Health and Social Care Bill

Lord Hunt of Kings Heath Excerpts

Thursday 8th March 2012 Lords Chamber

[Baroness Northover]

As we are on Report, perhaps noble Lords will allow the Minister to develop his argument and then put brief questions in the light of what he said—otherwise he will lose his train of thought.

[Lord Hunt of Kings Heath]

My Lords, I hesitate to take issue with the noble Baroness because clearly she is in a position to help the House. However, interventions on Report are quite allowed. I am very puzzled that the Government are trying to seek to rule that Report stage procedure should change so that we simply listen to the Minister. That is not Report.

[Baroness Northover]

My Lords, I am not saying that short questions cannot be put. However, it might be beneficial to the House if the Minister were able to develop his argument. Then, if noble Lords had questions that he had not addressed, that would be the relevant time to put them.

[Baroness Northover]

That is what the noble Lord, Lord Hunt, preferred when he was a Minister. I hear from around the House some sympathy for the point. If the suggestion does not work, no doubt we can take the matter to the Procedure Committee and look at a different way of doing things.

[Lord Hunt of Kings Heath]

My Lords, the noble Baroness is not in a position to dictate to the House that it should change its procedure on Report. Surely the beauty of debate lies in interventions, and responses by Ministers. When I was a Minister for 10 years at the Dispatch Box, I always took interventions and welcomed effective and proper debate. I am on my feet—

[Baroness Northover]

For clarification, perhaps I may remind the noble Lord that the Companion sets out that a Member shall not speak after the Minister on Report,

“except for short questions of elucidation to the minister”.

I realise that noble Lords are putting short questions of elucidation. The Minister made it clear that he wishes to make progress and that at the moment he does not wish to take interventions so that he can develop his argument.

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[Baroness Wall of New Barnet]

My Lords, I also support the amendment. Adding to what the noble Baroness, Lady Finlay, has said, the House may be aware that trusts are now committed to quality accounts, certainly for clinical staff, and an integral part of those quality accounts is education and training. I would like to see it being widened beyond the clinical staff, because there are lots of staff in a hospital who need that constant education and training, to make sure that patient care overall is as good as we would all want it to be.

[Lord Hunt of Kings Heath]

My Lords, I refer to my chairmanship of a foundation trust. From the opposition Benches, we very much support this amendment and wish to reinforce the importance of education and training.

It is right that we should emphasise the importance of NHS foundation trusts recognising their responsibilities in relation to education and training. It is equally important that they have an influence over the architecture for education and training. As the noble Earl will know, there are going to be local boards responsible for commissioning the education and training of professional people. It is very important that the people who run hospitals should be very much involved in the selection of students and ensuring that the curriculum is effective. The noble Earl will know that the Future Forum paper chaired by the chief executive of University Hospitals Birmingham NHS Foundation Trust emphasised the importance of looking at these matters.

We will be debating the quality of nursing next week, but there is no doubt that there is a real problem with public perception of the quality of nursing in particular, and issues to do with nutrition and basic nursing skills. I am convinced that there is a real problem that the universities that train our nurses, in the end, are much more focused on academic practice, because that is what universities do. I am anxious that no one has been able to put their finger on the solution. One way of improving the quality is to involve the foundation trusts much more in these matters. My noble friend’s amendment is very helpful in that respect.

[Earl Howe]

My Lords, as noble Lords will know, we have had a number of earlier discussions about education and training and I welcome this new opportunity to return to the subject. As the noble Lord, Lord Turnberg, is aware, we are putting in place what we see as a strong national system for education and training, with a strengthened focus on quality outcomes.

In the Bill we have introduced a clear duty on the Secretary of State to ensure that such a system is in place. We are now making good progress in establishing Health Education England and the local education and training boards. We are acutely aware of the importance of a safe transition to the new system. We are proceeding with care and at a sensible pace to ensure that the new system is fully up and running by April 2013.

We have also introduced amendments to strengthen links with the wider system. Our Amendments 61 and 104, which were accepted in an earlier debate, place duties on the board and on clinical commissioning groups to have regard to the need to promote education and training. They are designed to ensure that commissioners of NHS services consider the planning, commissioning and delivery of education and training when carrying out their functions.

We also accepted an amendment tabled by the noble Lord, Lord Patel, to strengthen co-operation among providers of NHS-funded services, which would place a duty on commissioners to ensure that any person providing services as part of the health service would have to co-operate with the Secretary of State in the discharge of his education and training duty, or with any special health authority discharging that duty—that is, Health Education England. This aims to ensure that providers, too, play an active role in education and training.

