NHS: Chiropody and Podiatry Services

Baroness Thornton Excerpts

Tuesday 26th April 2011 Lords Chamber

[Earl Howe]

My Lords, my noble friend makes an important point. She will know that there are universities that specialise in the training of chiropodists and podiatrists, and we place great reliance on them. What will emerge from the new architecture that is foreshadowed by the Health and Social Care Bill is a much greater sense of local prioritisation regarding needs. Flowing from that, with the advice and guidance of Health Education England, which will be the national body supervising workforce requirements, we may well see further centres of excellence in training emerging.

[Baroness Thornton]

My Lords, I hope that the Minister will forgive me for being slightly personal, but I wonder how often he trims his toenails. I expect that he can actually reach his own toenails unlike many elderly people who cannot reach theirs, do not have anyone to do it for them and cannot afford a podiatrist. Would the Minister be happy to have his toenails trimmed once every three months, which seems to be the standard offer by health centres and GPs at the moment? I am sure that he will share my concern that even that service is under threat from the cuts at PCT level. Will the Minister undertake to ensure that podiatry services for the elderly become a priority for the National Commissioning Board?

[Earl Howe]

My Lords, I am fortunate in being able to cut my own toenails. However, the noble Baroness makes a serious point about the elderly. It is often the lack of that simple service that prevents elderly people being as mobile as they wish and sometimes confines them to their own homes. This is a serious issue in terms of the way that we can prevent unplanned hospital admissions due to elderly people falling over. The process that I have referred to whereby we will see joint health and well-being strategies emerging from the health and well-being boards at local level should ensure a sufficient supply of the workforce over a period of time.

NHS: Consultation on Reform

Baroness Thornton Excerpts

Tuesday 26th April 2011 Lords Chamber

[Earl Howe]

The noble Baroness makes a very important point about local directors of public health, who most certainly do need the right qualifications for that role. As she will know, they will be jointly appointed by local authorities and by the Secretary of State and we need to ensure that they can perform their role properly. The four main themes to the listening exercise are: choice and competition; public accountability and patient involvement; clinical advice and leadership—that may be an area that impacts on her question; and education and training. In some ways it is difficult to separate those issues; they are all of a piece and we do need to look at them very carefully.

[Baroness Thornton]

My Lords, if the current listening exercise hears the almost universal concerns about the Government’s proposal to introduce a new economic regulator into the heart of the NHS—concerns, I have to say, that were expressed but ignored by the Secretary of State right through the autumn and the spring—will the Government be removing that part of the Health and Social Care Bill?

[Earl Howe]

My Lords, no, because we are clear that the current system requires independent oversight of competition within the health service. Essentially, we have an unregulated health service at the moment; the Government in which she played a distinguished part as a Minister rolled out the independent sector treatment centre programme but its terms were, in the judgment of many, not fair. We need independent scrutiny and determination of pricing in the health service to ensure that there is a fairer playing field for all those providers of NHS services.

NHS Reform

Baroness Thornton Excerpts

Monday 4th April 2011 Lords Chamber

[Earl Howe]

We are assigning particular staff to pathfinder consortia. Those staff will remain within the PCT clusters. They will not transfer officially to the consortia because the consortia are not officially in existence yet. The point here is to have staff who are dedicated to supporting the emerging consortia over the next few months. This is already in train.

[Baroness Thornton]

My Lords, given the progress that has already been made in dismantling the PCTs and the strategic health authorities ahead of legislation, and the millions given to GP consortia to establish their role as commissioners, are the Government not in danger of pre-legislative implementation? Does it not beg the question as to where the role for pre-legislative scrutiny, or indeed any meaningful scrutiny in the House, might be on the matter? Will the Minister assure the House that, when we eventually receive the Health and Social Care Bill, reorganisation will not have progressed beyond the point of no return?

[Earl Howe]

My Lords, the noble Baroness will know that her own party’s plans included a 30 per cent reduction in administrative and managerial costs throughout the health service. We agree with that and we have got on with it. It is right that, when a Government come in and announce their intentions, as we did, expectations should be managed, as we are doing, and uncertainties should be allayed. The way to do that is to get on with the process.

NHS Reform

Baroness Thornton Excerpts

Monday 4th April 2011 Lords Chamber

[Baroness Thornton]

My Lords, I start by thanking the noble Earl for repeating the Statement. I have to confess that this is a very puzzling moment. I do not recall a Statement in the middle of the proceedings of a Bill—a Bill that has only just finished in Standing Committee in the Commons. I would be grateful if the noble Earl could tell me whether there has ever been a Statement announcing a break, natural or otherwise, in the middle of the passage of a Bill. I wonder what might happen in this natural break, whatever that is. Perhaps the Minister can define this new parliamentary term. How long will it be? Why is it really necessary? What is likely to take place during that period? What exactly are the Government intending to do during that period? It seems to me that the things that the Government have said that they are going to do during that period should have happened anyway before the Bill was introduced and that they should have been ongoing. This should not be necessary.

However, I welcome the recognition in this Statement of the concerns that people have about the speed of change. I question the use of the word “continue” in the Statement in the context of listening and engaging. Frankly, if Mr Lansley had been listening and engaging, this Statement would probably not have been necessary. However, if it means that the Secretary of State really is going into listening mode, I welcome that and look forward to seeing it.

