Abortion (Sex-Selection) Bill
Baroness Thornton Excerpts(9 years, 6 months ago)
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Earl Howe
My Lords, the legal position is not in doubt. It is illegal to abort a foetus based solely on its gender. The Abortion Act states that two practitioners have to be,
“of the opinion formed in good faith”,
that the woman had grounds for an abortion. It is for doctors, in line with any guidance from their professional bodies, to satisfy themselves that they are in a position to give the opinion and to defend it if challenged. We refreshed the guidance in May of this year to make the position crystal clear.
Baroness Thornton (Lab)
My Lords, anyone who seeks an abortion on the basis of wrong gender is perpetuating a practice that is not only morally repugnant but illegal, as the noble Earl said. Sex-selection abortion is banned in the UK under the Abortion Act 1967. Does the noble Earl agree that because this practice happens in certain places in the world it may be taking place illegally in those communities in the UK? What are Her Majesty’s Government doing to identify whether this is the case?
Earl Howe
My Lords, our latest analysis of data by country of birth and ethnicity, which we have done for a second year running, found no evidence of sex selection taking place in the UK. Without exception, the wide variation in birth ratios was within the bounds expected. Any termination wilfully failing to meet the requirements of the Abortion Act will render those performing such procedures liable to prosecution under other legislation.
Abortion
Baroness Thornton Excerpts(10 years, 4 months ago)
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Baroness Thornton (Lab)
The Minister has explained the issue extremely clearly. When the next tranche of research on live births comes through, will the Government undertake to dig deep into it to ensure that illegal sex-selective abortions are not taking place? Secondly, there is a statement in today’s Daily Telegraph about 36 abortion centres that are giving unreliable and misleading advice to women who wish to discuss terminations—for example, by telling them that if they have a termination they may get breast cancer. I know that the Department of Health has issued guidelines on this but I would like to know what the Government intend to do about it.
Earl Howe
On the noble Baroness’s first question, the detailed analysis that we did last year was quality-assured by the methodology team at the Office for National Statistics. I can tell her that the team will quality-assure the future analysis of data each year. On the story in the Daily Telegraph, patients should be able to expect impartial advice from the NHS. CCGs and NHS providers must account for the counselling services that they recommend. Guidance on the provision of non-judgmental counselling was included in the Government’s framework for sexual health improvement, published in March last year.
NHS: Competition
Baroness Thornton Excerpts(10 years, 4 months ago)
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Baroness Thornton (Lab)
My Lords, I hope that the Minister is not feeling got at, and I am extremely pleased to note that the noble Baroness, Lady Brinton, will be speaking in the gap. I think that the lack of speakers in this debate bears out what we knew during the passage of the Bill—that this is a hellishly complicated matter. I wonder, indeed, where the noble Lords, Lord Clement-Jones and Lord Marks, and the noble Baroness, Lady Williams, are. I know that the noble Baroness, Lady Jolly, is here today, but she is now bound to support what the Minister has to say. Where are the noble Lords who helped to get the current competition regime through your Lordships’ House and on to the statute book two years ago, and why are they not here to explain how well they think it is working and that their support for it is therefore justified?
We know that people are fearful, as my noble friend has explained. They are fearful on the ground. They do not know how to express their worries, and often they realise too late that something precious has been undermined when the decisions their doctor is making may have something to do with Spire Healthcare or Richard Branson’s Virgin Care on the bottom line than what might be best for them—or that, at the least, those two things are being balanced against each other.
We know that competition comes in many flavours. Peer competition, as expressed by my noble friend, for clinical excellence is fine. Indeed, I have long championed the provision of social enterprises, and what value they can bring to some healthcare as being good for everyone concerned—not least the taxpayer because 5% to 10% is not being siphoned off into the pockets of shareholders across the world. That profit is being ploughed back into the social purpose of the provider and innovation. Indeed, we know that there has always been a mixed market in the provision of healthcare, and always as part of a planned process of provision.
Competition in various forms between NHS providers has been tried, as with the wide choice of acute providers for routine operations. As my noble friend has said, by 2010 the Labour Government had come to accept that there may be some occasions when an incumbent NHS provision could not be brought to the required standard and an open competition might be best. Tactical use of open competition could therefore be a tool. However, the Health and Social Care Act was always about competition as a strategy which essentially sees healthcare as a commodity and, essentially, Part 3 of the Act brings into play the ideas that have been used for the privatisation of utilities in the past. We went through this at length and, on this side of the House, we predicted what might happen.
The NHS has now tendered three-quarters of new contracts to competition. Section 75 regulations were made under the Health and Social Care Act in April last year. They appear to force competition on to the NHS in contravention of ministerial promises made during the stormy passage of the Act itself. At a critical juncture, the then Health Secretary Andrew Lansley wrote to the new local—as they became—clinical commissioning groups, telling them that,
“I know many of you have read that you will be forced to fragment services, or put services out to tender. This is absolutely not the case. It is a fundamental principle of the Bill that you as commissioners, not the Secretary of State and not regulators, should decide when and how competition should be used to serve your patients’ interests”.
He told the House of Commons:
“There is absolutely nothing in the Bill that promotes or permits the transfer of NHS activities to the private sector”.—[Official Report, Commons, 13/3/13; col. 169.]
Indeed, the noble Earl, Lord Howe, promised us here in your Lordships’ House:
“Clinicians will be free to commission services in the way they consider best. We intend to make it clear that commissioners will have a full range of options”.—[Official Report, 6/3/13; col. 1691.]
However, when the regulations emerged, there was a storm of protest. The noble Earl repeated:
“It has never been and is absolutely not the Government’s intention to make all NHS services subject to competitive tendering”.—[Official Report, 12/11/13; col. GC266.]
Can the Minister put a percentage on what he thinks is a reasonable amount to go out to tender and what he thinks is not a reasonable amount to do so?
