Lord Lloyd of Berwick
My Lords, perhaps I may speak later. I thought that the Liberal Democrat Benches wished to speak.
Baroness Jolly
My Lords, will the review look at whether the SHAs have made any approvals under any other legislation, such as the Mental Capacity Act?
Earl Howe
My Lords, the review by Dr Harris will take into consideration any lessons that need to be learnt. We have asked him to take into account any other possible lessons that we should take on board, particularly in the run-up to April 2013. However, I am happy to reassure my noble friend that her request will be passed on. If there is a relevance to the Mental Capacity Act, I will ensure that Dr Harris takes it into account.
NHS: Accident and Emergency Services
Baroness Jolly Excerpts(12 years, 1 month ago)
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Earl Howe
The premise behind the noble Lord’s question is that it is automatically worse to have fewer A and E departments in an area. I beg to disagree with that premise. In serious or complex cases, the noble Lord will know that patients need to access exactly the right care, so it is often better and safer for them to travel further to see specialists in major centres than to go to a local hospital. Although it may be closer, it may not have the right specialists, the right equipment or sufficient expertise in treating patients with their condition. The prime example of that has been stroke care in London, where 32 centres were reduced to, I think, eight and there has been a dramatic reduction in the number of deaths following admission.
Baroness Jolly
My Lords, does the noble Earl agree that wherever there are improvements to patient care that involve restructuring not only of services but premises, the impact assessment in the consultation document should include general transport and ambulance access?
Earl Howe
I agree with my noble friend. The planning assumptions made in north-west London, which is the subject of the Question, are a good example of that, where Transport for London is co-operating actively by producing some sophisticated analysis not only of ambulance transport times but of bus and car journey times to make sure that nobody loses out in any reconfiguration.
Care Services: Elderly People
Baroness Jolly Excerpts(12 years, 1 month ago)
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Baroness Jolly
My Lords, safeguarding the vulnerable needs real commitment from us all. Will the Minister tell the House whether the Government intend to support this by ring-fencing funds, as have Wales and Scotland?
Earl Howe
My Lords, we are not taking that approach. However, we have declared our intention to strengthen safeguarding arrangements to prevent and reduce the risk of significant harm to adults in vulnerable situations. That is a key priority for the Government. We intend to put safeguarding adult boards on a statutory footing. This will assist in furthering the agenda which my noble friend rightly raises, by ensuring that organisations involved in safeguarding have to make a co-ordinated contribution to local adult safeguarding work. Of course, it continues to be an offence for a provider to employ a person barred by the Independent Safeguarding Authority.
National Health Service (Clinical Commissioning Groups) Regulations 2012
Baroness Jolly Excerpts(12 years, 1 month ago)
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Baroness Finlay of Llandaff
The noble Lord, Lord Hunt of Kings Heath, has done us a major service by bringing forward a full debate on these regulations. We have discussed at length the problem of secondary care representation. Indeed, the fact that there will be secondary care representation and nurse representation on clinical commissioning groups is welcome. However, the principle of integration seems to be blown apart by the way in which these regulations are written. The Royal College of General Practitioners and the Royal College of Physicians—I declare an interest as a fellow of both—and the Royal College of Paediatrics and Child Health produced a document entitled Teams without Walls about involving generalists and specialists to ensure a better, more seamless journey for patients.
In an area—and we are trying to have more localism and more local involvement in decision-making—the very clinicians on half of this pathway are now excluded from involvement in the planning and decision-making for those services yet they are the clinicians who have an in-depth knowledge and experience of the health economy, integrated working and, indeed, of the deficits in standards. That is where I wish to focus my remarks for a moment. The Francis inquiry has not yet reported but I understand that the Government have given a commitment to implement the findings when they come out. I do not understand why the Government have not left this matter completely open at the moment. If the Francis inquiry considers that there is not enough integration between secondary and primary care in decision-making, planning of services and so on, then allowing a secondary care clinician from the local area to be on the clinical commissioning group would provide the flexibility that Teams without Walls refers to.