I welcome the fact that the Statement touches on the areas that are of concern to people. I also welcome the recognition in the Statement of the 10 years or so of investment by my Labour Government, which is why the NHS is as successful as it is today. However, I also note that the Statement, just like Andrew Lansley’s Second Reading speech when the Bill was introduced in another place, elides the question of Part 3, which gives great powers to a utility regulator—the new economic regulator, Monitor. Therein lie many of Mr Lansley’s problems, because people have worked out what the implications of that part of the Bill are for the NHS. When will Mr Lansley start to listen to the concerns that have been expressed by the Health Select Committee, all the royal colleges, the health regulators, all the bodies representing employees and staff in the NHS, including the BMA, the patients’ organisations, his partners in this Government, the Liberal Democrats, many of the voluntary organisations involved in health—those concerned with diabetes, heart disease, cancer, asthma and dementia, for example—and, in particular, organisations concerned with long-term conditions?

We can build a picture of what has happened in the past week or so. First, the Prime Minister was wrong-footed by Ed Miliband on 16 March on whether the health service would now be subject to European Union competition law. It seems to me that he went away, found out about it and confirmed that that was the case. Will the Minister confirm that? There has been a stream of media stories reflecting serious concerns about the Health and Social Care Bill. Most recently, in the Daily Telegraph, Sarah Wollaston MP urged her party to drop plans for the radical reorganisation. On 1 April, Elizabeth Rigby, chief political correspondent of the Financial Times, reported concerns about the rapidity of change.

On 2 April, the Telegraph said that the Prime Minister was drawing up key changes to the Bill and planning amendments. This article is remarkably detailed about meetings at Downing Street with David Nicholson, the head of the NHS, and Mr Lansley. It says that Mr Lansley was not for compromising and that reforms had gone too far to be undone, which was the subject of a question that I asked in Oral Questions only today. I ask the noble Earl to confirm whether that is the case.

The Statement also reflects the fact that Mr Lansley is very firm about the Government’s intentions for the NHS, but it is not consistent with the stories in the media about the activities at No. 10 Downing Street. Will the noble Earl tell us who is correct about these matters? I will draw a veil over what the noble Lords, Lord Owen and Lord Tebbit, have said about this matter in the past few days.

I am concerned about exactly what will happen during this natural break, which brings me to my final questions. My concern is that this break is being taken in order to strike a deal. I can just imagine a possible conversation between Nick Clegg and the Prime Minister. Nick Clegg says to the Prime Minister, “We want local accountability strengthened”, which I think many of us here would agree with. The Prime Minister then says to Nick Clegg, “Okay, but your people in the Lords must deliver Part 3 of this Bill to establish the economic regulator, Monitor, without dilution of its powers”. There is no doubt that that would be the prize for the Conservatives. It has been recognised by the noble Lords, Lord Owen and Lord Tebbit, and by the noble Baroness, Lady Williams. I fear that this is about keeping the coalition together rather than any assessment of what the NHS might need at this moment. The past few days have seen David Cameron conceding that he and the Health Secretary have failed to get their message across. There have also been anonymous briefings from No. 10, to which I have referred.

I am further concerned that this is about playing politics with the NHS. Will the Minister reassure the House that that is not the case? This is too important to be used as a political football or to see decisions taken about the NHS simply to save David Cameron’s face or Nick Clegg’s face. What is required now is a rethink, a pause in the legislation and some root-and-branch changes.

Health: Obesity

Baroness Thornton Excerpts

Monday 4th April 2011 Grand Committee

[Baroness Thornton]

My Lords, I congratulate the noble Lord, Lord McColl, on his persistence in calling this debate; he is well known for his concern about this issue. I also offer congratulations to my noble friend Lord Brooke on having lost a lot of weight by reducing his intake of food by 10 per cent since June last year. I am not going to tell the Committee what he has gone to or from, but it is very impressive. In a way, that proves a point made in the remarks of the noble Lord, Lord McColl.

I address my remarks to the growing crisis that is childhood obesity. There are high levels of concern about obesity in westernised society, and about obesity in children in particular. The National Child Measurement Programme was implemented in the UK to monitor changes in average body size among children who are starting or about to leave primary education. It showed that, in 2008-09, almost one in 10 children—9.6 per cent—aged four to five was obese, while for 10 to 11 year-olds the figure was almost one in five, or 18.3 per cent. Over the past 10 years obesity among six year-olds has doubled, and it has trebled among 15 year-olds. With such levels of obesity, diseases such as type 2 diabetes are now being seen for the first time in children.

I draw on a recently published report entitled The views of young children in the UK about obesity, body size, shape and weight: a systematic review. It was undertaken for BMC Public Health and published on 25 March, and I commend it to all noble Lords. Among other things, it states that recent research shows that,

“Children are likely to experience immediate physical and psychosocial problems as a result of being obese and are at a higher risk of obesity as they grow older”.

Therefore,

“Children’s attitudes to and beliefs about their bodies”,

including high levels of body dissatisfaction, raise enormous concerns.

I have to confess that so far, taking their rhetoric with all possible seriousness, I am underwhelmed by the Government’s strategy for tackling childhood obesity. It seems that they are intent on removing all the levers that might make a difference nationally. For example, today the school dinner grant loses its ring-fencing and can be used to cover other budgets in schools which, it is safe to say, will lead to a rise in prices of possibly up to 17 per cent and a fall in take-up of school meals. The official national statistics on school lunch prices show that the average price for a two-course meal across primary and secondary schools with catering provided by the local authority was £1.88 in 2009-10. The Observer reported yesterday that more than 30 local authorities plan to increase the cost to children in the coming months, with some schools seeing an increase of as much as 17 per cent to £2.60.