Critics, including leading lawyers, say the redrafted regulations did no such thing; they did not fulfil the promise that the noble Earl had said that they would. They still enforced compulsory markets in the NHS, regardless of clinical or local wishes and in contravention of government promises. Indeed, my noble friend has given some examples.
In the debate on 24 April 2013, Liberal Democrat health spokesperson, the noble Lord, Lord Clement-Jones, told the House of Lords:
“Commissioners will not be forced to tender”.—[Official Report, 24/4/13; col. 1486.]
Indeed, the noble Earl backed him up, saying that,
“it is NHS commissioners and no one else who will decide whether, where and how competition in service provision should be introduced”.—[Official Report, 24/4/13; col. 1508.]
The noble Baroness, Lady Williams, told the Lords:
“We have learnt in the debates in this House to trust the noble Earl, Lord Howe”.—[Official Report, 24/4/13; col. 1496.]
Well this is a matter not of trust or otherwise, but of whether the Government’s course is the right one. We believe that the evidence now shows that, indeed, it is not. The proof of the pudding is in the eating, as my noble friend has said.
Is the Minister now prepared to release the Government’s legal advice on this matter, which has not been released so far despite requests from various people, including my noble friend Lord Hunt? Overall, the impact of the Health and Social Care Act has been negative, as it has deflected money and energy from clinical care into administration. We have seen the fears from CCGs around what Section 75 means. It appears to mean—certainly, this is what many CCGs understand—that almost every service has to be competitively tendered.
We have seen a CCG offering the biggest NHS contract in history, in Cambridge, and making a thorough mess of that process. We have seen claims by a CCG in Oxford to be leading on competition for outcomes, and, again, stalling when confronted by providers. My noble friend has also mentioned what has been happening in Blackpool, in relation to Spire. I would like the Minister’s comments on what has happened in Blackpool, and what he thinks are the implications of the Spire challenge, and Monitor’s support for it.
I also want to ask the noble Earl about the amount of money that has had to be spent in Bournemouth and Poole on the merging of the hospitals there. The merger seems to be completely justified on clinical grounds; however millions of pounds have been spent on lawyers and paperwork. This is one of the hospitals that already have a deficit: the merger is urgently needed. Does the noble Earl think that can be justified in today’s cash-strapped NHS?
We have heard from many people that they believe that the requirement for competition is hindering the need for integration and co-operation—as we said it would. The people who seem to be benefiting most from the new regulations and the new NHS, as structured by the Government, are competition lawyers. They are being allowed to call the shots, it would appear. Most of all, the vision expressed by Mr Lansley in 2006 for a regulated market for our healthcare seems to be losing its supporters and its driving force is gone. Indeed, rumours abound that the once-enthusiastic Liberal Democrat fellow travellers are now seeing the light. Much of what Mr Lansley wanted is being rolled back or ignored.
The problem is that the market requires no strategic direction because it has its own impetus, which is to make profits where they can best be made. The NHS needs a strategic direction. The Government, however, are incapable of delivering that strategic direction because in the passage of this Act they have given away the levers that would allow them to do so. They can make statements, they can make plans, they can pass strategies, but they no longer have the levers to be able to deliver them.
What does the future hold? Would the Minister speculate about what the next Conservative manifesto might offer the NHS? Noble Lords may remember that the Prime Minister promised that there would be no more tiresome, meddlesome top-down restructuring. That statement may have been wiped off the internet by the Conservative Party, but we remember it very well. What does the Conservative Party think that it might bring forward in its next manifesto? I finish by quoting what David Nicholson, the retiring head of NHS England, has said about this:
“We are bogged down in a morass of competition law. We have competition lawyers all over the place telling us what to do and causing enormous difficulty”.
He also said,
“All of [the politicians who drew up the Health and Social Care Act] wanted competition as a tool to improve quality for patients. That’s what they intended to happen, and we haven’t got that…”.
Earl Howe
The market, however, did exist, which was the point that I made. The market was out there well before the 2012 Act and well before this Government came to office. It was incumbent on us to clarify and simplify the rules that the previous Government put in place. We did that through Part 3 of the Act. It was not a signal to anybody to marketise the NHS. Indeed, as I said, we explicitly provided for it to be illegal for Ministers or Monitor to prefer the independent sector over public sector providers. That is explicit in the Act, so the noble Lord cannot accuse the Government of enabling legislation to promote marketisation.
Baroness Thornton
My noble friend’s question was actually about the signal. If, as the noble Earl has told us, all these things existed before the Act, why did we have to have Part 3 of the Act? Why was it necessary? The only reason that it seems to have been necessary—we think that the evidence now shows that to be the case—is that it increased marketisation in the NHS.
Earl Howe
Let me be clear. Repealing Part 3 of the Health and Social Care Act, which is what the noble Baroness appears to be suggesting is desirable, would not stop competition law applying. It would not remove the powers that the OFT has, which were introduced by the previous Government. It would just mean that a health expert regulator—Monitor—would not be the body considering the application of competition law to the NHS. I do not believe that that is in the best interests of patients. That provision was widely welcomed by those who understood these matters.
I was asked about the case involving Blackpool and Spire. It would not be appropriate for me to comment on an ongoing investigation by the independent regulator but I stress that, in considering this case, Monitor is doing nothing that the Co-operation and Competition Panel could not have done under the principles and rules for co-operation and competition. As regards the Greater Manchester proposals which the noble Lord, Lord Hunt, raised, I can inform him that Monitor has closed that case and NHS England is pursuing its procurement of these services.
The noble Baroness, Lady Thornton, asked about Bournemouth and Poole. I want to be clear that there is nothing to stop two providers coming together if it is in the best interest of patients. The OFT has already cleared two out of three mergers. However, while in some places mergers have improved things for patients, there is evidence that some mergers can be costly and may not deliver the benefits that were intended. It is therefore right that these are examined. The competition authorities have listened to concerns raised in the system. That is why, in October last year, they set out their commitment to work together with Monitor to ensure that the interests of patients are always at the heart of the merger review process; that the process works quickly and predictably; and, importantly, that any costs can be minimised.