The clinical governance of an area and its problems will be known to the local secondary care services, and they will know it across the board. There has been concern about conflicts of interest, yet a medical director in a trust represents a range of different specialties, and that has not been a problem. Clinicians have learnt how to do it. The Royal College of Physicians has produced guidance. It will produce guidance on a competitive appointment process whereby the best person for the job gets the job, and it has produced a clinical commissioning hub as a support for secondary care in its involvement in clinical commissioning groups. You could say that the basic rule of physics pertains—two negatives make a positive. It is difficult to understand why the conflict of interest that the GPs will experience, where they may be providing part of secondary care services themselves, does not matter in this, and yet it is completely prohibited to have a secondary care person who might understand how that interface between primary care and secondary care will work better at a local level. That person is excluded. It seems to work particularly against rural areas.
The last point I should like to make—apart from reminding the Government that the absolute reverse principle has been in place with the local education and training boards, where local people are involved in the very processes of commissioning the education—is about the people who will come forward. We already know that, to date, there is underrepresentation of secondary care. A clinician who is going to apply to be on a board and leave their clinical service, travel long distances and be involved elsewhere is not going to be the clinician who is completely dedicated to their local NHS service. The clinician who is dedicated to their local service and driving up care for patients is going to be the very person who will be most motivated to work with the clinical commissioning group to improve the services and the seamlessness across the piece. Excluding local clinicians seems unnecessarily to be closing down flexibility.
Baroness Jolly
My Lords, this is a debate about conflicts of interest and getting the right person for the job. During the passage of the Bill, my noble friend Lady Barker led the call for conflicts to be declared where a board member has connections with a provider, where GPs can provide secondary services from their practices and where there are connections with commissioning support organisations. This was deemed right and proper, and was incorporated into the Bill.
It is important that the right people sit on clinical commissioning group boards and there are clear guidelines about competence, as well as protocols about conflicts of interest. This piece of secondary legislation puts restrictions on a clinical commissioning group in the choice of its members, irrespective of their competence, in two areas. One restricts councillors from being on the board and the other restricts the clinicians to those who work for providers from whom the clinical commissioning group does not commission services.
Time restricts me from addressing both issues so my noble friend Lady Williams will address the area of clinicians. In nearly 10 years as a member of an NHS trust board, I have sat with members of all political parties and none, some of whom were councillors. Where we had conflicts, they were declared. In that time, everyone left their party allegiances at the door. They were clear that they were there to look after the interests of the NHS in their patch, and had the skills and competences required for that role. It has been like this all over the country for years. It is worth mentioning that the work of Torbay Care Trust, which has been referred to frequently, depended on both NHS non-executive directors and councillors being on the board and working together.
Clinical commissioning groups want the right person for the role. They advertise, interview and appoint. It might be that the right person is a councillor, or not. This SI restricts their choice. Councillors know the community and, furthermore, particularly in the beginning, could have given useful guidance on the workings of the council because that is an area where GPs have generally not ventured—unless of course they are a councillor and a GP. This legislation has an unintended consequence for both doctors and indeed a nurse appointed as one of the two clinicians. The LGA wrote to the then Secretary of State as soon as the SI was published. The letter was signed by Councillor David Rogers, who is chair of the LGA Community Wellbeing Board and the only councillor member of the NHS Future Forum. He wrote:
“We do not accept the case for barring councillors from the governing body who hold professional roles within the NHS, as the reason for the appointment would be their professional experience within the health service—such as the GP … The Government, if it does not listen, is in danger of creating an unintended consequence of both discouraging experienced health service personnel from getting involved in their clinical commissioning group and from discouraging them from getting involved with their local authority”.
Councillor Rogers adds:
“I know that you are fully aware that all councils have standing orders that address conflicts of interest. We expect all public bodies, including clinical commissioning groups, to have equivalent rules regarding membership of their governing bodies but the proposed statutory instrument is far too wide-reaching and disproportionate. It will not only affect GP councillors serving on the governing bodies of clinical commissioning groups but any health professional group that a clinical commissioning group decides it wants represented on the governing body”.