Research by the School Food Trust reveals, not surprisingly, that the uptake of school meals correlates with price changes. According to its studies, a typical lunch brought in from home is not as nutritious as the average school lunch, which must meet national food standards. Packed lunches can also be repetitive. Therefore, despite reports of increased lunch fees in some areas, the School Food Trust says that it is “really encouraged” that many schools have continued to put the same level of investment into their school meals and has welcomed proposals to make it easier for schools to offer price deals such as ‘buy one get one free’ for larger families. Indeed, writing in yesterday’s Observer, Jamie Oliver said that he hopes the Government will continue to invest in,

“quality school food and the integral support and training of kitchen staff”.

However, we then have to add into the mix on school meals that the Welfare Reform Bill is a leap in the dark on this matter and raises the issue of the future of free school meals. Apart from the fact that it may mean children who need them may not get them, it introduces instability in funding.

Food education in schools is also incredibly important. It was made compulsory for children in secondary schools in 2008 and is due to come into schools this September. However, it is already under threat of being removed from the curriculum completely.

On nursery schools, in responding to the publication of recommendations by a government-commissioned panel on voluntary food and nutrition guidance for early years settings in England, Charlie Powell, director of the Children’s Food Campaign, said:

“While we welcome the substance of the recommendations from the Advisory Panel on Food and Nutrition in Early Years, we already know—from years of experience—that more voluntary guidance is almost certain to be largely ignored”.

That is simply not good enough. We should have legal standards for nursery food.

I agree with what Charlie Powell said when the Health Secretary announced the responsibility deals. He stated:

“They are little more than a continuation of schemes that were being done anyway by the Food Standards Agency—until the Government took away its nutrition remit”.

So instead of introducing effective measures to tackle alarming levels of childhood obesity—such as regulation to protect children from junk food marketing—the Government’s pledges require little or no extra work on the part of food businesses, which are delighted by the support they are receiving from the Government.

I urge the Department of Health to ensure that these voluntary commitments are independently monitored and evaluated and to set a timetable for regulation for when, as we expect, they fail to improve public health. As the noble Lord, Lord Patel, said, it is an embarrassment that Diabetes UK and the British Heart Foundation joined alcohol health charities in not signing up to the deal.

Dr Vivienne Nathanson, the head of science and ethics at the BMA, said:

“Children and parents are surrounded by the marketing of unhealthy cereals, snacks and processed meals. This has to stop”.

Two of the partners in the Government’s responsibility deal had the following to say. The Food and Drink Federation rejected the need for restrictions on advertising and a spokesman said:

“Any simplistic scheme that demonises products does not take into account the complexity of people’s lifestyles and the way they eat”.

The boss of McDonalds, Peter Beresford, has made clear that he rejects TV advertising restrictions. He said that McDonalds is not to blame for rising obesity, adding:

“There is no good food or bad food, only bad diets”.

Statistics show that about 70 per cent of commercials shown during children’s viewing are for food and that, of these, between 80 per cent and 100 per cent are for junk food. We are sending the wrong messages to children at a time when we are seeing this terrible increase in weight problems. As noble Lords will be aware, because I promoted a Private Member’s Bill on this matter some years ago, I am strongly opposed to allowing advertising of foods high in fat, salt and sugar during the pre-watershed hours. National Consumer Council expert Sue Dibb has said:

“Anything less than full restrictions on TV ads and promotions for high fat, salt and sugar foods before the 9 pm watershed would be extremely disappointing”.

I agree with that.

On sport and exercise, the Government’s record is again not good. We saw last year the U-turn that they had to make on school sports and the scrapping by the DCMS of the free swimming programme, designed to be a key part of the London 2012 legacy plans. I agree with the noble Lord, Lord Patel, that nudge and suggestion have yet to prove themselves. I have not limited myself to talking about the Department of Health because this is a cross-government matter. I therefore have two questions for the Minister: is there a cross-government approach, and where are the interventions and levers? Although I shall not repeat the questions of the noble Lord, Lord Patel, I add my name to them.

NHS: Standards of Care and Commissioning

Baroness Thornton Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Thornton]

My Lords, I start by thanking my noble friend for initiating this debate and for emphasising the importance of standards of care and of the effect on patients of the proposed changes to the commissioning regime. Indeed, I congratulate all speakers in this debate. On this occasion, the point of my noble friend’s remarks was possibly, “We’re all in this together”, in dealing with the standards of care. However, he also said that we face some major challenges here, which are the challenges that he posed, as did several other noble Lords, including the noble Baronesses, Lady Emerton and Lady Hollins, and my noble friend Lady Sherlock. The question is: will the Bill help or not?

I welcome the noble Lord, Lord Owen, to both this debate and our wider discussions. I look forward to reading his pamphlet, Fatally Flawed, this weekend, and I suggest that the Minister might choose to do the same. However, I will resist the temptation to join the noble Lord in what would be a Second Reading speech.

I start by quoting a young woman who works in healthcare and who spoke last Saturday to between 200,000 and 500,000 people—personally, I think it was nearer the latter. In many ways, her simple eloquence says it all about how thousands of dedicated health workers feel. She said: “I am an NHS physiotherapist and have been for 13 years. My patients are people living with complex disability from conditions such as MS, brain injury, spinal cord injury and stroke. I work with a wonderful team of NHS workers such as occupational therapists, speech therapists, psychologists and rehab assistants, as well as social workers, to support our patients to overcome barriers to their independence, often supporting them back to work and working with their carers to support them to stay in their homes for as long as possible … David Cameron told you all in his election campaign that he would ‘cut the deficit, not the NHS’. Well, if 50,000 frontline NHS posts at risk doesn’t count as a cut, I shudder to think what does … For the sake of my patients, I fear the introduction of ‘any willing provider’. I fear that it will fragment services, will make the postcode lottery of care worse, and the most vulnerable patients, those least able to stick up for themselves—the kind of patients I treat every day—will be hit the hardest. Good quality patient care relies on good communication. How can we guarantee this, when services that currently work together are pitched into direct competition against each other? … In parts of the country, physios are already starting to see the rationing of care to just one or two treatment sessions, regardless of need … This is not the NHS I signed up to work for. I don't believe it is the kind of NHS that people in this country want”.