Monitor will take a more active role in supporting merging parties and advising the OFT. This means that some mergers may not need to go to the competition authorities at all, and that those which do can be dealt with more quickly. For example, the proposed merger involving Torbay and Southern Devon Health and Care NHS Trust—an integration pioneer—and the South Devon Healthcare NHS Foundation Trust is one of the first cases in which, with the help of Monitor, the trusts have been able to self-assess and conclude that they do not need to notify the merger to the OFT, as it would be unlikely to raise concerns from a competition perspective.
The noble Lord, Lord Turnberg, challenged me on the evidence for the value of competition. There is robust evidence, as I have already mentioned. A report of January 2012 by the Office of Health Economics states that,
“evidence both from the UK and internationally suggests that quality based competition with prices fixed by a regulator can be beneficial, producing higher quality care at the same cost on average and, importantly, not leading to increased inequity in access to care”.
Researchers at the London School of Economics have found that hospitals in areas where patients have more choice of provider have shorter lengths of stay in hospital and lower death rates than in less competitive markets. Research by York University found an increase in quality at a hospital stimulated local rivals to respond, as well as to increase the quality of their services. The research found improvements in relation to mortality rates, stroke readmission and patient satisfaction.
There are various other answers that I would like to give, but I have been advised that I am well over time, for which I apologise. I simply conclude by saying that this has been, as ever, a stimulating debate on a topic to which I am sure we will return in coming months. I hope that my comments today have at least partially clarified the legal position and wholly clarified our intentions regarding the place of competition in the NHS. I hope, too, that they have provided some measure of reassurance to noble Lords that the system is acting upon the concerns that it hears.
Children and Families Bill
Baroness Thornton Excerpts(10 years, 7 months ago)
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Baroness Young of Old Scone (Non-Afl)
My Lords, I hope I am not the only person who is going to speak at this point. I would find it really awesome to be the only one who caused this rather rare event of an amendment being carried over between two sessions of business.
I support Amendments 264, 265 and 266 on standardised packaging. I do not want to make too many of the points that have already been made—at breakneck speed, may I say; it showed that we can speed up if we put our minds to it—but will bring in a few others. There really is quite a consensus stacking up that there is a pressing case for standardised packaging.
The World Health Organisation says that standardised packaging would produce,
“the maximum reduction in the marketing effect of tobacco packaging”.
Australia has adopted it, as everybody knows, and the early evidence is that the standardised packs there are making smoking less appealing and have not caused any problems for retailers, which was one of the predictions. Scotland and Ireland have committed to it in principle, and I have it on very good authority that the Health Minister in Wales is convinced of the evidence. New Zealand, Canada, France, Norway and India are all considering this way forward.
We have huge support here from the medical colleges, including the Royal College of Paediatrics and Child Health, from the BMA, and from charities such as my own charity, Diabetes UK—I declare an interest as chief executive—as well as Cancer Research UK and the British Heart Foundation. They all believe that there is an increasing body of hard evidence. Of course, the public support standardised packs, with 64% polling in favour.
Standardised packs are really important because packaging is the last advertising route left to manufacturers and tobacco companies are spending a huge amount on pack design, and they do not do that for no reason. They recognise the truism that kids and young people are attached to brands. If you have ever tried to persuade your child to buy a pair of supermarket trainers you will know exactly how attached to brands they are.
When I was a kid and all my friends were starting to smoke, there was a league table of cachet. I am really old so Navy Cut was considered a bit more gentlemanly than Wills Woodbines. Embassy and Regal were the great working man’s fags and of course Silk Cut was for the ladies. Then the 1980s came and people took up Camels or Gauloises or, the height of cool, Lucky Strike. I was terribly tempted, I must say, by Balkan Sobranie, which were wonderfully coloured little cigarettes with gold filters. I had a friend, Brian, who smoked them and I used to sit there with one unlit, toying with this beautiful, chic sophistication while he puffed away. Alas, he died at 51 of lung cancer.
Helena Rubinstein used to say:
“In the factory we make cosmetics but in the store we sell hope”.
But of course we are not talking about selling hope; we are talking about selling addiction, cancer, heart disease, poor quality of life and early death for our children and young people.
Noble Lords have already shown that more than 200,000 kids aged between 11 and 15 start smoking each year. We really should take the step. Why do the Government continue to delay? I am sure the Minister will tell us. If they are waiting for the emerging impact of the Australian policy, they should not. The conclusive evidence could take two or three more years with another 500,000 kids addicted to a killer habit. We know that HMRC believes that there is no evidence that standardised packaging would increase the illicit trade that is one of the concerns, so there is no case for waiting for the Australian evidence. Why does the Minister believe there is a case for further delay? Will he please simply give in and get the Government to support Amendments 264, 265 and 266? I particularly commend Amendments 265 and 266, which strengthen the amendment further.
Baroness Thornton (Lab)
My Lords, the noble Earl and I have been discussing the regulation of tobacco products since 2008. At that time he was often sceptical about the efficacy of our proposals for the retail marketing of tobacco products. I particularly welcome these amendments because it is important that we keep this issue alive. Since 2010, my noble friend Lord Hunt and I, as well as others, have asked a series of questions about the enactment of the legislation concerning the display of tobacco products. I congratulate the noble Earl on making that happen successfully. It has been a success: it is now normal to walk into your corner shop and not see tobacco products side by side with comics and chocolates, which used to normalise tobacco for our young people.
It is important to be clear in what we are talking about. There are all the statistics in the world that people can talk about in terms of cancer, addiction and all those other things. However, we are talking about whether we are prepared to allow the over-powerful and wealthy tobacco companies to gain their next market for the profits they need to make from tobacco products. That is what this amendment is about. They can exist only if they continue to recruit young people to tobacco addiction so that they have their next generation of smokers, and that is what this is about. It is about reducing the number of young people who, by becoming addicted to tobacco and tobacco products, provide tobacco companies with their next generation of smokers. We know how hard it is to stop smoking once you have started, and I speak as an ex-smoker.
