National Health Service

Lord Lansley Excerpts

Thursday 14th January 2016 Lords Chamber

[Lord Lansley (Con)]

My Lords, I join noble Lords in thanking the noble Lord, Lord Turnberg, for this debate and I look forward to the maiden speech from the noble Baroness, Lady Watkins. With regard to debates, I put on record that it would be very useful for this House in particular each year in the late autumn to debate the draft mandate that the Government give to NHS England. That is the primary basis upon which the accountability through the Secretary of State to Parliament should be exercised. It was not debated here or in the other place, and it should have been.

I am very proud that, as my party’s spokesman over nearly 10 years, we made unambiguous and absolute our commitment to the values and constitution of the NHS, as my noble friend Lord Fowler equally made clear, and that we made a commitment to increase the budget of the NHS in real terms. Frankly, in the last Parliament it was 0.5% in real terms on average per year; the long-term average has been something over 4% in real terms per year, so the pressure on NHS budgets is unambiguous.

I agree with the noble Lord, Lord Turnberg, that the only reason that in 2014 the Commonwealth Fund could say that we had the best healthcare system among leading economies was because NHS staff deliver a superb service with modest resources. Over the last five years, they continued to deliver substantial efficiencies; in doing that they met the so-called Nicholson challenge of delivering £20 billion. We did it in part not least because—my noble friend the Minister and his colleagues hid this away on 21 July last year—the reform process cost £1.4 billion but delivered £6.9 billion of direct savings during the course of the last Parliament.

However, we need to do more in the future. Time does not permit me to do more than list the things we need to do. We need an NHS digital infrastructure that is user led and that delivers what the Wanless report called for but which did not happen. We need a preventive system. In the creation of Public Health England, the responsibilities of local authorities and the public health strategy in the White Paper of 2010-11 there is a strategy, but it needs to be funded, as my noble friend said, and as Wanless recommended, it needs to be delivered. On commissions, Wanless is a cautionary tale. To agree that a large amount of money should be available for the NHS does not necessarily deliver the preconditions for the success of that service in using that money effectively. We also need new models of care—integrated and personalised care—and better procurement, on which I look forward to hearing from the noble Lord, Lord Carter of Coles. We need the Dilnot report on social care to be implemented, as we heard in the debate before Christmas. Not least, we need tariffs for the acute sector to be realistic, even if challenging in terms of quality and efficient care.

Finally, we need a long-term future for the NHS, and I am not just referring to the next £20 billion of efficiencies over the next five years. There needs to be an understanding that, while there is a requirement to continue to be efficient, there is light at the end of the tunnel and that when we get to 2020 and beyond, the NHS budget, having gone down from 7.8% to probably 7.1% of GDP, does not go down any further and prove unrealistic in relation to rising demand. From that point onwards, for the subsequent five years, NHS England can then build a vision around a commitment to a sustained level of NHS funding relative to the income and wealth of this country.

Four Seasons Group

Lord Lansley Excerpts

Monday 11th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the idea of having a commission has been discussed a number of times in this House, and there will be a long debate on this matter on Thursday. In the spending review the Government are enabling local authorities to increase their precept by 2% and they are increasing the contribution to the better care fund by £1.5 billion, which will see a real increase in the resources available for adult social care.

[Lord Lansley (Con)]

My Lords, does my noble friend agree that in circumstances of provider failure one of the most important things is for residents to be maintained in their existing homes? In fact, that was achieved in the overwhelming majority of cases following the Southern Cross collapse. It is often possible to separate the going-concern basis of individual homes from the commercial situation of the provider as a whole.

[Lord Prior of Brampton]

I fully agree. Our interest is in the residents in the homes. The CQC’s oversight regime is not intended to prop up a provider—that is an entirely different matter. My noble friend is absolutely right that when Southern Cross went into insolvency, very few homes—in fact, I do not think that any homes—closed as a direct result at the time; most of them carried on as going concerns.

Residential Care: Cost Cap

Lord Lansley Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Lansley (Con)]

My Lords, I am grateful to have the opportunity to contribute to this debate and to thank the noble Baroness, Lady Wheeler, for initiating it. It is my privilege, not having been here for long, to hear your Lordships on this important subject.