In this short response to the debate I am going to argue that we would not start here with reform and I will ask some questions about the risks to standards of the proposed commissioning system. I put a plea to the Minister: could we perhaps have some new words in his answers to these debates? I have looked back at the debates and discussions in the House since the White Paper was published last July, and time after time the Minister has stuck admirably to the Andrew Lansley brief, with what is becoming the famous NHS techno-jargon that weaves a web of words but really does not serve to comfort, or even leave one any the wiser. It is very noticeable that when the Minister comes off script and is back to his old, clever self, we prefer it and I, for one, understand things better.

We are nearing the point, after many questions and sustained criticism from professionals, patients and even the Minister’s partners in the coalition, when we need some real answers to real concerns, not least on the commissioning that is the subject of this debate. Notwithstanding the progress of the Health and Social Care Bill, I invite the Minister to agree that there is no doubt that the period 2011-14 is likely to be the most challenging ever faced by the NHS. The NHS is faced with the challenge of producing £20 billion in efficiency savings, putting considerable pressure on the system to maintain current standards of care. Given those constraints, we on this side of the House are still of the view, perhaps even more so now, that this is not the right time to embark on the largest structural reorganisation in NHS history, which includes scrapping those layers of the NHS structure with real experience of commissioning—family care trusts and strategic health authorities—and putting the power in the hands of untested and inexperienced consortia.

I am not saying that PCTs and SHAs have been unfailingly brilliant; in some cases, they have not even been good or average. There was and is significant room for improvement, and I think we would all agree on that. Most notably, clinical leadership and engagement in PCTs has often been weak, local accountability has been lacking and imbalances in status and power that exist between commissioners and providers appear to have limited substantially the former’s ability to influence service provision, to say nothing of the lack of clinical presence in the whole process. However, we believe that it would have been better to tackle this problem rather than to turn the whole NHS upside down.

What of the transition? Responsibility for maintaining and improving the quality of services will fall initially to the new PCT clusters. At a time of major reorganisational transition it will be especially important to have in place adequate performance measures supported by transparent and robust mechanisms, through which the GP consortia and PCT clusters can account to local people for the quality and performance of local health services. I do not see how this can be achieved when PCTs are being decimated either by the efficiency cuts or people jumping ship to work elsewhere. Perhaps the Minister can say how he thinks this will be achieved.

We know that PCTs are responsible for commissioning a range of primary, community, secondary and tertiary health services, often in partnership with local authorities—for instance, in mental health—and, indeed, other PCTs, through networks or consortia for specialised services, and primary care clinicians through practice-based commissioning. That has already been mentioned by the noble Lord, Lord Patel—cancer networks being one of these. This is a complex landscape and it is about to become even more so. It will grow a whole new bureaucracy of its own if the competition which the Government intend to put at the heart of the Bill, whatever one believes about that, is as envisaged.

The majority of concerns with the health Bill in relation to commissioning of services fall into five broad areas: multidisciplinary commissioning; commissioning of long-term conditions; specialist commissioning; a lack of national guidance leading to fragmentation; and communication and co-ordination between providers and commissioners. A theme that runs throughout these areas is concern about the involvement of GPs and the ability of relevant commissioners to secure appropriate clinical input when commissioning services.

The King’s Fund report of the beginning of March highlights the need for strong, strategic commissioning to reconfigure some services such as cancer, cardiac and stroke care across large geographical areas. It argues that this will not be delivered by the Government's health reforms, which will abolish the strategic health authorities currently responsible for leading this work and leave GP consortia to fill the gap, which they are unlikely to be able to fill—to which I add that that will probably be the case for at least 10 years or so.

Briefly, on long-term and specialist conditions, throughout the debates since last July various advocates and campaigning organisations on almost every long-term condition have commented on the proposed reform. The Minster must accept that the Alzheimer’s Society, the cancer campaigns, diabetes organisations and many others are very worried about the commissioning for their conditions becoming fragmented and incoherent, to say nothing of end-of-life care and, for example, treatment for children with very serious conditions.

The Government are asking those who have fought long and hard for recognition of and improvement in the treatment and care of people to take on trust that everything will be okay. The Minister needs to accept that this clamour about commissioning, although we are joining it, is not motivated by Her Majesty’s Opposition being oppositionist; it is about a long list of concerns, questions and anxieties that we have to address without the proposed revolution. I look forward to the Minister’s reply.

Health: Neuromuscular Services

Baroness Thornton Excerpts

Wednesday 30th March 2011 Grand Committee

[Baroness Thornton]

My Lords, the noble Baroness, Lady Thomas of Winchester, has rightly been raising these issues in the House since her welcome arrival here, and I have lent her my support whenever I have been able to do so.

The Muscular Dystrophy Campaign website asks all parliamentarians to take an interest in what the future holds for people with neuromuscular disorders, so this debate is very appropriate. Over the past few years, we have had the Walton report, led by the noble Lord, Lord Walton of Detchant, and the all-party parliamentary group. We have also had the Thomas report in the Welsh Assembly, so named after Ray Thomas, a tireless campaigner in Wales whose sons both had Becker muscular dystrophy, and the Mackie report in the Scottish Parliament. It was very wise to cover all three nations.

