Health: Cancer
Baroness Jolly Excerpts(12 years ago)
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Baroness Jolly
My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for securing the debate. It is timely and allows all areas around the treatment of head and neck cancers to be discussed. I will examine areas around diagnosis, prevention, treatment and the pivotal role that cancer networks have played in achieving improved head and neck cancer services.
The noble Baroness is well known for her championing of the role of the dentist. In the area of cancers of the head and neck they can be key players in diagnosis, spotting signs and symptoms before the patient and their GP. However, there are issues around this that need resolving in the area of the training and continuing professional development of dentists and GPs.
The evidence on the incidence of head and neck cancers and their occurrence in younger age groups is mixed. The prime causes of most of these cancers are smoking, alcohol and a poor diet—back to the five a day and three different-coloured fruits—as well as the human papilloma virus. That suggests that the age range of those affected might be wide.
There is a clear public health role in prevention. If Public Health England and public health departments in local authorities carry out the roles envisaged for them in the Health and Social Care Act, the incidence of these cancers should reduce. However, care must be taken to ensure that the NHS, Public Health England and local authorities co-ordinate their approaches and campaigns. At least three-quarters of oral cancers could be prevented by the elimination of tobacco smoking and a reduction in alcohol consumption. The scheme to make cigarette purchase less easy is to be welcomed and I urge the Government to follow the advice and not the tobacco lobby in adopting plain packaging for cigarette packs at the earliest opportunity.
Can the Minister tell the Committee what plans the Government have to address the issue of underage drinking in the home? Despite the scenes of rowdy young people in town centres, most alcohol is actually drunk at home by young and old alike.
As we have heard, HPV is often linked to oropharyngeal cancers. The evidence of this cancer has doubled in 10 years. There must be a case for vaccinating all teenagers and not girls alone. Will the Minister consider looking at the evidence for this?
Most people do not know that radiotherapy cures more cancers than drugs. Cancer patients should have access to treatments that their doctors think will be best for them. It is essential that new radiotherapy techniques, such as intensity modulated radiotherapy—IMRT—are rolled out swiftly. IMRT can be really beneficial to patients with cancers of the head and neck. It focuses very much around the cancer itself and does not spread to surrounding tissue. It is a welcome announcement that £15 million is to be found for such targeted radiotherapy treatment. For this to be widely available across England there are implications for both equipment and training, but it is a good start.
Currently all aspects of cancer care are co-ordinated by cancer networks, multidisciplinary teams looking at the whole pathway through diagnosis, treatment, hospice and palliative care where required, and aftercare when the patient returns home. This is all about integration at work. They have played a key role in driving up the quality of cancer services and patient experiences for the past 12 years. I draw attention to the excellent work of cancer networks and raise some concerns about their future in the new system.
In England there are 28 cancer networks that, since 2000, have been bringing together providers and commissioners of cancer care to work together to plan and deliver high-quality, integrated cancer services for people living with and beyond cancer in their local areas. These networks drive forward local cancer strategies. They are a key source of cancer expertise, encourage service redesign and integration, and monitor the performance of providers to highlight poor outcomes. Many cancer networks have been central to the implementation of NICE’s guidance on improving outcomes on rarer cancers. Many of the cancers that we are discussing today fall into that category. More specifically, they have also been acknowledged as key players in delivering NICE’s service guidance on improving outcomes in head and neck cancers. These are not common cancers, and the networks have been used to disseminate information.
NICE recommends that networks should be charged with deciding which hospitals will diagnose, treat and care for these particular patients. So when it comes to the quality of care that people living with head and neck cancers receive, networks have been driving service improvements throughout the country. An example of integration and service improvement is the Greater Manchester Cancer Network, which has a head and neck clinical sub-group with the aim of overseeing, supporting and bringing together multidisciplinary teams working on these types of cancer to ensure that each patient gets the most appropriate treatment and the highest standards of care. There are several networks that have co-ordinated to inform local strategies for head and neck cancers and to promote integration: East Midlands, Anglia, Central South and North London to name a few. These have been absolutely pivotal. They have also been critical in driving up patient involvement. The Peninsula Cancer Network hosts head and neck cancer support groups across Torbay, Cornwall and Plymouth for people who find it difficult to eat, drink or speak after having treatment due to head and neck cancers.