It is important that we are discussing this two weeks after the Autumn Statement and the spending review. I am sorry that the noble Baroness, Lady Wheeler, characterised the spending review, albeit perhaps quoting others, as she did at the end of her remarks. I think that the spending review offered considerable additional resources over the course of this Parliament. I am frank and realistic enough to recognise, not least from conversations with directors of adult social care over the past couple of weeks, that they are sufficient at best to maintain the level of local authority-funded care in circumstances where the demand continues to rise and therefore the gap between availability and demand will grow. At worst, we will be in the situation, as we have been recently, where the availability of local authority-funded care has been falling at a point where demand is rising.

The noble Baroness’s point that there is a need for strategic vision is well taken. It is not simply a matter of resources, even though they are an integral part of the issue. Some of that strategy is being implemented and more is available to us. I pay tribute to my friend Paul Burstow who was a Minister with me in the Department of Health. In the coalition Government, we led together on the preparation of what subsequently became the Care Act. It contains a very important set of measures, including the availability of assessments, additional carers’ rights, more consistent eligibility for care and the availability of universal deferred payments.

We need to go further. Social care and healthcare need to be integrated. Everybody supports that in terms of the integration of service design and commissioning, but, vital as that is, we can and must go further. Integration will only be real if and when care users are increasingly able to exercise control and choice through personal health and social care budgets. To make that real we have increasingly to aggregate the availability of personal health and social care budgets to those care users so that the service providers have an aggregated level of demand to be able collectively to respond and create a market for this.

We must also recognise that this will mean integrated providers with the NHS working with private sector social care providers and housing providers. There is enormous potential for housing providers and other services, particularly personal care services, to redesign the nature of the service they provide. For example, extra care housing providers together with social care providers are able to put together packages that work really well for people who are able to choose between different kinds of accommodation and service.

Time permits me to say one more thing which I think is really important. Much of what we already have in place is the product of the implementation of the Dilnot commission’s view. I hesitate because I may be stealing the thunder of the noble Lord, Lord Warner, and others in the Chamber who may have participated in equivalent work on prior commissions. I asked Andrew Dilnot and others to undertake that work and I think the result was important and right. We have included some of it in the Care Act. The Government have not implemented the cap on care costs and, to be frank, the cap that was intended was in my view insufficient. I continue to subscribe to the view that we should aim to implement a cap on care costs broadly in the way that the Dilnot commission recommended, at around £50,000 with a structure of assessment that means that probably no more than 40% of somebody’s assets would be depleted in the process of means-testing.

The combination of these two things would make it attractive to individuals to insure against this risk in so far as they have to meet that cost, and by taking away a much more substantial part of the risk of high-cost care over a longer period of time make it a more insurable risk for private sector insurers. Additionally, since the Dilnot commission reported we have more options in relation to pension flexibilities, and we always have housing asset flexibilities to enable these insurance products to become available if it is necessary for us to have those resources come into the system.

The original intention for the implementation of Dilnot before the election was that it would be funded out of inheritance tax and changes to opting out of national insurance. That moment has gone, but in internal discussions in 2012 from my point of view we were very clear about how this ought to be paid for, but it was not acceptable inside government. There was not agreement to do it because within the system we have discrimination against residential care in favour of domiciliary care. That creates an artificial distinction that we have to escape from, which is the exemption of the main or only home for the means test on charging for domiciliary care. At any given moment, about 120,000 people benefit from that, and £1.3 billion a year is available to them by virtue of that exemption. That is broadly speaking the amount that is necessary to construct a different proposition for people who are facing the insecurity of potentially very high long-term care costs. We need to go beyond simply enabling people not to have to sell their home to pay for care and give them the security of being able to find, as you do in so many other walks of life, the opportunity to insure against the often arbitrary effects of having to receive long-term care in old age.

Alcohol

Lord Lansley Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, I can only repeat that we will have an independent review of the responsibility deal, at which point we will have objective evidence on which to assess it. I agree entirely with the noble Baroness that the health world, including the BMA and many of the royal colleges, takes a very strong view about alcohol. Many doctors see the appalling impact that it has on individual lives day in and day out, so we take their views extremely seriously.