I hope that, over the years when the noble Earl has distinguished himself as the Minister in his job at the Department of Health, he has had access to all the information and research, and now has at his disposal all the facts about tobacco addiction and all the terrible diseases that this brings to everybody, so that he will be convinced that we need to take this forward. I hope he will tell the Committee either that the Government will support these amendments, or that they are not necessary because the Government intend to take plain packaging forward as quickly as possible.
Lord Judd (Lab)
My Lords, my noble friend just referred to how difficult it is to break the habit once you have formed it. I was a smoker in my youth. I progressed to a pipe, and on one occasion I was in some gathering with fellow young people when the bowl of my pipe dropped off into a pint of beer. I realised that this was a message from God and that one or other had to stop. I had little difficulty in choosing beer with which to continue. We all have these experiences. I am sure I am not alone in remembering with some guilt that, having joined the smoking culture—certainly the presentation of tobacco and cigarettes was an important part of the wooing of a person into the habit—I used to take tremendous pride in choosing the right cigarettes for my father on his birthday or at Christmas. That was very important, because he was a smoker and I was able to present him with a well wrapped packet of what he would like. Later in life, he suffered a severe stroke which left him speechless for the rest of his life, and I have always had an element of guilt about the fact that I no doubt contributed to that development in his health.
I do not understand why we prevaricate on these issues, as we are talking about a killer. Let us get this absolutely straight: it is a killer. We have no hesitation in saying that we must have rules about seat belts in cars because children get killed in accidents. We have special rules about children in cars because of how vulnerable they are. Why, if we take this seriously for seat belts and the rest, do we not take it equally seriously for tobacco?
My final point is that, as a society, we are agonising over the difficulties faced by our health service as it tries to grapple with the pressures on it. By enabling and encouraging young people to become part of the smoking community—by allowing them to drift into it or, indeed, by encouraging the deterioration in their health because of our failure to take rigorous action—we are deliberately adding to the problems of the health service. It seems to me that this is not only wrong but irresponsible. On the one hand to be grieving and agonising about the problems of the health service and the shortage of funds, and on the other hand to be aggravating it by our failure to act where we could act, seems to me irrational behaviour.
I commend noble Lords who have tabled these amendments, which certainly deserve support. I believe we shall be looked at very critically indeed in history for having prevaricated and pussyfooted for so long on such a crucial issue.
Health and Social Care (Amendment) (Food Standards) Bill [HL]
Baroness Thornton Excerpts(10 years, 7 months ago)
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Baroness Thornton (Lab)
My Lords, I thank the noble Baroness, Lady Cumberlege, for this comprehensive Private Member’s Bill and I commend all speakers in this knowledgeable debate. Clearly, despite many initiatives and endeavour over a long period of time—it has to be said that there has been some improvement in the quality and nutritional value of hospital food because of the focus of the previous Government and this—this Bill and this debate show that there is still a great need for improvement. The Library note about the Bill was immensely helpful, as was the publication, Twenty Years of Hospital Food Failure, in February 2013 by the campaign group Sustain, an alliance of organisations. It outlined government hospital food initiatives since 1992. As my noble friend Lord Turnberg mentioned, an enormous number of initiatives have been taken.
I read with interest the Government’s guarded response to that report. The report said that,
“public spending on government voluntary initiatives has failed”,
and called on the Government to set mandatory health and sustainability standards for hospital food in England. The Department of Health issued a response to Sustain’s hospital food standards campaign, which states:
“The government’s preferred approach remains to encourage the adoption of Food GBS”—
government buying standards—
“within the NHS through incentives, signposting and assessments”.
That does not sound to me to be consistent with the noble Baroness’s Private Member’s Bill and the tone of this debate.
I volunteered to speak on this issue, partly because when I was appointed to a ministerial job in January 2008 as the health Whip, my first question in your Lordships’ House concerned nourishment and nutrition in hospitals. I can still recall my nervousness at the time but the House was kind to their new Front-Bencher and I survived. We all know that the noble Baroness, Lady Knight, is very concerned with these issues and she asked the Government:
“How they will respond to the recent reports about the levels of malnourishment of patients in NHS hospitals”.
At the time, I spoke about the fact that the then Government had published in October 2007 Improving Nutritional Care: A Joint Action Plan to outline how nutritional care and hydration should be improved in NHS hospitals and had introduced protected mealtimes and focused on nutritional screening. I concluded:
“There are three strong mechanisms for assessing the quality of food and nutritional care: the Healthcare Commission’s annual health check, in-patient services, and the annual Patient Environment Action Team inspections. These show how seriously the Government are taking the issue”.—[Official Report, 30/1/08; col. 619.]
I wonder whether the Minister is about to say something along the same lines in his response to this debate.
I was very struck by the huge list of initiatives over 20 years that have tried to raise the standards and quality of hospital food. My noble friend Lady Gibson told us a sorry and miserable story. Her example of Scarborough Hospital was most heart-warming. Recently, I met the head of catering for a hospital who explained to me how it produces high-quality meals, how it uses hotel nutritional and food standards, how much of its food is locally sourced and how much as it could possibly manage was freshly prepared.
My noble friend Lord Rea spoke about changing the whole hospital food system and he is right. We know that those beacons of good practice exist and that it is entirely possible to achieve a satisfactory outcome for patients and their families. My most recent experience of hospital food was when my daughter had a short stay following the birth of our first grandchild. I suppose that, because there are lots of relatives on maternity wards who bring food, cakes and all sorts of things, there might not be quite the same problem. However, I was very impressed by two things. First, there was access to the kitchen on the ward for patients and their families to make toast, warm drinks and so on. Secondly, the food was very plentiful and nourishing, and a lot of fruit was available. I am referring to a very large London teaching hospital. If large teaching hospitals can achieve that, I cannot see why any other hospital cannot do so.