It was encouraging that, last year, the former Health Secretary made a public commitment to fund and support cancer networks in 2012-13. I welcome the proposals on clinical networks recently published by the NHS Commissioning Board Special Heath Authority which officially establish cancer networks as strategically clinical networks in the new NHS.
However, the significant changes proposed for the new structure for cancer networks leave me with a worry about how networks will be supported in delivering their key services. In the sector, there are fears in three distinct areas. The first fear is of a drastic reduction in the staffing levels for cancer networks. The proposals indicate that there will be only eight permanent staff in each regional team, compared to 20 staff members currently in post per network. Research carried out by Macmillan also showed that a number of network directors reported difficulties in recruiting and retaining staff because of uncertainty around resourcing. Can the Minister assure the Committee that cancer networks will have sufficient staff to carry out their functions effectively?
The second fear is of a loss of experienced directors, which would have an impact on the effective running of cancer networks. Under the proposals, existing directors with a wealth of knowledge in the development and delivery of high-quality cancer care in their region will have to reapply for their roles. Recruiting and training senior staff, some of whom have had no previous experience in cancer, could have a negative impact on the quality of services and support that cancer networks provide. Can the Minister suggest what steps he will take to ensure that experienced directors and cancer experts are retained?
The third fear is of cancer networks’ role being limited to early diagnosis. Although improving earlier detection of cancer is essential to preventing people dying prematurely—as we have heard today, head and neck cancers often go a long time before they are detected—cancer networks need a comprehensive remit to be able to continue delivering the functions mentioned above. They must continue to play a leading role in improving outcomes and the experiences of people living with head and neck cancers across the pathway. Can the Minister confirm that cancer networks will be able to continue delivering functions that cover the whole pathway? Cancer networks have played a leading role in delivering improved outcomes for rarer cancers, including head and neck cancers. I am pleased that the Government have recognised their value and formally established them as strategically clinical networks. However, significant steps are needed to ensure that they continue to have a comprehensive remit beyond early diagnosis. The Government should be mindful that severe reductions in resource would make it difficult for them to meet their commitment of supporting networks after 2013 and reaching their ultimate ambition of saving 5,000 lives a year. I would be grateful if the Minister could update the Committee on the Government’s plans for cancer networks and reassure us that they will have sufficient resource, human and financial, in the system.
I again thank the noble Baroness, Lady Gardner, for securing such an important debate. We must not forget that the NHS reforms offer an opportunity to refocus on delivering the best possible cancer care and outcomes for all patients, including those with head and neck cancers.
NHS: Health Workers
Baroness Jolly Excerpts(12 years, 3 months ago)
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Earl Howe
There is a clear role here for the professional bodies. Training should be done in the right disciplines and numbers and in the right way. I am sure I do not need to tell the noble Lord that in virtually all the medical royal colleges and through the Royal College of Nursing, there is an increasing emphasis on leadership backed by resources from the Department of Health. We are seeing a drive forward for innovation and the breaking down of professional barriers, which is another aspect of this issue.
Baroness Jolly
My Lords, we now accept nurse prescribing as perfectly normal and sensible, and these changes were implemented when the NHS was the major provider of health services. Therefore, what challenges or opportunities does the Minister think that the new diverse health economy will pose to task shifting?
Earl Howe
My noble friend poses an extremely complex question. She is right that regulatory improvements such as nurse prescribing are making a difference and we are looking to see what other professions can also share in that sort of freedom. As the NHS gets more plural, we are able to drive the consistency and quality of practice through the NHS standard contract, through regulation, as the noble Lord, Lord Crisp, emphasised, and also through the clinical leadership referred to by the noble Lord, Lord Kakkar. That applies not only in NHS settings, but in private and independent settings as well.
NHS: Specialised Services
Baroness Jolly Excerpts(12 years, 3 months ago)
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Baroness Jolly
To ask Her Majesty’s Government what is their assessment of the future of the work of the Advisory Group for National Specialised Services.
Baroness Jolly
My Lords, I declare an interest as chair of the Specialised Healthcare Alliance, a coalition of 79 patient-related organisations receiving financial support from 11 corporate members, which campaigns on behalf of people with rare and complex conditions.