The three reports that have been produced, together with their recommendations, provide a focal point for the continued battle to ensure that action is taken to address the significant gaps in the provision of specialist neuromuscular care and to implement service improvements. I take this opportunity to congratulate the Muscular Dystrophy Campaign on its tireless and very effective work in raising the profile of the different and severe orders and also on the fact that it points without fail to the challenges, and sometimes the hardships, suffered by the families of people with these disorders. I shall not go into detail about the different types of muscular dystrophy, as the noble Baroness, Lady Thomas, has already done that, save to say that 1,000 children and adults out of every million people in the population are affected by muscle-wasting neuromuscular diseases in England. These disorders cause progressive muscle wasting and weakness, and they often result in premature death and lifelong disability. They often start in childhood or young adult life. As we know, the diseases are sometimes genetic and sometimes they are acquired.

Perhaps I may say how much I welcome the national programme of work for neuromuscular services that has been announced. The 10 regional NHS specialised commissioning groups, or SCGs, and the national specialised commissioning team met earlier this year and agreed a national programme of work around neuromuscular services for the year ahead and that the outputs of that work will be used to support a national approach to commissioning specialised neuromuscular services. Their 10-point plan is absolutely admirable, and I should like to highlight some of the things that are in it. They are: to write a service specification for specialist neuromuscular services; to carry out an audit of unplanned emergency admissions for patients with neuromuscular conditions; to clarify the current arrangements across England for access to genetic testing in order to obtain a clearer understanding of what genetic testing is being undertaken; to understand the current workforce of community physiotherapists and key community-based staff to identify what skill development is required; to create a service directory for each neuromuscular service, which would mean that healthcare professionals such as GPs would have access to a database containing standardised information; to understand the current arrangements for access to specialist equipment and to map that across the country to find gaps to understand the current arrangements for access to non-invasive ventilation; to make sure that neuromuscular patients have their specific needs for end-of-life care and that the national end-of-life work programme has considered the specific needs of patients with neuromuscular disease; to support the development of neuromuscular networks when they are appropriate; and to collate and review the various SCG reviews of neuromuscular services.

I thought that it was worth listing those points. I am sure that the noble Earl is going to go into more detail about them, but I thought that it was significant that after a meeting with the Muscular Dystrophy Campaign the Minister said in a letter to the noble Lord, Lord Walton of Detchant, that there are,

“weaknesses in commissioning, which is behind the patchiness and problems accessing vital services for those living with these dreadful conditions”.

That is exactly right.

Given that we know that comprehensive neuromuscular services should be designated within the specialist services national definition set, an audit of current services should be undertaken and the Department of Health should work with the emerging British Myology Society, mentioned by my noble friend Lady Wilkins, in approving a standard diagnosis and care for neuromuscular conditions. Is it possible that this progress will be able to be maintained under the current circumstances, both in the short, medium and long term? My question, echoed by virtually every the noble Lord who has spoken today, is: how will the specialist services weather the transition in the short term, when strategic health authorities and PCTs are disappearing and the GP consortia are being created? Indeed, how will we ensure that GP consortia will be able to recognise and commission for these rare diseases, picking up what commissioning has produced at a national level? Will the national commissioning use the 10-point plan? How will services such as hydrotherapy be delivered? The Minister will remember that I asked this question when we discussed this in the Chamber some months ago with the noble Baroness. This is an expensive but very effective therapy. Furthermore, what research are the Government supporting? How are they investing in research? Would the research be able to look at things such as the effectiveness of hydrotherapy and the pain management mentioned by the noble Lord, Lord Luce? I echo the point about NICE guidelines and look forward to hearing the Minister’s reply.

Health: Polymyalgia Rheumatica and Giant Cell Arteritis

Baroness Thornton Excerpts

Wednesday 30th March 2011 Grand Committee

[Baroness Thornton]

My Lords, I congratulate my noble friend Lord Wills on calling this debate. These short debates are ideal for a discussion about something very specific and important such as the disease giant cell arteritis. It is always a challenge, therefore, to find anything new to say when the matter has been thoroughly explored with the eloquence of the experts who are here today. That never stopped anybody in the House of Lords from making a few remarks, but I will be brief.

To put this in the vernacular, the issue is a bit of a no-brainer. Indeed, when I was practising the pronunciation of polymyalgia rheumatica, about which I had no previous knowledge, one of my colleagues piped up that her mother had that, so I ran off a very helpful fact sheet about giant cell arteritis to give her.

As noble Lords have said, the problem with giant cell arteritis is that the symptoms are so commonplace—headaches, tenderness on both sides of the forehead, feeling unwell and so forth. The treatment is also relatively straightforward—urgent treatment with steroids, which will prevent the blindness that can occur and which is irreversible. Clearly, doctors and patients need to be aware of the risks of giant cell arteritis in people and should be on the lookout for symptoms of the disorder. That is the first point, which echoes what other noble Lords have said. If someone is diagnosed with polymyalgia rheumatica, doctors need to warn them that this is a possible consequence.

At this point, my noble friend read a list of requests for the Government, which were echoed by many other noble Lords. In many ways, I cannot better his action list, which, as ever, shows my noble friend’s ability to analyse and put forward practical solutions that are also achievable. I hope that the Minister will undertake that his department will seriously consider making blindness from giant cell arteritis a never event and I hope that he will ask NICE to make an appraisal of giant cell arteritis services to produce guidelines.

Perhaps I may add one or two requests of my own. Have the Government estimated the cost of blindness caused by this condition, or does the Minister agree that my noble friend’s estimate is in fact the true cost? Linked to that is the issue of research. Something that costs so much and which, I suspect, does not receive as much dedicated research as we would wish creates an imbalance that we ought to address. I should like to know what research is taking place into this condition—the noble Lord, Lord Black, made this point very eloquently—because we need to find new drugs to treat it. It is clear that that needs to happen because of the vulnerability of old people to massive doses of steroids.