[Lord Lansley (Con)]

My Lords, can I tell my noble friend the Minister—

[Noble Lords]

Ask.

[Lord Lansley]

Can I ask my noble friend the Minister if he agrees that the report from the Institute of Alcohol Studies is purely polemical in character and not a research report at all? Actually, its argument is based on a flawed proposition, which is that the pursuit of voluntary agreements through the responsibility deal prevented the pursuit by government of minimum unit pricing. Does my noble friend agree that from the very outset of the responsibility deal, it was made clear to the industry that its pricing of alcohol and indeed the Government’s attitude in terms of tax and pricing were no part of the responsibility deal, and that within government no discussion of minimum unit pricing was affected by the fact of the responsibility deal?

[Lord Prior of Brampton]

I am happy to be told that by my noble friend and I can only agree with him.

Junior Doctors Contract

Lord Lansley Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Prior of Brampton]

There is a recognition that the weekend effect is caused by many factors. It is certainly not just the ability of trusts to roster junior doctors at weekends but the absence of senior cover and the fact that much diagnostic capacity is not available at weekends. Of course, you also have to be able to discharge patients at weekends, which means that social care has to be working as well. To have a truly seven-day NHS requires a lot more people and resources to be available than just junior doctors.

[Lord Lansley (Con)]

My Lords, my noble friend the Minister’s repetition of the Statement and what he was able to say additionally in response to noble Lords was very welcome. Does he agree that going back more than 20 years, to when the new deal for junior doctors was first brought in and we supported them on their concerns about Modernising Medical Careers, we on these Benches have never been lacking in support for junior doctors? We understand that when one is on the ward in a hospital at the weekend, very often the doctor who you see is a junior doctor. The point is that it is in the best interests of junior doctors and patients for seven-day working to be introduced, with proper rostering, rather than discriminating between Monday to Friday and the weekend as if they were different parts of what is in truth the same service. If we get it right, as my noble friend says, it should be possible to achieve such an agreement without bringing any detriment to junior doctors as a consequence, but rather by supporting them in the work that they have to do.

[Lord Prior of Brampton]

I thank my noble friend for those comments. One of the issues often raised by junior doctors is that they do not always feel properly supported at weekends. I think that having more seniors available at weekends—and late at night, for that matter—will be welcomed by junior doctors. There is also sometimes a misunderstanding in the public mind, as junior doctors can actually be quite senior doctors. A medical registrar is, by most standards, a senior doctor so junior doctors are not just people who have recently finished their training.

National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) (No. 2) Regulations 2015

Lord Lansley Excerpts

Tuesday 24th November 2015 Grand Committee

[Lord Lansley (Con)]

My Lords, this is the first time I have had the opportunity to say something in Grand Committee, so I hope that I will be forgiven if I trespass on any of the procedures. I was tempted to speak, not least by the noble Lord’s reference in his Motion to the potential perverse incentives surrounding the referral to treatment time targets.

We do not need to speculate on where there might be perverse incentives in the system of targets and the impact they can have on how the NHS manages such targets, as we can see them. We saw them under the previous Labour Government. They had two referral to treatment time targets relating to admitted and non-admitted patients for complete pathways. The net result, of course, was a perverse incentive not to treat patients once they had passed beyond the 18-week point. It was precisely for that reason, after the 2010 election, that my colleagues and I in the Department of Health thought it was necessary to have a third target. For example, we were presented with 18,000-plus patients who at the time of the May 2010 election had waited for their treatment beyond 52 weeks.

There was a perverse incentive. It was very straightforward: if they were brought in in any significant numbers, and they and others like them had gone well beyond the 18 weeks into treatment, they would not be counted for the then 90% or 95% target—particularly the admitted patients on the 90% target. They were simply ignored. That was not acceptable. It was not what the targets were intended to do and it was not for the benefit of patients. So we introduced the incomplete pathway which had a salutary effect. It brought the numbers waiting beyond 52 weeks from more than 18,000 down to the low hundreds. It is still only about 800 patients who have waited. We introduced zero tolerance subsequently, once we had brought the numbers down for beyond a 52-week wait. We do not need to speculate about perverse incentives; they were there.