The noble Lord, Lord Hunt, spoke with his customary authority on this subject and I agree with what he said. I particularly agree that employers best understand the workforce they employ and the kind of workforce they want to employ. They also understand the need to link service planning and workforce planning. They are able to focus on the whole workforce and to recognise the levels of contact with patients and service users, and the varying local needs. Evidence from other sectors and feedback from providers has been clear that in order to deliver successful and responsive world-class services, employers need to have clear ownership and involvement in the education and training and planning of their workforce. I am entirely at one with the noble Lord on that.

Employers have welcomed our plans for education and training. They believe that this approach should provide real opportunities so that healthcare providers have the right incentives to secure the skills that they wish to have, invest in training and innovate to improve the quality of services that they provide. They welcome the opportunity to have the incentives to align service, financial and workforce planning, and to have greater flexibility to respond to the strategic commissioning intentions of the NHS Commissioning Board and clinical commissioning groups.

The NHS Confederation, NHS Employers, Foundation Trust Network and the Association of UK University Hospitals all support a system that provides greater accountability for employers. Strategic health authorities are working with employers to support them in developing these local partnerships so that they can take full responsibility for workforce planning, education and training.

I hope that that is of reassurance to the noble Lord, Lord Turnberg. What is happening on the ground almost pre-empts the speech he so articulately made. We are rapidly moving towards the kind of system to which he and other noble Lords aspire. Having secured the amendments that are already in the Bill, we do not believe that it is necessary to build in any more. On the strength of what I have said, I hope that the noble Lord will feel comfortable in withdrawing his amendment.

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Moved by

[Lord Hunt of Kings Heath]

220A: Clause 163, page 159, leave out lines 36 to 40

[Lord Hunt of Kings Heath]

My Lords, I beg to move.

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[Baroness Murphy]

I have concerns similar to those of the noble Lord, Lord Warner, but this amendment is different from those that I have seen floating around from the noble Lord, Lord Phillips. I also have questions, but we must be very clear about what we mean by “queue-jumping”. If an NHS patient goes to an ordinary NHS hospital consultant and is told that they need an operation, it is completely legitimate for them then to ask to go privately and pay for the operation. That is, as the noble Lord, Lord Warner, said, enshrined in the NHS Act of 1948, and completely legitimate. Queue-jumping is when a patient sees a private consultant who then inserts the patient into the NHS list ahead of other NHS patients. That is what we want to avoid, and it is already completely illegal and highly frowned on. Most hospitals do what they can to exclude it, but I take the point made by the noble Lord, Lord Phillips, that it goes on, and we know that it does. It is an unpleasant practice and should be stamped out, but I do not know whether this amendment does that.

As the noble Lord, Lord Kakkar, reminded us, the conundrum of private units in NHS hospitals must be borne in mind. That may be the most constructive way in which to ensure that NHS consultants are available to NHS patients when they need to be, as the noble Baroness, Lady Finlay, said. But often private patients have operations that go wrong—and then, if there are two patients in need of an NHS intensive care bed, the patient who takes priority is the person with the clinical need. It is very much the same as someone on a battlefield. It does not matter whether it is an enemy soldier or a domestic soldier.

[Lord Hunt of Kings Heath]

I thought that the amendment was focused not so much on clinicians but on the board of the trust. That is a slightly different argument.

[Baroness Murphy]

The noble Lord may be right. If the change in wording applies to how the management behaves but makes no change in clinical priorities—the noble Lord, Lord Kakkar, said that it would not interfere with clinical priorities—I would support it. It is necessary to ensure that management acts like that, as long as it does not cut across the clinical priority that the sickest person comes first, whether private or NHS.

[Lord Campbell-Savours]

I want to intervene briefly because we want to vote on these matters today. The amendment subtly gets to the problem at the heart of the Bill, which totally underestimates the new pressures that will build up within foundation trusts on management to change the nature of the patient body that comes into the trust for financial reasons. The noble Lord who has just spoken in many ways let the cat out of the bag. Pressures are exerted on clinicians by management to take actions that they do not necessarily want to take. If a trust is building up a substantial body of patients referred to it by insurance companies, it will want to be sure that within that trust’s operation some element of priority is given to its patients if only to minimise the liability that the insurance company has to the patient to pay their bills. In 10 years’ time, when the Government review the Bill, they will find that the pressure on management to change what happens in hospitals will lead to the beginning of the destruction of the National Health Service as we know it.

[Lord Hunt of Kings Heath]

My Lords, I have a great deal of sympathy with the amendment. When I first worked in a hospital in 1974, the Nuffield Orthopaedic Centre in Oxford, we had a private patients’ ward called Mayfair. The succession of senior consultants, the head OT and head physio, gave me an impression of the priority that was given. There will always be debate about the phasing out of paid beds—this was the case even under Barbara Castle—but some of it arises from real concerns over differentiation in equity of treatment.