My noble friend Lord Turnberg pointed to the problem of the voluntary approach so far. We know that voluntary approaches can work but they will work only if management and hospitals have the will to make them work. The issue that we face with this Private Member’s Bill is whether we have reached the end of the road of the voluntary approach on this matter.
I can understand why the noble Baroness exempts outlets in hospitals that sell food, including cafes, shops and such like. I wonder whether we might find ourselves in a similar position to that of Jamie Oliver when he introduced nutritional standards to school meals and stopped children from going out to buy their lunches. We then saw parents pushing burgers and pizzas through the railings of the school.
I have a serious question to ask the noble Baroness, Lady Cumberlege, and the Minister. Is this Private Member’s Bill and its proposal consistent with this Government’s resistance to statutory regulation, the setting of standards and the administration and monitoring of those standards in other areas of the NHS? I draw the attention of the noble Baroness and the Minister to the Government’s resistance to statutory regulation of healthcare assistants, which we believe would have a beneficial effect for patient care in the NHS. Will they explore the consistency of their arguments in this matter?
Finally, why is this Private Member’s Bill about only hospitals? Why is it not inclusive of the other areas, such as care homes, under the aegis of the CQC? I ask that question particularly given the campaigns of organisations such as Age UK on the nourishment of older people, people with mental health problems and such like in places of residential care.
On these Benches, we welcome the Bill. We believe that we have to keep pushing on this issue until we have it cracked and sorted. I hope that the noble Baroness will have some words of encouragement from the Minister in his response to her Private Member’s Bill.
Cigarette Packaging
Baroness Thornton Excerpts(10 years, 11 months ago)
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Baroness Thornton
To ask Her Majesty’s Government what action is being taken to ensure that they implement their obligations under Article 5.3 of the World Health Organisation Framework Convention on Tobacco Control when consulting on cigarette packaging.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government take very seriously their obligations as a party to the World Health Organisation’s Framework Convention on Tobacco Control. This treaty places obligations on parties to protect public health policy from the vested interests of the tobacco industry. Our tobacco control plan has a chapter dedicated to how we are going about protecting tobacco control from vested interests. Our approach is consistent with guidelines that have been agreed to assist parties to implement Article 5.3 of the treaty.
Baroness Thornton
I thank the Minister for that Answer but, for the information of the House, the guidelines for the implementation of Article 5.3 state that parties to the convention,
“should require rules for the disclosure or registration of the tobacco industry entities, affiliated organizations and individuals acting on their behalf, including lobbyists”.
The guidelines specify that that covers meetings, receptions and all conversations which should be a matter of public record. Will the Minister ask his right honourable colleague the Secretary of State for Health to write forthwith to all his colleagues across government, reminding them what HMG’s long-standing commitments to the World Health Organisation’s convention are and how they should be enacted? Can he assure the House that Article 5.3 has been complied with in every particular in the past year while leading up to the disappointing announcement that plain packaging has been delayed?
Earl Howe
I can give the noble Baroness that assurance. She will know from her time in government how seriously the Department of Health takes its obligations in this area, not least around transparency but also minimising the extent to which officials meet representatives of the tobacco industry. I am sure that my colleagues in other departments need no reminding of their obligations as well. We do of course interact with the tobacco industry, as the framework agreement allows, but we encourage those representations to be in writing and minimise face-to-face contact.
Care Bill [HL]
Baroness Thornton Excerpts(11 years ago)
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Baroness Thornton
My Lords, it is a great pleasure to be back on the Front Bench as part of my noble friend’s health team, even if it is for a short time. I join other noble Lords in sending best wishes to the noble Lord, Lord Willis, for a speedy recovery.
As noble Lords will know, I have been interested in the future of the HFEA and HTA both as a Minister and during the course, in the early days of this Government, of the slash and burn Public Bodies Act, which both these bodies survived. The idea of merging the HFEA and HTA is not new, as my noble friend Lord Warner said, and has been rejected on more than one occasion. I am puzzled by the noble Lord, Lord Patel, raising it now, especially in the middle of yet another review. What I waited to hear, particularly from noble Lords with scientific and research backgrounds, was what the public thought. The right reverend Prelate was right when he said that this is also about how people feel about these issues, not just how the great doctors and scientists think things should be done. In fact, that was how we started out with all these issues.
As my noble friend Lord Warner said, this was first raised by my Government. We proposed establishing a new arm’s-length body called RATE—the regulatory authority for tissue and embryos. According to my research, in 2007 the Government wisely decided not to proceed with that following criticism from a Joint Committee set up to scrutinise that draft Bill. The arguments advanced against RATE then were just as persuasive as they are today. Many of us have held that there is little overlap in the work of the two bodies and that the specialist expertise each provides should be maintained to ensure that regulation remains effective and public confidence is maintained. The discussion we have had so far today has not convinced me that this proposal is the best way forward at the moment. The independence of the HTA and HFEA is important for a number of reasons, not least because of the public confidence needed in both the areas they cover.
In 2010, the Government proposed as part of their bonfire of the quangos that the functions of the HFEA and the HTA should be transferred largely to the CQC. Noble Lords will remember the debate about that during the passage of the Public Bodies Act. Following an extensive public consultation, that proposal was also rejected by the Government in January this year. Once more, a clear majority of those who responded thought that the risks involved in such sensitive areas of medicine were just too great. Instead, the Government decided that an independent review of the way the HFEA and HTA carry out their functions should be undertaken by Justin McCracken. I understand that Mr McCracken’s review is complete and Ministers have yet to decide what to do. Perhaps we will have a sneak preview of that today.