As my noble friend Lady Bakewell said, “It is spring. Please help”.

Health: Preventable Sight Loss

Baroness Thornton Excerpts

Tuesday 29th March 2011 Lords Chamber

[Earl Howe]

My Lords, the National Institute for Health and Clinical Excellence—NICE—has recommended treatment with Lucentis as a clinically effective and cost-effective use of NHS resources for patients with wet, age-related macular degeneration meeting specific clinical criteria. I am aware that, initially, the practice mentioned by the noble Lord was being reported, but I think that it is less true now. I will of course check whether what the noble Lord says continues to apply. I would just say that primary care trusts are legally required to make funding available to enable clinicians to prescribe Lucentis, which is the drug of choice for this, in line with guidance. The PCT allocations take account of expected growth in the drugs spending, including the impact of this type of technology.

[Baroness Thornton]

My Lords, last week the BBC programme “In Touch” asked the question, “Can the NHS cope with the demand for treatment for the UK’s most common cause of blindness?”—a question which follows on from the one asked by the noble Lord, Lord Walton of Detchant. The programme was made with the recently formed Macular Disease Society, which aims to raise awareness and money for both dry and wet macular disease. Will the noble Earl join me in welcoming the creation of this society, and will the Government ensure that the society is involved in the consultation process leading to the strategy for the early diagnosis and treatment of macular disease?

[Earl Howe]

My Lords, I join the noble Baroness in welcoming the formation of the Macular Disease Society, and I can assure her that my department will wish to engage closely with it; I think that it is a very positive development. Reducing avoidable sight loss is clearly an issue that we have to take seriously. The prevention of sight loss will be an aim of work undertaken across the new public health system, as I have indicated. At national level we are proposing that Public Health England will design some specific public health services including screening, as has been mentioned, and locally we propose new responsibilities for local authorities.

Public Bodies Bill [HL]

Baroness Thornton Excerpts

Monday 28th March 2011 Lords Chamber

Moved by

[Baroness Thornton]

49: Schedule 5, page 18, line 15, leave out “Human Fertilisation and Embryology Authority.”

[Baroness Thornton]

My Lords, we turn to Amendments 49 and 50 and the subject of the HFEA and the HTA somewhat late in the evening again. We have now had time to reflect on what the Minister said on 9 March, to read the letter to my noble friend Lord Warner, which the noble Lord thoughtfully copied to me and others, and to compare the two. In reading the debate on 9 March, I realised it had centred on the issues that arise out of the siting of the HFEA rather than on the proposals for the HTA, so I shall start by raising a few issues that are particularly pertinent to the HTA.

Since the previous debate, the Government have announced that the HTA has been appointed as the competent authority to regulate the quality and safety of organs under the EU organ donation directive. The HTA is now the competent authority for two EU directives. I would be grateful if the Minister will explain where this competence will sit under the various options he outlined in his letter to my noble friend Lord Warner. In addition, the HTA’s responsibilities with respect to EU legislation extend across the UK, but the Care Quality Commission’s remit extends to England only. The Minister can see where I am leading with this question because of the statutory implications that such a move might involve. For example, have the Government consulted the Welsh Administration about this matter or would they divide the legislation or extend the geographical remit of the CQC? Indeed, what if the Welsh said no to such matters regulated by the CQC?

We also need to look at the context in which these changes are being proposed. There are loopholes between coroners legislation, the Human Tissue Act and the Police and Criminal Justice Act which the HTA is addressing at the moment. I think it is right to be concerned with the Government’s continued determination to abandon the idea of establishing a chief coroner’s officer, the abolition of the National Policing Improvement Agency combined with proposals to break up the HTA’s functions. Added to the squeeze on resources in the central government’s resource, one should ask what guarantees will continue to be there and where they will be concerning human tissue not being retained without consent.

When the Minister answered this debate on 9 March, he took the trouble to explain in some detail the Government’s thinking about the future of the HFEA and the HTA and spoke about the possible creation of a new health research agency, which I think largely met with a great deal of approval across the House, and I shall return to that matter in a moment. His letter to my noble friend explores the various options that the Government might take with the powers that the Bill will grant them. I know my noble friend Lord Warner will want to explore the contents of that letter, so I shall limit myself to two issues that are still outstanding and need to be addressed before Parliament grants such powers with regard to these two bodies.

The first is the nature of the pick-and-mix proposals for the future of the HFEA and HTA, which the Minister suggested in his reply to the House on 9 March and in his letter to my noble friend, because I do not think it is acceptable to ask for powers fundamentally to change these organisations and not to know at this stage how those changes might be achieved and what they will do. The Minister spoke about this being a road of travel. Roads of travel are fine when one is developing policy but they are more difficult when one is putting into legislation things which will have a direct effect—in this case, on these two organisations.

Secondly, I return to public confidence, which I raised in Committee. I have read the Minister’s reply on the importance of keeping public confidence in the functions of the HFEA and the HTA. It centres around the fact that he is keen to assure the House that the legislation, and the ethics that underpin that legislation creating the HFEA and HTA would not be fundamentally changed. But I am puzzled: I do not see how, as regards the options outlined by the Minister—the orders that would need to be consulted on—he would intend to stop those ethical issues that lie at the heart of that legislation being discussed at length because of the public confidence that resides in them. When change is being proposed, that reassurance and the assurance that the new arrangements will do their job is obviously very important. Option papers do not usually provide the necessary assurance about people’s jobs or functions and, in this case, about where the ethical issues that underpin that legislation would lie.