The Advisory Group on National Specialised Services, or AGNSS, was established in 2010. Its role was to provide a single source of advice to Ministers on whether services, products or technologies for very small patient populations, usually not exceeding 500 for England as a whole, should be commissioned at national level rather than by PCTs, individually or collectively. Some 65 services are enormously important to over 10,000 people with a range of very severe and frequently life-threatening conditions.
What makes AGNSS different is that it brings eminent clinicians together with commissioners in considering these complex matters and integrates other vital perspectives through members with health economics and ethical expertise and from the lay community. For the first time, AGNSS evaluates services, products and technologies using an ethical decision-making framework that holistically balances a range of factors, including patient need, clinical severity, clinical effectiveness, affordability, service efficiency and the value to society. It would be fair to say that the development of AGNSS and its decision-making framework, with widespread input from all parties, was seen as a model of its kind and that the group, under the capable leadership of Professor Michael Arthur, has only grown in stature over the past two years.
Organisations and others with an interest in the health and welfare of people with very rare conditions were greatly concerned when it was announced at the turn of the year that AGNSS would be entering a moratorium, pending decisions about its future. If the reaction to this debate is anything to go by, it is much appreciated and valued by research scientists, organisations representing patients and pharmaceutical companies, who have all expressed their alarm at its possible demise.
My understanding is that this decision stems from the view that an advisory group for Ministers will be incompatible with the provisions of the Health and Social Care Act 2012, which devolves responsibility for the commissioning of all specialised services to the NHS Commissioning Board. To quote from my noble friend the Minister’s letter of 8 June to Mark Simmonds MP:
“In the future, there will be a clear differentiation between what services the Board should commission and how those services are commissioned. It will remain the responsibility of ministers to consider, on the basis of appropriate advice, the list of services that should be directly commissioned by the Board. Ministers will then consult with the Board on those services before laying regulations that will specify the services that will be commissioned. It will be for the Board to decide how it commissions the service”.
As the letter acknowledges, Ministers will need advice on what services are to be prescribed in regulations for commissioning by the board. My understanding is that the Clinical Advisory Group, presently chaired by a civil servant, Dr Kathy McLean, will fulfil this function in relation to the generality of services. The question is whether highly specialised services should be channelled through the same route.
The views of eminent clinicians presently sitting on AGNSS or leading services commissioned through the AGNSS process suggest that this is at least worthy of debate. In particular, AGNSS is recognised as a route whereby such services can engage with commissioners. I am told that this is an iterative and demanding process, taking some considerable time before a decision is taken. The net result is generally one where there are indeed costs to the NHS, but often costs that are reduced as a result of coherent commissioning. For example, the decision to commission severe acute porphyrias means that young people presenting with potentially fatal attacks should now have speedier access to expert care with less wastage of the relevant drug, haem arginate, which has a short half-life. Similarly, AGNSS was able to advise on the managed introduction of extracorporeal membrane oxygenation, or ECMO, which has saved many people whose lungs are severely distressed, most notably as a result of swine flu.
The danger is that without a clear port of call in the form of AGNSS, these important services may get lost from sight, as will the opportunity to develop them in a way that meets the needs of patients and delivers best value to the NHS. Furthermore, Ministers may be hard pressed to decide on whether the board should commission such services without high-quality advice on what they comprise.
The relevance of these services, not just to England but to all parts of the United Kingdom, would also seem to count in favour of retaining an advisory group alongside Ministers, as would the broader strategic importance of issues such as proton beam therapy. I therefore put it to my noble friend the Minister that in the case of highly specialised services there might be merit in retaining a group providing a single source of advice to Ministers but with a dual reporting function to the board in determining how such services should be commissioned.
As for the composition of this group, I have heard it said from reliable sources that if AGNSS did not exist it would need to be invented. In a recent conversation with Professor Arthur, he outlined the three components that made AGNSS effective, unique and special: the support from the national specialised commissioning team, the strength of the group—an ethicist, a health economist, a geneticist, a pharmacist, representatives of all royal colleges, representatives of SHAs, lay people, carers and patients, commissioners from PCTs and a member of the HTA—and excellent advice to AGNSS from public health doctors.