Is there new evidence that there is an advantage in merging these two distinct and expert organisations? As I said, they have different roles. According to the brief I was sent, there are fewer than 10 organisations jointly regulated by both organisations. As context, around 130 organisations are regulated by the HFEA and 800 by the HTA across diverse sectors. On these Benches we are nervous that the amendment tabled by the noble Lord, Lord Patel, to merge the boards of both these organisations risks losing specialist expertise held by the HTA and HFEA and the unique roles in law that their respective boards have.
During the committee scrutiny of the Bill in its draft form—as the Care and Support Bill—the committee advised against a full merger of the boards. In its call for evidence, the committee asked for views on precisely this question. As far as I know, respondents unanimously opposed the abolition of either body or the transfer of their functions. The Academy of Medical Sciences replied:
“There is a great deal of support among our community for the HFEA and the HTA; both are perceived as having developed the experience to respond in a balanced, practical way to the changing landscape that reflects the evolving risks and benefits of research. The relatively small savings to be made through disbanding the HFEA and the HTA need to be balanced against the inevitable period of disruption and uncertainty, and any potential risk of loss of expertise, efficiency, effectiveness and coherence that could hinder research and practice and result in the loss of public and professional confidence … We therefore support retaining both the HFEA and the HTA, providing they work closely with the HRA and other regulators to further streamline the regulation, inspection and governance process for patient and public benefit”.
I accept precisely the point made by my noble friend Lord Winston and others that there are unnecessary delays and that there are clearly issues to be addressed in the way that these bodies operate.
The committee concluded that Ministers should not have the power to abolish the HFEA or HTA and recommended that the relevant clause should be deleted. While its conclusions were about abolition, these same points apply to the merger of the boards: expertise would be lost, there would be huge disruption and all for relatively tiny cost savings at the moment. The work of the HTA and HFEA is of enormous scientific and ethical importance. We accept entirely that there is always room for improvement and we should never be complacent. The review led by Justin McCracken will no doubt make recommendations for further efficiencies. We would be jumping ahead of his proposals by agreeing this amendment at this time.
Earl Howe
My Lords, this has been a very instructive debate and one to which I have listened with enormous care and interest. It takes us back to a well-worn area, as noble Lords have been keen to point out. The amendment proposed by the noble Lord, Lord Patel, would abolish the HFEA and HTA and replace them with a new regulatory body, the human tissue and embryo authority. It would also transfer responsibility for the regulation of infertility treatment involving embryos, sperm and eggs to the CQC.
I listened with great care, as I always do, to the noble Lord, Lord Patel, when he moved the amendment. As has been amply demonstrated in the course of this debate, the prospect of the merger of the HFEA and HTA, or of the transfer of their functions elsewhere and the subsequent abolition of the two bodies, is by no means a new one. It has been considered carefully and consulted on on a number of occasions over recent years, including by Members of this House.
In 2007, as we were reminded, a Joint Committee of both Houses of Parliament, chaired by my noble friend Lord Willis, considered a proposal to replace the HFEA and HTA by the regulatory authority for tissue and embryos—RATE. The committee roundly rejected that proposal. It recognised concerns expressed by stakeholders about the risk of losing the specialist expertise that the HFEA and HTA individually hold and the small extent to which the two bodies actually cover common ground. That point was made very powerfully by the noble Lord, Lord Walton, today.
The Government are as keen as anybody to minimise the number of arm’s-length bodies when we possibly can. A substantial exercise was undertaken across government when the coalition was new to do exactly that and a great number of bodies were abolished. Within that framework, last year the Department of Health undertook a public consultation on a proposal to transfer the functions of the HFEA and HTA to the Care Quality Commission and the Health Research Authority, as part of our review of the arm’s-length bodies. Across the full range of respondents, a majority of three-quarters disagreed with the proposal. The main reason cited was that the HFEA and the HTA have developed considerable expertise in their highly specialised fields. They were said to be trusted and respected by the regulated sectors. Respondents believed that this expertise and trust would be lost were a transfer of functions to take place. That point was well made by the noble Baroness, Lady Thornton, who I am delighted to see on the Front Bench opposite. The noble Lord, Lord Patel, indicated that in his view it was unnecessary to have two separate organisations, but that was not the view of those who responded to the consultation.
Respondents also said that they did not believe that the CQC was well-placed at the time to take on the functions of the two bodies and they feared that those functions would be subsumed by the CQC’s other responsibilities. Another strong message from the consultation was that the small size of the two bodies and the small overall anticipated savings did not warrant the risks involved in abolishing them and transferring their functions. I recall that the noble Lord, Lord Warner, made that very point when we debated these issues during the passage of the Public Bodies Bill. The Government listened to the responses and decided not to proceed with the transfer and abolition. However, we also recognised the clear message from the consultation that there is scope for the HFEA and the HTA to achieve further efficiencies in the way that they operate. That much, I hope, all noble Lords agree on.
The noble Baroness, Lady Thornton, asked whether there was any new evidence about the value of a merger. It was with that very question in mind that we commissioned an independent review of the two bodies by Justin McCracken, former chief executive of the Health Protection Agency, in January this year. The review included looking at the scope for shared membership and leadership of the HFEA and HTA and for their merger. The report of the review was submitted to Ministers in April and is currently under consideration, so I am afraid that I am not in a position to share any conclusions quite yet. I will give way.
Earl Howe
I sincerely hope and anticipate that we will, but I am afraid I do not have a particular date in my brief. If I am able to supply the noble Baroness with that information, I will be happy to do so. The noble Lords, Lord Winston and Lord Patel, cited the number of different regulators involved in the organisational arrangements and the regulation of regenerative medicine in the UK and pointed to the complexity of these arrangements. I understand that point of view, but we are now in a world where the regulators in this area work very closely together to provide regulatory clarity to the sector and to ensure that the system actually works. I know, for example, that the MHRA and the HTA work closely together and have carried out joint inspections.