I also received an email from a councillor GP who had been told that he had to make his mind up. Did he want to sit on the clinical commissioning group or did he want to remain a councillor? This level of restriction was not mentioned during the passage of the Bill. He asks:
“What are the justifications for this action which makes clinical commissioning groups the most politically restricted Public Body within the UK ? Where is the evidence”—
we spent a lot of time during the passage of the Bill trying to ensure that things were evidence-based—
“that this is in the public interest? Will GPs be banned from holding political office as Councillors on the basis that they could influence Health and Well Being Boards?”.
I should like the Minister, in summing up, to reassure the House that this was indeed an unintended consequence, and that when the implementation of the Bill is reviewed in 2014, clinical commissioning group governance will indeed be part of that review. Also, for those councillors who would have wished to become engaged in the commissioning of services, will he indicate how the clinical commissioning group might still involve them, so that their skills and competences are not lost?
Baroness Cumberlege
My Lords, I declare an interest, which is in the Register of Lords’ Interests. I want briefly to address two points. The first regards the wording that the noble Lord, Lord Hunt, has tabled for the debate, which concerns the prohibition of,
“a registered nurse or secondary care specialist if employed by a body which provides any relevant service to a person for whom the Clinical Commissioning Group has responsibilities”.
My second point is simply about local authority members being members of clinical commissioning groups.
In the past two months, I have had in-depth discussions with four CCGs in different parts of the country. I will be visiting a fifth tomorrow. The impression that I get, quite understandably, is that they are very variable. Some are only just getting established and hardly have their membership in place, and others are well under way. We expect that. It is a new architecture. CCGs have a lot to do, as the noble Lord, Lord Hunt of Kings Heath, said, and some are quicker than others. We would expect that.
However, in one of the London CCGs, the consultant from a well known and respected London teaching hospital, which is outside the CCG area and its commissioning remit, is clearly playing an important part in advising the CCG—as is the very impressive nurse. Neither has any conflict of interest within the CCG because they are people from outside, but they are using their experience, as the noble Baroness, Lady Finlay, said, to explain clearly the implications of some of the decisions that could be taken in future. I thought that the CCG was getting really good advice and I could see how that was going to inform it in the future.
NHS: Professional Qualifications Directive
Baroness Jolly Excerpts(12 years, 1 month ago)
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Earl Howe
The SiMAP and Jaeger judgments are very much the focus of our representations to the EU Commission. The disquiet about those judgements and the inflexibility that they have brought is shared by other member states. It is also important to recognise that none of us wants to go back to the past, with tired doctors working excessive hours. Tired doctors make mistakes; there is substantial evidence to support that. No one wants or deserves to be treated by tired doctors. There is a balance to be struck. The inflexibilities in the directive need to be addressed, but we should not go back to the bad old days when doctors became too tired to do their work.
Baroness Jolly
My Lords, if a clinician fails to understand a patient or to make themselves understood, their clinical competence is undermined. Will the noble Earl tell the House the current situation regarding the required level of English language competence of a doctor or other clinician from an EU state who wishes to practise in England?
Earl Howe
My Lords, we are now talking about the mutual recognition of professional qualifications directive. We have made it clear that we want to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests. As a result, we have explored the idea of strengthening language testing for doctors through the use of responsible officers; and explored also the GMC’s ability to take action where concerns arise. The directive review is a key priority for the Government, and the Commission’s proposals include greater flexibility on language. It is helpful that the proposal from the Commission makes it clear that controls on language checks are permissible and may be undertaken before a professional is able to practise.
NHS: Walk-in Centres
Baroness Jolly Excerpts(12 years, 1 month ago)
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Baroness Jolly
My Lords, no one doubts the worth of walk-in centres or minor injury units. It is well established, but we need to know where they are. Will the noble Earl tell the House how often the information on the Department of Health website is updated? Who is responsible? Will he please pass on the message that it is woefully out of date and inaccurate, thus defeating its object?