I take the amendment to be very focused on the board of an NHS foundation trust, not on individual clinicians. It is an important safeguard regarding the way in which the board of a foundation trust may wish to deal with the financial pressures that it is under. We should not be under any doubt, and I speak as an FT chair, that many foundation trusts are facing financial pressures alongside the rest of the NHS. They are required to make efficiency savings and, probably, to move resources from acute hospitals into primary care without any reassurance that primary care is going to demand-manage. There is a real worry that GPs will give more money to themselves but with no guarantee that that will impact on the flow of patients through acute hospitals. There is concern that the pressure on acute hospitals, instead of reducing, which we would like to see, will actually grow.

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[Baroness Rawlings]

May I just remind the noble Lord that the Companion sets out that a Member shall not speak twice on an amendment on Report.

[Lord Hunt of Kings Heath]

My Lords, I have to say that we are seeing a reinterpretation of the normal procedure on Report. Nothing in the Companion prevents a noble Lord intervening and asking the Minister a short question. The fact is that by ploughing on and refusing to answer questions, the Minister is not serving the House appropriately.

[Baroness Rawlings]

I shall just read from the Companion:

“A member of the House who is speaking may be interrupted with a brief question for clarification. Giving way accords with the traditions and customary courtesy of the House. It is, however, recognised that a member may justifiably refuse to give way, for instance, in the middle of an argument, or to repeated interruption, or in time-limited proceedings when time is short. Lengthy or frequent interventions should not be made, even with the consent of the member speaking”.

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[Baroness Bakewell]

My Lords, the amendment calls for a commissioner for older people. When I moved such an amendment in Committee, I suggested the role as a freestanding one. In this amendment, I seek to have it subsumed into the agenda of HealthWatch England, requiring a commissioner to be a member of HealthWatch England but exercising this function entirely independently.

After a fruitful meeting with the noble Earl, Lord Howe, I realise that there are certain limitations around this suggestion—also put to me by other Members of this House—to which I shall come in a moment. However, first let me briefly revise the need for such a position. On every hand, the calls get stronger for the case of the old to be heard. Earlier this week, some 1,000 older and disabled people came to lobby their MPs about the crisis in social care. The Care and Support Alliance, which organised the event, represents more than 60 charities and organisations across the social care and health sectors. MPs heard stories from some of the estimated 800,000 people needing care who are currently not receiving it. Recent reports from the Equality and Human Rights Commission and the Commission on Dignity in Care have reported neglect and abuse. All this since the Committee stage of the Bill. Older patients take up most of the beds in our hospitals where they are patronisingly accused of bed blocking. Given the demographics of a growing population, this situation is set to get worse. No one now doubts that there is a growing national crisis.

All these commissions and reports are fine and often very thorough. However, they tell us about “them”, the old—a category of the population who need to be dealt with and have their needs met. But the old are not a lumpen mass; they are each as highly individual as those in any other age group. They need someone to speak in different terms and in a different tone about, “what we need” and, “what I am asking for”. A commissioner for older people would answer that need and relate directly to the personal stories that arrived in my post bag when I was the Voice of Older People. I feel confident in saying this because Wales already has an Older People’s Commissioner—Ruth Marks, who has a fine record of touring the country, visiting care homes, day centres and individuals, and bringing individual concerns to bear on the Government in Cardiff.

Let me now come to the limitations of this role. The NHS Future Forum report states:

“If the fundamental purpose of the Government’s proposed changes to NHS—putting the patient first—is to be made a reality, the system that emerges must be grounded in systematic patient involvement”.

The problem here is the word, “patient”. Older people are indeed patients, but their needs extend much further than this. As the noble Earl discussed with me in our very useful meeting, the needs of the old extend much further. They extend to matters that concern not only health but work and pensions, housing and transport. They extend across all other activities of life and all departments of government. I am wary of confining the function too tightly within the health Bill agenda. I take the noble Earl's argument, and other Members of the House have expressed similar concerns. I would value their views on this matter put on the record.

However, we have to start somewhere. Some initiative has to start the ball rolling. People want their voice, our voice, a voice, to speak out about our needs. The impulse to establish such a post is right, but the move to have a commissioner for older people has to be triggered somewhere. I hope that it will be triggered by the amendment. I beg to move.

[Lord Hunt of Kings Heath]

My Lords, my noble friend has made a powerful case for having a champion for older people to look not just at the impact of decisions made in the NHS but going much wider. She is right to refer to pejorative remarks such as bed-blocking being very insensitive to old people. We face a considerable challenge within the health service to ensure that we are sensitive and reflect that there is huge demand from frail older people which is not being met as effectively as we would wish.