The department, along with the UK regulators, worked together to produce a regulatory map for stem cell research and manufacture, and I think that too has been helpful. I fully understand and appreciate the interest of noble Lords in this matter and their desire to streamline regulation. We all welcome that aim. I hope that noble Lords will appreciate that the Government have given this matter consideration in some depth, including through public consultations. The strong message we have consistently received from stakeholders is that the HFEA and the HTA should not be abolished or merged or their functions transferred elsewhere. Our latest consideration of this is the scope for regulatory streamlining that the McCracken review looked at, including the scope for regulators to work closely together. That consideration is currently taking place. As soon as the Government’s position on it is determined I will ensure that noble Lords are informed. I am additionally told by a most reliable source that we do not yet have a confirmed date for that announcement.
I am always loath to disappoint the noble Lord, Lord Patel, but I hope he will understand that we did not reach this position without due deliberation and indeed without taking extensive soundings among the stakeholders who are most concerned in this area. I hope he will feel, if not exactly comfortable in withdrawing his amendment, at least satisfied that the matter has been fully debated.
NHS: Clinical Networks
Baroness Thornton Excerpts(11 years, 6 months ago)
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Baroness Thornton
To ask Her Majesty’s Government how they will address any shortfall in the funding of clinical networks.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, national funding for clinical networks has been maintained at £33.6 million since 2009. Forty-two million pounds has been allocated by the NHS Commissioning Board to support strategic clinical networks and clinical senates in 2013-14. It is for local health communities and the board to determine the number and size of networks, based on patient flows and clinical relationships, and to deploy their resources appropriately.
Baroness Thornton
I thank the Minister for that Answer. His boss, the Secretary of State, is on the record as saying that clinical networks funding is increasing and will continue, yet on Monday a freedom of information survey revealed severe cuts to budgets and staff in clinical networks, so I wonder who is right. Cancer networks are cut by 26% and stroke and cardiac by 12% in the same period—2009-13—with the loss of hundreds of experienced and motivated staff. Do the figures that the Minister has given to me also cover clinical senates? Will those cuts be restored? What incentives are the Government putting in place to ensure that local health organisations contribute to the additional funding of cancer networks? Indeed, how will the local diabetes networks be supported in the new commissioning regime? We know that these networks work.
Earl Howe
My Lords, I agree with the noble Baroness’s last comment. These networks are extremely valuable. I confirm that the figure I gave her in my Answer of £42 million covers clinical senates as well. It is perfectly correct that the share of the pot which cancer networks will be able to avail of is likely to be smaller next year than it is this year. However, I can categorically confirm that, as I said in my Answer, national funding has not been cut to date and is going up next year very considerably. Furthermore, we should recognise that the Commissioning Board’s announcement amounts to a ringing endorsement of the value of networks in improving patient outcomes. Not only will funding be increased but for the first time there will be nationally supported networks for mental health, dementia and neurological conditions as well as maternity and children’s services. I say to the noble Baroness that recruitment to the networks is proceeding very smoothly and encouragingly.
NHS: Diabetic Services
Baroness Thornton Excerpts(11 years, 7 months ago)
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Baroness Thornton
My Lords, I thank my noble friend Lord Harrison for bringing this important debate to the House. I am going to concentrate on one aspect of diabetes services today, and it is one that I have raised in the House at least once since 2010. I wish to examine the impact and efficacy of podiatry services for those with diabetes. The Minister may recall that in April last year I asked him about nail-cutting services, including his own, and on 4 November 2010 I asked,
“how the Government can ensure that both the teams and the technology are available and funded”—[Official Report, 4/11/10; col. 1828.]
to avoid amputations and deaths. So here we are a year later returning to what is a worsening situation. I thank the College of Podiatry for its excellent brief on this matter.
The starting point for my contribution is the undeniably shocking statistic that was mentioned by my noble friend. Each week, 125 amputations take place, and in many ways it is even more shocking that 80% of those are preventable. My contention is not only that something must be done, and done urgently, to bear down on this unacceptable state of affairs but that to do so would save the NHS money. There really cannot be any reason not to give this issue some real priority, end suffering and save money. Why can that not be the case?
We all know that 4% of the population currently suffers from diabetes and 15% to 20% of those will develop a foot ulcer at some time. It has been estimated that 61,000 people with diabetes in England have foot ulcers at any one time. It is certainly possible to manage foot ulcers but too many are being missed, not spotted in time or not being treated swiftly enough, unfortunately leading sometimes to complications, surgery and amputations. Amputation is not only devastating but significantly increases the likelihood of death. According to NHS Diabetes statistics, the mortality rate for those with diabetic ulcers and who have had amputations is greater than for those with breast or prostate cancer. Although the five-year survival rate for those with breast or prostate cancer is now about or above 80%, for those with diabetic foot ulcers it is worse, at just under 60%. In other words, two out of five people with foot ulcers that are not treated will not survive for five years or more. I am afraid to say that once someone has had a lower limb amputation their survival rate worsens considerably—after five years it has been estimated somewhere between 68% to 79% will die. Of these amputations, which lead to these deaths, 80% are preventable.
Ulcers and amputations also cost the NHS, according to the acknowledged expert Marion Kerr, between £600 million and £700 million each year. If better foot care was available and these amputations were prevented, that much money would be saved. However, as things stand, the number of amputations is going up not down, as the diabetic population increases. I invite the Minister to support the alliance that has come together under the Putting Feet First banner, which has already been mentioned and which includes NHS Diabetes and Diabetes UK as well as the College of Podiatry. Does the Minister think that it would be sensible to say—I will use the word “target” but I do not mind what terminology he uses—that there should be a 50% reduction in amputations by, say, 2018? How does he believe that could be delivered? It seems to me that surely an effort from everyone, from the national Commissioning Board to CCGs and from the Government to clinicians on the ground, is what is needed. Of course there is also a huge role for patients learning to manage their own condition and becoming, as my noble friend put it, “foot fetishists”, specifically by taking care to maintain their own healthy feet.