We are going through a period of enormous change in the NHS, but change for change’s sake is to be avoided at any time—and surely now more than ever. I therefore urge the Minister and the chief executive of the NHS Commissioning Board to think carefully about disbanding AGNSS when the need for it remains unchanged. Historically, the view has been taken that NICE would struggle to combine under one roof the evaluation of products with a cost per quality-adjusted life-year often very substantially higher than the threshold which usually applies. Furthermore, in this highly specialised field, where a service develops around a novel treatment, the distinction between services, products and technology is sometimes difficult to make in areas of previously unmet need.
The AGNSS decision-making framework therefore represents a major step forward. It recognises that the evidence-base for small patient populations may be less developed. At the same time it imposes demanding standards in terms of the number of patients whose condition improves as a result of a treatment, compared to the total number of patients treated. This approaches 100% for more expensive services, products and technologies.
That progress has been hard won and should not be squandered but built upon. In a debate in the House of Commons on 30 April about a strategy for rare diseases, the Minister of State, the right honourable Simon Burns MP, appeared to suggest that value-based pricing will supersede the need for separate arrangements for treatments for very rare conditions, but that alternative options will be explored in case of need.
All are agreed that value-based pricing has exciting potential. The challenge of expressing that potential will be considerable for the generality of treatments, but it will be undoubtedly greater for very rare conditions. In the mean time, retention and development of the AGNSS framework would seem to have great merit.
AGNSS represents something of a jewel in the crown. The dancer cannot be easily separated from the dance in determining which highly specialised services to commission and how to commission them. Ministers will continue to need high-quality advice. I would hope also that the first mandate to the board recognises the value of this heritage and bestows it for safekeeping.
NHS: Private Finance Initiative Costs
Baroness Jolly Excerpts(12 years, 3 months ago)
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Earl Howe
My Lords, the Treasury has been very helpful in advising my department on the kinds of flexibility that we may have in these difficult situations. It has also been helpful in refining the current PFI model so that, as and when we use PFI again, we have a tighter structure which strikes a better balance between risk and reward to the private sector.
Baroness Jolly
My Lords, many community health schemes were funded using the LIFT programme. What is the Government’s view of their affordability now?
Earl Howe
My Lords, LIFT is one tool that we have in financing capital schemes in the community, many of which have been successful. Such schemes promote integrated services, which I know my noble friend will welcome. All LIFT schemes have been and will be assessed for affordability and value for money. It is not a universal prescription by any means, but we look constructively at LIFT as one way of delivering capital schemes.
Care and Support
Baroness Jolly Excerpts(12 years, 3 months ago)
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Earl Howe
My Lords, I fully agree with the noble Lord about the need for cross-party consensus. If we are to have a long-term sustainable solution for the funding of social care, we must have that political consensus. Indeed, that was the intent behind the cross-party talks. I very much regret the leaks. These were not our doing, but they did create an impression of bad faith. Again, I regret that. No bad faith was intended from our quarter or indeed from any other quarter in government. I think there was an element of misunderstanding about our intentions, but I agree with the noble Lord that the cross-party bonhomie has been disrupted. We very much wish to put the whole process back on track, and I hope that his party will respond accordingly.
Baroness Jolly
My Lords, I am a glass half-full sort of person, so I heartily welcome the White Paper and the draft Bill on care and support, and note the progress report on funding reform. We are certainly looking forward to pre-legislative scrutiny. Can the Minister give the House some indication of the timetable and the process? Will he also tell the House what the Government’s view is on including enabling clauses in the draft Bill to allow the Dilnot-based scheme to be implemented?
Earl Howe
My Lords, my provisional understanding —and I stress that—is that pre-legislative scrutiny will begin in the autumn, probably in November. Between now and then, plans will be put in place to decide the composition of the pre-legislative scrutiny committee so that the process will conclude by the end of this Session of Parliament. In principle, there is no reason why enabling clauses should not be inserted into the legislation. As I have emphasised before, it would be preferable if they were clauses on which we could all agree.
NHS: Dental Care
Baroness Jolly Excerpts(12 years, 4 months ago)
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Earl Howe
My Lords, my noble friend is correct. Treatment provided on the NHS carries only one pricing tariff, which cannot be varied. The OFT report found that only 1% of NHS patients and 2% of private patients chose a dentist on the basis of price. I stand to be corrected, but I do not believe that it made any suggestion that NHS charges were uncompetitive; they are, and always have been, a subsidised contribution to NHS costs—they are not a market price. Therefore, I imagine that the OFT report reflected the fact that patients were comparing private charges with NHS charges. Of course, the NHS is in general free at the point of use, but my noble friend is right. It is important that we are clear that some charges exist, as they have in dentistry for 60 years.