I can understand where Sir Bruce Keogh has seen that the combination of these targets can create a degree of confusion. The success of having introduced the incomplete pathway standard is something that we can build on. That is what Sir Bruce and NHS England are aiming to do—a simple standard that no less than 92% should be treated within 18 weeks. That reinforces the 18-week standard and it is very clear in the minds of patients.

Of course, there is scope for perverse incentives; there always is. In this instance, we know that by failing to distinguish, as the previous targets have done, between admitted and non-admitted patients—non-admitted patients having been less costly and complex to treat—there is a perverse incentive to concentrate on the non-admitted patients relative to the admitted patients. It is fair to say that if we see that emerging, we would have to respond in terms of the structure of the targets. To introduce something that dealt with the transparent detriment to patients of waiting beyond 18 weeks and then simply being dropped from the system and ignored was the right thing to do. When the noble Lord talks about perverse incentives, we have dealt with what was the principal perverse incentive. It is perfectly reasonable for NHS England and for the Government now to focus on one standard to make life more straightforward for those who have the responsibility of managing an increasing workload in hospitals.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, once again I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this to the Committee. My noble friend Lord Lansley has pretty much done my job for me, but I think I had better go through with this to put it on the record. I thank my noble friend for that articulate and eloquent exposition of why we now have one incomplete standard and not the three that we had before.

We all accept that waiting times are critical. I should pay tribute to the Government of which the noble Lord was once a member. Bringing down waiting times was a huge success and there is no doubt that targets were one of the instruments used to do so. However, the noble Lord accepts that they are a blunt instrument and can lead to distorting clinical priorities. They can lead to gaming and extra cost, so they are not the whole answer. In particular, they can lead to perverse consequences. That is why the Secretary of State for Health and Simon Stevens accepted the recommendations made by Bruce Keogh earlier in the year. I will place a copy of his letter to the Secretary of State and Simon Stevens in the Library. The noble Lord may already have seen the letter but I will place it there.

Sir Bruce’s clinical advice on the standards used to measure the 18 weeks NHS constitution right was to remove the two standards that looked at how long people who have started treatment waited and to focus on the incomplete pathway standard—that is, the people who are still waiting. Perhaps I can explain that by using the analogy of a bus. The two earlier standards measured the people on the bus and the incomplete standard is designed to measure those who are left behind at the bus stop. As all three standards were written into the standing rules regulations, this statutory instrument, which took effect from 1 October, was required to make that change.

The change affects the metrics by which we measure the NHS’s performance on waiting times. It does not change the patient’s right. It is important that that is on the record. Patients can still expect to start treatment within a maximum of 18 weeks if they want to and it is clinically appropriate. If this is not possible, patients have the right to ask to be referred to an alternative provider that can see them more quickly, and the NHS must take all reasonable steps to meet patients’ requests. Sir Bruce Keogh recommended this change because having a set of three standards could be confusing and give rise to perverse incentives.

My noble friend described those perverse incentives. The perverse incentive was such that you could treat only one patient who had waited for more than 18 weeks as opposed to nine who had waited for less. There is no doubt that hospitals were managing their waiting lists on that basis. As a consequence, there were people waiting beyond 18 weeks for far too long. That was the wrong that the incomplete standard tried to address. As Sir Bruce said in June, while hospitals may be the ones penalised directly when they breached waiting time standards, the true penalty was laid on the patient who was waiting for much longer than he should have done. I wholly agree that that was not right.

In 2012—I think my noble friend was Secretary of State at the time—the Government introduced the incomplete pathway standard that a minimum of 92% of patients yet to start their treatment should have been waiting less than 18 weeks, to give NHS organisations a reason to prioritise patients who had been waiting a long time. The removal of the two completed pathway standards further minimises the potential for management of the waiting list to cut across clinical decision-making. Clinical priority should always be the main determinant of when patients should be treated. This clinical priority should not have been distorted because it should have been possible to meet all the clinical priorities and meet the waiting time standard, but in practice that was not always the case. Clinicians should make decisions about patients’ treatment and patients should not experience undue delay at any stage of their referral, diagnosis or treatment.