However, it is indisputable that better services are also needed and that this will require more podiatrists, more specialist nurses and more multidisciplinary teams. I wonder how this might be delivered with the urgency required at a time when economies, reorganisation and cuts in podiatry services are already apparent. What will the Government do to drive forward a programme that delivers across the country?
Currently there is, as has been mentioned, a staggering tenfold variation in amputation rates across former PCT areas. Such a variation, as an example of a postcode lottery, is surely unacceptable. However, it is not surprising if one knows that more than half of hospitals do not have a multidisciplinary foot care team, while 31% of hospitals do not even have an in-patient podiatry service, an increase from 27% in 2010. There is evidence that one of the current problems is that GPs have no incentive to refer their patients on to foot protection teams for education, follow up and so on. There is evidence that the number of posts is being frozen or reduced, which is not the way to deal with a preventable problem. With that, staff are also experiencing “de-banding”, leading to reduced morale.
The College of Podiatry, along with Diabetes UK and NHS Diabetes, believes that the time has come for this goal to be promoted by the Government, adopted by the NHS Commissioning Board and worked towards by every clinical commissioning group. The QIPP—quality, innovation, productivity and performance—agenda also provides an opportunity to redesign services along the best practice lines so that there is a multidisciplinary foot care team in each hospital as well as foot protection teams in every community. However, unfortunately at the moment there is evidence that the opposite is happening and that services are not improving. The danger of new arrangements is that this important issue falls between the cracks, is left to local decision-making and does not get the prioritisation it deserves.
The College of Podiatry tells me that it is,
“fearful that public expenditure constraints mean that rather than being prioritised through the QIPP agenda, current podiatric services are at best, being frozen and in some cases being reduced, with patient services including the diabetic foot service deteriorating as a consequence”.
We know that best practice exists. For example, the multidisciplinary foot care team approach for in-patients with diabetes in Southampton led to a reduction in the length of in-patient stays from 50 days to 18. Not only were patient outcomes improved but annual savings to the NHS of £889,000 were generated on the back of an investment of £180,000. Let us imagine if that were repeated everywhere.
To address this issue is wholly in line with the outcomes that the NHS mandate has identified for the NHS Commissioning Board; that is, reducing preventive mortality, improving care for the chronically sick and driving up patients’ experience of care. The Putting Feet First campaign has already produced guidance and circulated it to CCGs and existing PCT commissioners showing how savings and improved patient services might be achieved. What is required now is political prioritisation; what is required is a guarantee of an increased supply of podiatrists. Given that the number of those suffering from diabetes will have increased to 5 million by 2025 and that as diabetes increases so do preventable amputations, it really is imperative that action is taken now to end what is really nothing short of a scandal.
National Health Service (Clinical Commissioning Groups) Regulations 2012
Baroness Thornton Excerpts(11 years, 8 months ago)
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Baroness Thornton
Before the noble Earl leaves the issue of lay members, I have a question about having only two lay members—I am sorry that I did not jump up in time to ask it before he started summing up. The noble Earl and I sat opposite each other for several years discussing regulatory reform of the NHS, and one thing that I think we agreed on was that for all the new regulatory bodies that are now appointing lay members, 50:50 was the right balance to ensure proper regulation and accountability. Why is that not the case with the CCGs? What is different here? We felt that it was safer to have 50% in the regulatory reform of the NHS. Why do we not have 50% on the CCGs?
Earl Howe
My Lords, it will be up to local CCGs to determine their own constitutions, as I have said. What we are attempting to do in these regulations is simply to set down the bare minima. As we discussed during the passage of the Act—these provisions were well rehearsed—providing there are two lay members, a secondary care clinician, a nurse and an accountable officer, that is the extent of the prescriptiveness that we feel is appropriate from the centre. Otherwise, it looks very much like the Government dictating the governance arrangements. The Future Forum’s recommendations were very clear that we should not go down that path.
It was suggested that CCGs were experiencing difficulties in appointing secondary clinicians or a registered nurse. I understand the concerns that noble Lords have raised on that score but I have recently spoken to the NHS Commissioning Board, which has started the process of considering applications from emerging CCGs. The news I have is that CCGs have so far successfully recruited to these roles. In addition, the medical and nursing royal colleges have offered to help CCGs in sourcing appropriate candidates, which is very welcome.
The noble Lord, Lord Warner, referred to the HSJ article of 11 October. I will clarify my answer when I write to him, which I will be happy to do. We are very pleased not only that so many clinicians have chosen to apply for leadership roles, which they have, but that so many first-rate clinicians have done so, whether as clinical chairs or clinical officers in CCGs. What is important is that there is a good mix of expertise in the broader leadership team of clinicians and managers, to help the CCG discharge its responsibilities effectively, and that is what we are now seeing.
I have a number of examples of where the drive towards integration is really taking shape on the ground. My noble friend Lady Jolly mentioned South Devon and Torbay; this is a service designed by secondary care doctors and GPs working together in a clinical pathway group for urology, and the whole impetus of the CCG is to improve collaboration and get over the gulf between primary and secondary care. There is another excellent example of integrated services in Wokingham, which again I would be happy to write about.
The noble Lord, Lord Hunt, asked whether police commissioners and Peers could be members of a CCG governing body. Yes, they can. He also asked who was consulted over these regulations. As I have indicated, the proposals were developed in response to the NHS Future Forum, the listening exercise that set out requirements around the secondary care doctor and registered nurse. The proposals were further discussed with emerging CCGs, primary care organisations, the medical royal colleges and, yes, colleagues in the NHS Commissioning Board Authority.
The regulations discussed today provide a fair and transparent rules-based framework to complement the provisions in the Health and Social Care Act around the establishment of CCGs. Creating a responsible and accountable CCG with good governance is essential for good management, good performance, good stewardship of public money, good public engagement and—our ultimate goal—good outcomes for patients. I commend the regulations to the House.