I feel that the Government have the opportunity to move forward with the creation of a new science body, and the future of the HFEA and the HTA, with a great deal of agreement across the House and with a great deal of good will to make that happen. I do not think that this Bill is the place to start that, which probably is the heart of the problem.

[Lord Willis of Knaresborough]

Before the noble Baroness leaves the issue of ethics, if the agency model is developed, which would have a separate ethics committee that I think most of us would accept, does she agree that it is not just simply the ethics of research that is important, it is also the ethnical decisions about developing clinical practice? The need for those to be kept together within the new agency is of paramount importance in order that there is public confidence. Without the setting up of the agency, there will be a huge gap that needs to be filled.

[Baroness Thornton]

The noble Lord, Lord Willis, makes the point extremely well and much more eloquently than I was able to. It underlines the point that I have been trying to make. Taking the powers to break up the HFEA and the HTA, as it were, is not the way to start that process. The noble Lord makes exactly the right point. The Minister should recognise that there is a great deal of good will to make this happen across the House but not starting here. I beg to move.

[Baroness Warwick of Undercliffe]

My Lords, I declare my interest as chair of the Human Tissue Authority. I and my authority remain concerned about the impact of the Bill on public and professional confidence in the safe and ethical use of human tissue, as has already been raised by my noble friend. My first question to the Minister is to seek reassurance that the HTA’s functions will not be divided. A division of our functions into three or possibly four different parcels would, in my view, risk undermining the legislation that the HTA was set up to implement, increase the regulatory burden on the sectors we regulate and damage public confidence that has been so hard won.

We must not forget that the HTA was established as a result of scandals at Alder Hey and Bristol Royal Infirmary. Those events caused profound grief among affected families, outrage amongst the public and a crisis of confidence. Those events are still recent. The Human Tissue Act, which set up the HTA and was subject to more than 100 of hours of parliamentary scrutiny, was passed in 2004. The HTA began regulating as recently as 2006. In a relatively short period, it has successfully turned around that crisis of confidence. When people know there is effective regulation, they are more confident in donating their tissue for medical research, their organs for transplant and their bodies for medical education and training. Increased public confidence should mean more donation; more donation should increase professional confidence, thereby creating a virtuous circle beneficial for all. More lives are saved; more people are given back their quality of life; and there is more research and surgical skills training for the benefit of the public.

The Government’s arm’s-length bodies review sets out proposals for transferring the HTA’s functions across three or four different organisations. I fear that separating the HTA’s functions would risk undermining the progress that has been made in building public and professional confidence. Leading thinkers have voiced profound concerns about dismantling the HTA. Senior legal academics have said in the Sunday Times:

“The proposals to abolish the Human Tissue Authority—HTA and the divisions of its functions among larger, non-specialist regulators—risk confusion and error in the implementation of the Human Tissue Act 2004, which in turn will erode public confidence”.

In addition, earlier this month, senior consultant surgeons writing in the Guardian said that moves to break up the HTA would,

“undermine professional and public confidence in the area of medical consent”,

and urged,

“the government to think again and stop trying to operate on things that aren't broken”.

I hope that the Minister will listen to these voices.

The Minister has said that the HTA’s health-related functions should transfer to the Care Quality Commission. I am still not clear about the fate of the HTA’s organ donation and research functions. The ALB review does not suggest a home for its organ donation approvals and suggests that its research functions should transfer to a single research regulator.

With regard to organs, the Human Tissue Act requires board approval of highly sensitive and ethically complex cases of organ donation from living people. If this were to be placed with the CQC, how would the Minister meet the statutory requirement that at least three authority board members who are specifically trained in this area review such cases?

With regard to research, the new regulator for health research will provide a potentially helpful way forward for streamlining medical research in the UK, simplifying life for researchers and increasing the quantity and quality of research. The Minister stated at Second Reading that the purpose of this Bill was to streamline the process of regulation and to reduce costs and bureaucracy. I do not see how the proposal to transfer the HTA's research functions to this new regulator would achieve simplification; nor do I believe the proposals would save money. The sectors that the HTA regulates are interrelated and interdependent, and although it regulates a separate research sector, the licensing framework also allows establishments in the post-mortem, patient treatment and anatomy sectors to store tissue for research as well as for other purposes.

I take the post-mortem sector as an example. The proposal would result in at least one-third of post-mortem establishments needing to be licensed by an additional regulator if they wished to store material for research. A similar proportion of establishments storing tissue for patient treatment would also need to be licensed by an additional regulator. The regulatory burden on an estimated 200 establishments would therefore increase, not decrease. So can the Minister explain what impact this proposal will have on the regulatory burden on these establishments? Can he explain who would be responsible for producing the statutory code of practice on consent and who would be responsible for ensuring consistently high standards if the HTA’s functions were divided?

My noble friend Lady Thornton raised concerns about the ethical dimensions of the work being lost in the rush to amend the mechanical processes. I share these concerns. This is a complex ethical landscape. The HTA has the professional expertise to respond to emerging forms of communication such as Facebook and Twitter. These are now being used as conduits for patients looking for organ donors. We are launching consultation on this very issue in May, and this is a good example of how agile and sensitive the authority can be. Can the Minister assure me that the credibility that lay and professional board members bring to the HTA will not be lost in the Care Quality Commission, when the CQC has only a small number of commissioners? An advisory group has been mentioned. If that model is proposed, can the Minister say what guarantee there will be of its independence?