These changes will mean that there is a simplified, clearer focus on only one standard, covering all patients on the waiting list, and ensuring that those who have been waiting a long time are not left languishing. The noble Lord raised the issue, which was addressed by my noble friend, of whether having just the one standard will result in new and different perverse incentives. My noble friend made the important point that it could lead to priorities being skewed in favour of non-admitted, simpler, cases rather than admitted, more complex, cases. That is something we need to keep a very close eye on. NHS England will continue to measure trusts’ performance against all the standards except that there will be only the one measure in the contract.

I stress that changing the standards is not moving the goalposts in response to poor performance. This change has been made on the basis of clinical advice and in the best interests of patients, and has received widespread support, for example from the Nuffield Trust and the Patients Association. More than a million NHS patients start treatment with a consultant each month and the overwhelming majority are seen and treated within 18 weeks. However, the NHS is busier than ever, which is why we are investing the extra £8 billion that NHS leaders have asked for to support the five-year forward view. I hope that the noble Lord will accept that this was done in good faith and in the interests of patients and that it was a decision informed by clinicians, not by politicians. I have not addressed the concerns he raised about the eligibility criteria for nursing, because they are not strictly relevant to these regulations, but perhaps I could write to him on that matter.

Health and Care Professions Council (Registration and Fees) (Amendment) (No. 2) Rules Order of Council 2015

Lord Lansley Excerpts

Tuesday 24th November 2015 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, this order concerns the Health and Care Professions Council and its fee raise, which is in relation to 330,000 health and social care professionals. They include paramedics, occupational therapists, biomedical scientists, chiropodists, dieticians, physiotherapists, radiographers, prosthetists, orthotists, speech therapists and social workers. That list brings home the importance of this group of professionals. Parliament, through various pieces of legislation, has seen fit to ensure that they are subject to mandatory regulation in the interests of public protection. Parliament also has a role, therefore, in overseeing the performance of the regulatory bodies.

On 1 August, the annual registration fee for members of the professions covered by the HCPC went up by 12.5% overnight as a result of the order that we debate today. The order was passed in the face of cross-party concern, including 100 Members who signed up to an Early Day Motion and indeed the tabling of a Motion to annul in committee at Holyrood. The 12.5% increase in fees followed on the heels of a 5% rise the previous year and in the face of assurances given by the HCPC in 2014 that it would not look to raise fees again until 2016. This is not being done in isolation. I know that we are not discussing other regulatory bodies, but I would mention to the Minister the NMC, which raised fees for nurses in 2013 from £76 to £100 and in 2015 from £100 to £120. The points that I want to raise in principle relate to a number of these regulatory bodies.

The contrast that I want to make is between the regulator’s demand for an increase in fees alongside what is essentially the sixth year of pay freeze and pay restraint and the Government’s policy on austerity generally. It is a puzzle as to how, when the public sector in general is under tight financial control, the one area that seems to be able to raise its fees willy-nilly is that of the professional regulatory bodies and the Care Quality Commission. The Minister will know that the CQC proposes to raise fees hugely, at some financial risk, particularly in the care sector. That is not for debate today, but there is an issue of principle here: in contrast to the issue of pay restraint and restraint generally on the public sector, a group of regulators seems to be able to put forward proposals, which the Government accept, for large fee increases.

I read the consultation paper issued by the HCPC, which said that the unexpected fee rise was prompted by the levy that it now has to pay to fund the Professional Standards Authority for Health and Social Care, the regulators’ regulator. I understand that and it was fully discussed in a debate in the other place in March. However, it subsequently emerged that the levy that it said had to be paid because of the Professional Standards Authority actually accounted for only 30% of the fee rise, and the remaining 70% was so that the HCPC could buy new accommodation for hearings, IT and quality assurance systems. In the consultation document, as far as I can see, that was not made clear. There was no breakdown or detailed justification of the fee increase.

That is particularly striking in light of the judicial review proceedings brought by the British Dental Association against the increase proposed by the General Dental Council whereas I understand that the High Court said that a regulator’s consultation on fee increase must set out a clear and detailed breakdown of the financial case for proposed increases. My point to the Minister is that that did not happen in relation to the HCPC consultation. There are three areas that I want to touch on. The first is that the consultation itself was extremely short. It covered the Easter holidays, May Day bank holiday and the purdah period. It closed on 6 May, the day before the general election. It totalled just 26 working days, leading many to suspect that it was designed to be buried away from scrutiny.