Baroness Jolly
My Lords, some may avoid the dentist because they cannot find one, others for fear of high costs, and others just for fear. Have the Government carried out any work to determine what proportion of the population does not attend a dentist, and the reason why?
Care Quality Commission (Registration and Membership) (Amendment) Regulations 2012
Baroness Jolly Excerpts(12 years, 4 months ago)
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Baroness Jolly
My Lords, we all want the CQC to be effective and efficient. The noble Lord, Lord Hunt of Kings Heath, has laid out a clear description of its history and where it is now. It has a difficult task: it has to balance registration complexity for those providing both health and social care and ensure safety and quality of services. Of course, since the Act of 2012, all providers in the public, private and voluntary sectors are involved and it has to extend its remit to include dentists and GPs. It has a huge task. There have clearly been failings in the past, but the organisation as a whole has faced up to them and has made many strides forward.
We have this SI as a result of the Health and Social Care Act 2012. It is in two parts—registration, and governance and membership—and it throws up more questions than answers. I was reminded of a long time ago when I was a CHI reviewer. The training was superb; the teams went in and the inspection was intensive and penetrated every corner. Perhaps there would be some mileage in looking back at that model to see whether it could be incorporated into what currently exists.
Lord Hunt of Kings Heath
I was interested in the noble Baroness’s comments about the CHI training process. Does she agree that one of the great advantages of the CHI approach was that, when a team went in, it had respect because the people in the team were the equals, if you like, of the people whom they were inspecting and, although it was an inspection and allowed people to work with an inspection team, it was almost a development opportunity for the organisation as well?
Baroness Jolly
Certainly that was my experience. Although there were instances where we had uncomfortable inspections, afterwards an awful lot of work was put in to try to remedy issues that had been raised. The team went in as a team and worked as a team. Everyone on the team had experience of working within the NHS in one format or another and, although we may not have carried out identical roles to those that we were inspecting, there was a clear awareness that we knew what we were about. I shall not carry on at great length because of the time.
The amendments to the registration are a tidying-up exercise. All that we are doing is replacing the National Patient Safety Agency with the NHS Commissioning Board Authority, so it is a cut-and-paste job, if you like. Will the Minister confirm that in due course this will subsequently transfer to the board when the board becomes the board and not just the authority? Will the Minister clarify the situations where deaths and other incidents in these situations involving service users—vulnerable people—are reported and say why they might be reported to the board and not to the CQC? If we are to learn anything from this information, it is critical that the board commits to publishing it on a regular basis. It also needs to be part of the board’s regular agenda.
On a related issue, will the Minister update the Committee on deaths of service users and untoward incidents, which cause difficulty for carers and, in the case of untoward incidents, the patients themselves? During the consideration of the 2012 Bill, there was much debate about the duty of candour. Will the Minister give us some sort of update on where things are? I remind him of his comment on 27 February:
“I reiterate the commitment that I have given today that the Government intend to use the ‘standing rules’ regulations to specify that the contractual duty of candour must be included in the NHS standard contract”.—[Official Report, 27/2/12; col. 1055.]
That was a welcome move but I would appreciate it if the Minister could update us on where we are. I appreciate that this will not happen overnight; it will require training and a large amount of cultural change.
I move on to the governance and board membership issue. Today we had the interesting interim report on the Winterbourne View Hospital. Bearing that in mind, will the Minister reflect on whether he believes that the new governance arrangements proposed in these regulations will minimise or even avoid a repetition of this level of behaviour or such an appalling lack of dignity for those with learning disabilities? Does he believe that adequate funding is available for the CQC? Again, the noble Lord, Lord Hunt, gave us a long list with numbers relating to its remit—it is really broad and deep. The Committee would probably feel comfortable if it felt that the CQC was being ably supported with adequate resources. It has had a difficult role in changing times and it can use its registration requirements to drive up quality. To that end, the Government must work with it. I think that we would all agree that service users and carers deserve no less.