My noble friend said that the amendment may not be perfectly formed but that we have to start somewhere. I wonder whether the noble Earl, late on this Thursday afternoon, might give some comfort. After all, it would not be impossible within HealthWatch England to have a designated person with responsibility for overseeing—or, if you like, monitoring—services for older people. It could be well worth exploring whether the thought behind my noble friend's amendment is worth pursuing.

[Baroness Barker]

I just make two or three simple points. I have enormous sympathy with the amendment of the noble Baroness, Lady Bakewell. My party's policy is in favour of the establishment of an older people's commissioner in England, building on the interesting work that has been done in Wales. I have a great deal of sympathy with what she is trying to do. She made the argument that one has to start somewhere. I disagree with her that this is the right place to start. If one had to start somewhere, it should be in social care. The deficiencies in social care matter more to more older people than those in health.

Having said that, the noble Lord, Lord Hunt of Kings Heath, is right. Given that older people are by far the biggest users of NHS services, it would be remarkable if healthwatch were not to include people with the expertise to follow up older people's issues.

My deep resistance stems from two things. First, I think that the biggest challenge set out in the Bill, which has been overlooked, which is why I take the opportunity to mention it again, is the challenge for the NHS to get to grips with social care and enabling older people—all people, but, by definition, older people—to live healthier lives for longer and not to wait until they turn up in the NHS.

However, my fundamental point is that I have talked to lots of older people over the years and I believe that old age has to be about more than the health service. If the only government recognition that older people have is the right to have someone to complain about the health service, I think we will be in danger of medicalising old age and inadvertently removing the full experience, wealth creativity and knowledge that older people bring to many aspects of life. I know that, given her former role, the noble Baroness, Lady Bakewell, would not intend that. Therefore, I hope that she will accept my support for what she is trying to do and my reservations about the way that she is trying to do it with this amendment.

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[Baroness Northover]

Again, my Lords, what shines through is a great commitment to public and patient involvement at a local level; the only dispute is over the form of that. Again, noble Lords are familiar with the fact that various models have been tried, and I emphasise once again that we are seeking to build on the strengths of what has worked and mitigate some of the problems that have been encountered.

My noble friend Lady Jolly has tabled Amendments 234 and 235, the result of which would be to replace references to “people” with “local people” in Section 221 of the 2007 Act and insert the definition of “local people”. We talked about the difficulty of organisations— LINks in particular—reaching groups that were defined as hard to reach. The definition in my noble friend’s amendment says that when carrying out its functions, local healthwatch has to be representative of people who live in the area, service users and people who are representative of the local community. That applies to people of all ages and emphasises the need for local healthwatch to champion the views of the whole breadth of the local community. I am therefore grateful to my noble friend for this contribution, and I am happy to support her amendments.

Although I am sympathetic to the sentiment behind my noble friend Lady Cumberlege’s Amendments 232, 236 and 237, I hope I can reassure noble Lords that, as corporate bodies, local healthwatches will have the flexibilities to make their own arrangements for securing staff, accommodation and so on, so the local authority should not have to make such arrangements on their behalf. There is no need for express provision on payment of expenditure because the legislation requires local authorities to make arrangements to ensure that the relevant activities can be carried on in their area. Necessarily, that means providing adequate funding to enable the functions to be carried out. This is an important point that I hope reassures noble Lords: the statutory functions must be delivered, and that is a protection of these bodies.

My noble friend Lady Cumberlege is quite right about local healthwatches working out their own priorities and work, and they will no doubt be doing that in conjunction with what is found to be good practice around the country, information coming from HealthWatch England and so on. I assure my noble friend that staff are there to help to facilitate such work, not to dominate it. My noble friend Lady Jolly is right: local healthwatch is a partner with local authorities—the eyes and ears, as the noble Baroness, Lady Murphy, and others have said.

My noble friend Lady Cumberlege was concerned that government amendments would damage local healthwatch’s independence. I do not agree: the amendments do not dilute in any way the statutory functions of local healthwatch, including the ability to give advice to local authorities among others. In response to concerns that local authorities may try to suppress local healthwatch, we specifically brought forward Amendment 236E giving the Secretary of State the ability to publish conflicts of interest guidance that both local authorities and local healthwatch would have to have regard to.

The noble Lord, Lord Harris, raised a number of issues. He regretted the fact that yesterday he was not at the seminar that I mentioned. I regret that he was not there. It was interrupted by a couple of votes, but I am sure that he would have engaged with those who were speaking there. That would have helped to inform everybody. All Peers were invited and some from his group attended. I see a few shaking heads.

[Lord Hunt of Kings Heath]

My Lords, the seminar was held during the regular meeting of Labour Peers which has occurred at 5 pm on Wednesday evenings since time began.

[Baroness Northover]

I am very sorry if there was a conflict of timing. Obviously it is difficult to schedule all the various meetings. My noble friend Lord Howe has had 100 meetings on this Bill.