I apologise for raising so many issues at this late hour but there are many issues still to be resolved. In summing up, I say only that the reason the HTA was established has not gone away and there is still work to be done. My argument is not against the Government’s intention to simplify the regulatory landscape; rather, I want to avoid putting at risk the substantial gains that the HTA has made by splitting its functions across a number of different organisations and losing the overall coherent approach which has been so successful in supporting public and professional confidence and ensuring that tissues and organs are used safely and ethically and with proper consent.

I have one final plea. David Thewlis and Stuart Taylor, both parents affected by the events at Alder Hey, brought it all home to me recently when they said:

“All the effort and soul searching that went into the establishing of the Human Tissue Authority cannot afford to be overthrown by abolishing the HTA and splitting its functions”.

I urge noble Lords to take this on board when deliberating the future of the HTA.

--- Later in debate ---

[Earl Howe]

The direction of travel for the HFEA is one that we have mapped out. I am not aware that we are considering consulting on keeping the HFEA together. If I am incorrect about that, I will write to the noble Baroness. I understand why she wishes to press me on the point. However, I have not heard this option put forward, and it was not contained in the arm's-length bodies review.

I can assure the noble Baroness that the consultation will give an opportunity to all those with an interest to express their views on where would be the best place to transfer the functions, and on the merits of keeping functions together where appropriate. I recognise that the expertise of the HTA, and the extent to which this will be carried forward, is a key issue. The consultation that we plan will, as I mentioned, give an opportunity for interested parties to express their views on the point.

The noble Baroness, Lady Thornton, asked who would take over the role of competent authority for the EU tissue and organ directives from the HTA. That role will be considered for transfer to other bodies, as with other functions. It involves regulating according to quality and safety standards. We will consult on the most appropriate body for those functions to be transferred to.

My noble friend Lord Willis made clear his view that we should not split research functions. I can tell him that we envisage that the health research agency will cover what is now covered by the approval of research licences. In the context of human embryo research, the legislative requirements that the research is necessary or desirable, and that the use of embryos is necessary, will remain firmly in place. If that consideration includes an assessment of the research technique proposed, it will remain so in future.

The noble Baroness, Lady Thornton, and the noble and right reverend Lord, Lord Harries, asked how we would deal with the devolved Administrations. The intention of the proposals is to reduce both the cost of regulation and the bureaucracy for regulated establishments. It is important that a workable solution is found for the devolved Administrations, while recognising that the subject matter of the legislation is reserved. The Human Fertilisation and Embryology Act extends to the whole of the UK, and the Human Tissue Act extends to England, Wales and Northern Ireland. We hope to agree a way forward with the devolved Administrations that avoids any unnecessary duplication of effort in order to keep costs and bureaucracy for regulated establishments to a minimum. We have had constructive discussions already at official level, and these will continue. The CQC is at present an England-only body. If reserved functions were transferred to the CQC, we would extend its territorial remit in respect of those functions alone.

I will return to where I began. It is surely right that the Government and Parliament should look for opportunities to streamline regulatory mechanisms, as long as this is done in a way that preserves the legal functions, and the ethical underpinning of those functions that Parliament has put in place. The Bill provides us with the means to do that in respect of the HFEA and the HTA. In view of the Government's broader concessions on the Bill, and our intentions to consult widely on the proposed transfers of functions and to protect existing ethical and legislative safeguards, I hope that noble Lords will not press their amendments.

[Baroness Thornton]

I thank the Minister for another detailed response. I also thank the noble Lord, Lord Willis, the noble Baroness, Lady Deech, the noble and right reverend Lord, Lord Harries, and my noble friends Lady Warwick and Lord Warner. I counted 17 to 20 questions that the Minister was asked. He gave us a great deal of information, some of which was useful and very interesting. However, I do not think that he answered all the questions.

The Minister raised the issue of us not being convinced. We are not being perversely unconvinced. The problem is that there are still too many unknowns about this part of the Bill. Extensive consultation in the summer, to which the noble Earl has referred on many occasions, is after the decision has been taken and after the powers have been taken.

For example, the Minister was pressed on the concern about registers and databases. His answer was that the decision would be part of the consultation, that they would not be dissipated and that there would be options put in the consultation. That is not a satisfactory answer at this point. The same goes for the impact assessment, which will be carried out in the context that the Government will have already taken the powers to do what they want to do.

On the ethical issues that I raised, the Minister suggested that those would go with whoever it seemed appropriate to be the responsible body. Frankly, at this stage of the Bill, an answer that has “whoever” in it is not satisfactory. There is widespread agreement that the medical research agency proposals sound promising, but that simply underlines the point that we should not proceed with including these two bodies in the Bill at this point.

The Minister has said several times that it is a complex process. We agree, and indeed the noble Lord, Lord Willis, made an extremely good suggestion about one way to simplify the process by using forthcoming legislation. Having been the Minister responsible for several Bills that might have been called Christmas-tree Bills, I am not sure that he does not have a very good point.

That begs the question: what is the hurry? If streamlining can be achieved without powers being taken in this Bill, money can be saved—as several noble Lords have said—without taking such powers, and a much larger discussion will be taking place as we move forward. It seems to me that those points remain outstanding.

At this point in our consideration, I do not think that we have reached a satisfactory and conclusive point in our discussions about the HFEA and HTA. I hope that we can resolve and clarify the remaining and outstanding uncertainties on this issue before Third Reading, and I very much welcome the fact that the Minister has said that he will be responding to certain points. I am sure that he is prepared to continue those discussions and I hope that we can resolve them before Third Reading. Otherwise, I fear that we may have to return to this issue. I beg leave to withdraw the amendment.

Amendment 49 withdrawn.