Baroness Wall of New Barnet
My Lords, I, too, support my noble friend’s view of the CQC. I want to mention, as he has done, the work carried out by the previous chief executive and the chair of the CQC, and welcome the new chief executive. The noble Lord may remember that when we had a discussion in the House on the social services Bill about care in some care homes, he made a plea, in response to a question, that we should look at the CQC’s responsibilities and not blame the CQC itself for everything that happens. More and more, that is certainly my view.
I am not aware of any detail of the alternative ways that the noble Lord and the noble Baroness, Lady Jolly, have mentioned, but I am concerned about—my noble friend raised this issue—the credibility of the CQC. I have noticed from my experience in the trust that the more responsibilities the CQC has been given, the greater the perception that it is going to be very thinly spread and that its expertise will in some way be weakened. That may be people’s view rather than the reality, but I think that we owe it to everyone who has a relationship with the CQC not to dilute it by continually adding to its responsibilities. I know from my own experience how important its inspections are, certainly in hospitals.
The noble Lord referred to my trust, which covers a two-district general hospital, and also to some very small GP practices and other areas of work. I am a great supporter of the CQC, as the noble Lord will know. I feel that it has done a tremendous job and has made a difference compared with what happened before it came into being. I want to strengthen that rather than in any way to dilute its reputation. For example, people who work in my hospital say, “My goodness, it’s doing everything now”, but what does that really mean? I am sure that the noble Earl will have listened to everything that has been said and that he will think very carefully about what the CQC’s credibility means to all of us in terms of its responsibilities.
Older People: Health and Social Care
Baroness Jolly Excerpts(12 years, 4 months ago)
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Earl Howe
My Lords, decisions about the content of the mandate will be made on the basis of a full public consultation, which will take place in the summer. More details on that score will follow in due course so there is a limit to what I can say at the moment. However, as I indicated during the passage of the Health and Social Care Act, the mandate is likely to include expectations for improving healthcare outcomes for patients, based on the NHS outcomes framework. That framework reflects the Government’s ambition for an NHS that provides high quality, safe and effective care, treating patients with compassion, dignity and respect.
Baroness Jolly
What measures will be taken by the national Commissioning Board to ensure that clinical commissioning groups always pay proper attention to dignity when commissioning services for older people?
NHS: General Practitioners
Baroness Jolly Excerpts(12 years, 5 months ago)
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Earl Howe
My Lords, this is a very exciting area. I have seen some extremely good examples of telemedicine that will deliver not only greater efficiency within the health service, sometimes enabling clinicians to diagnose conditions in patients from a remote standpoint, but also greater safety and effectiveness of care for patients. For example, I saw a demonstration of stroke diagnosis that can be done remotely by laptop. This is an area on which the department is focusing a lot of attention, not least through the 3millionlives initiative, through which we hope over the next few years to ensure that 3 million people benefit from telecare and telemedicine.
Baroness Jolly
My Lords, what role should practice-based patient participation groups have in moulding the services that their GPs offer?
Earl Howe
My noble friend is extremely familiar with this area. I have also come across some extremely effective practice-based patient groups that are enormously valuable, and are valued by the GPs and other primary care staff with whom they interact. It is very much part of the world of the NHS today and we wish to see it continue.
NHS: Risk Register
Baroness Jolly Excerpts(12 years, 5 months ago)
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Baroness Anelay of St Johns
My Lords, there is time, and we have not yet heard from the Liberal Democrat Back Benches.
Baroness Anelay of St Johns
I am most grateful to the noble Lord, Lord Peston, for resuming his seat. Naturally, only one person should be on their feet at one time. There is time, although we have now wasted a little more of it, so perhaps we might hear from the Liberal Democrat Benches and then from the noble Lord. We have had two questions from the Labour Benches.
Baroness Jolly
My Lords, risk registers are a tool to inform policy-making, so is the department currently working on a risk register for the implementation of the social care Bill, including the risks around the failure to reform the funding of social care?
Earl Howe
In answer to that characteristically helpful question from my noble friend, the department will put in place thorough programme-management arrangements as it takes forward the draft care and support Bill and plans for its implementation. That will include monitoring and assessing risks as they arise, to ensure smooth passage through to implementation.