My second point is about accountability. Of those who did respond to the consultation, 86% of individual respondents objected to the increase, as did three-quarters of organisations. Their objections made not one iota of difference.

I come now to the role of the PSA, the regulators’ regulator. One of the problems is that while in a sense it can ask for a levy in order to fund itself, it does not seem to have a role to intervene on how regulators set fees or consult on them. In the light of experience with the HCPC, it would be good for the PSA to take a more proactive role. We know from submissions that I have received from staff organisations—I particularly refer the Minister to a survey by UNISON of nearly 5,000 registrants across the professions—that the fee rise was commonly referred to as a stealth tax. If you have no choice but to pay to practise your profession then it feels like a form of taxation. Yet registrants have little representation in the decision-making process that sets that fee.

Will the Minister also comment on the issue of the HCPC? Does it represent value for money? I know that the HCPC has done very good work, and I do not deny that it has absorbed a number of professions over the years successfully. However, these large fee increases bring concerns about whether the overall operation of the HCPC—and the other regulated bodies—is as efficient as it could be.

I want to raise with the Minister an issue that has been presented to me: although the fee might not be considered large in absolute terms, it is, none the less, a consideration for part-time staff in their choice of profession. The Minister may be aware that, as I understand it, the HCPC has declined to introduce a pro-rata structure, or differentiated fee structure, for part-time workers. That is a pity, given the need for us to attract staff and the fact that part-time staff have a lot to offer.

I understand that nine trade unions and professional associations representing registrants in HCPC fitness-to-practise processes have written to advise the HCPC that more could be done to control its costs, improve its efficiency and reduce the number of unnecessary hearings. They also made detailed recommendations on how the investigating process could be improved in order to root out unnecessary investigations, reduce the number of lengthy hearings and facilitate consensual resolutions. Seeing the noble Lord, Lord Lansley, here of course brings great joy to us all, but I cannot help commenting on the draft Bill drawn up by the Law Commission, which he would have received some time ago. Well, he may have commissioned it, I do not know whether he received it.

[Lord Lansley (Con)]

If I remember correctly, it was commissioned in 2011 and received by my successors in April 2014.

[Lord Hunt of Kings Heath]

My Lords, if he had still been in place I have no doubt that he would have acted on it. The point is, however, that a lot of the problems with the current fitness-to-practise procedures among health regulators generally derive from the fact that we have not implemented the Law Commission’s Bill, which would have allowed for a much more streamlined process.

The HCPC has, as I say, earned a great deal of credit for the way in which it has absorbed new professions over the years. I hope, however, that in this short debate the Minister will agree to look at some of the general principles raised. Does he agree that in any future proposal for a fee increase there needs to be a full breakdown and detailed justification for it? Does he also agree that it is not a good thing for Ministers to entertain fee rises that are higher than the percentage fee rises that are going to be given to NHS staff? There is an issue about pay restraint on the one hand and what seems to be the regulator’s ability to raise fees well above that rate on the other. Will he consider discussing with the PSA whether it will take a more proactive role in monitoring and evaluating any proposed increases by the regulator it oversees? Will he also look at whether the HCPC should be required to introduce a pro rata, or differentiated, fee structure for part-time workers?

Lastly, and I am sure the noble Lord will say yes to this, will he say that the Government will make it a priority to bring in primary legislation as soon as possible to implement the Law Commission proposals? The alternative is that the Minister will have to go through a succession of Section 60 orders when as a general principle he would find widespread support for the Law Commission proposals—there are one or two issues that we will debate—for a streamlined process that would apply consistency across all the regulated bodies. I am sure that it would reduce the cost of the regulators and, if the Government are not able to bring this in as a full Bill, at the very least it lends itself to pre-legislative scrutiny. However, there is enough consensus around the proposal to allow the Government to introduce a Bill. This short debate is a good opportunity to raise the issue of transparency of the regulators, and I hope that the Government are prepared to give this further consideration when a proposal comes up in the future. I beg to move.