Adult Social Care

Debate between Lord Lansley and Lord Prior of Brampton

Tuesday 15th November 2016 Lords Chamber

[Lord Prior of Brampton]

I cannot answer specifically the question raised by the right reverend Prelate, but I would say that voluntary and support groups of the kind that he mentions have a hugely important role to play in delivering social care. I visited Crossroads in Gloucester with the noble Baroness, Lady Royall, last Thursday and was struck by the extraordinary work that voluntary groups do—and what carers do, of course. If we relied purely on statutory services, the whole health and social care system would collapse tomorrow.

[Lord Lansley (Con)]

My Lords, my noble friend will recall that in the coalition Government, Andrew Dilnot and his team produced a report on how to give longer-term sustainability to social care and enable people not to suffer catastrophic losses when they are long-term care recipients. Will the Government commit not only to introducing the Dilnot recommendations but, perhaps earlier, to funding it, and to do so by bringing the domiciliary care means test in line with the residential means care test, which would raise £1.3 billion a year?

[Lord Prior of Brampton]

My Lords, the Government are committed to introducing the proposals of the Dilnot commission by the end of this Parliament in 2020, and I understand that during 2017-18, we will bring back those proposals to refresh them, but with a view to phasing in implementation in 2020.

NHS Funding

Debate between Lord Lansley and Lord Prior of Brampton

Monday 31st October 2016 Lords Chamber

[Lord Prior of Brampton]

I entirely agree with the comments made by the noble Lord. We have to integrate health and social care to a much greater extent. We also have to integrate healthcare: healthcare is delivered in silos and is highly fragmented around the country, and that comes out of the same budget, so he is absolutely right. However, we have to recognise that another massive reorganisation between social care and healthcare could be highly disruptive. The great beauty of the STP process is that people in local areas—local authorities, health providers and commissioners—are sitting around tables coming up with plans for their local areas.

[Lord Lansley (Con)]

My Lords, does my noble friend agree that it is only by virtue of the 2012 Act that NHS England is an independent body, able to express, on behalf of the NHS, a plan for the future, and that this would not have been possible otherwise? Will he further confirm that the coalition Government, in the last Parliament, met their promise to increase the NHS budget in real terms, year on year, but that that promise applied to an NHS budget that included public health and NHS education and training? The NHS’s future sustainability requires a more preventive approach and increased numbers of domestically trained NHS staff.

[Lord Prior of Brampton]

I entirely agree with my noble friend that the independence of NHS England has been very important. Had the NHS plan been developed by politicians it would have had a lot less credibility. I entirely agree that prevention and public health are hugely important, but of course it takes a long time for public health initiatives to have an impact, so I do not think that any reductions in them in the last two years will have any major impact over the five-year period. Clearly, it will have an impact over a longer period. As for the changes to Health Education England, those savings have largely been generated by moving from a bursary system for nurses to a loans system, which will actually deliver more nurses and therefore help to deliver the five-year forward view.

Health: Alcohol

Debate between Lord Lansley and Lord Prior of Brampton

Thursday 12th May 2016 Lords Chamber

[Lord Prior of Brampton]

I am sure we will all be following in the noble Baroness’s wake when we do that. It is worth making the point that one of the benefits that came out of the responsibility deal, which I know not everyone in this House thinks was successful, is that the labelling on alcoholic products has got much better.

[Lord Lansley (Con)]

My Lords, my noble friend will be aware that the risk of dementia in later life is now one of the public’s principal concerns, and of course it is established that there is a relationship between harmful alcohol use and the risk of alcohol-related dementia and Korsakoff’s disease. The One You website does not readily click through to give that information so that people’s concern about dementia is something that they understand can be related to the harmful use of alcohol.

[Lord Prior of Brampton]

My Lords, that is an interesting point, which I will draw to the attention of Public Health England. If that click-through is not clear, it should be. Since the Blackfriars Bridge agreement, PHE has been working with Alzheimer’s UK to do more research into analysing the impact of alcohol on dementia.

Healthwatch England

Debate between Lord Lansley and Lord Prior of Brampton

Tuesday 26th April 2016 Lords Chamber

[Lord Prior of Brampton]

I disagree. I had a private sector background when I became chairman of the CQC, I might add, so perhaps I am slightly biased in this regard. Having a mix of people from all different backgrounds, whether private, public or voluntary sector, is a very good thing.

[Lord Lansley (Con)]

My Lords, would my noble friend the Minister agree with me, as one who was responsible for the creation of Healthwatch, that there is a powerful rationale for its close working relationship with the CQC? The CQC needs to listen to the patient voice in the exercise of its responsibilities, and Healthwatch benefits significantly from being able to trigger action by the CQC where it finds that things are going wrong.

[Lord Prior of Brampton]

I agree with my noble friend. Healthwatch has two principal roles: first, to gather intelligence locally, which it can then feed into the CQC and its inspections; and secondly to be the strong voice of patients at a national level.

Mental Health Taskforce

Debate between Lord Lansley and Lord Prior of Brampton

Tuesday 23rd February 2016 Lords Chamber

[Lord Lansley (Con)]

My Lords, does my noble friend the Minister agree that in order to secure parity between physical and mental health services, it is important to ensure that mental health service providers are properly and fairly reimbursed for the activity they undertake rather than subject to a block grant system where physical health service providers are paid for the work they do? In that respect, will the Government commit to working with NHS England and NHS Improvement to make progress now in the development of tariff-based systems for mental health services which fairly reimburse for delivering quality in outcomes?

[Lord Prior of Brampton]

My noble friend is absolutely right. I am glad he finished by referring to quality in outcomes rather than just activity. That is the critical thing about getting the tariff right, that it is based not just on activity but on quality in outcomes.

Junior Doctors

Debate between Lord Lansley and Lord Prior of Brampton

Monday 8th February 2016 Lords Chamber

[Lord Prior of Brampton]

It was always agreed that the package offered to junior doctors would be cost-neutral.

[Lord Lansley (Con)]

My Lords, does my noble friend the Minister recall, as I do, that it was a Conservative Administration who introduced the new deal for junior doctors and established a process by which unsafe, excessive hours for doctors were not to be pursued? That started happening in the early 1990s and no one is thinking that we would go back to that. I was delighted that my noble friend was able to make it clear how the negotiations can introduce additional guarantees about not having unsafe hours for junior doctors. However, I put it to him that at this stage in the negotiations there may be an alternative approach—an objective of enabling seven-day rostering for junior doctors, in this instance but also more widely, and an overall financial envelope. It might be put to the BMA that rather than it standing aside from the negotiations, it should take responsibility and say how it proposed that junior doctors should be remunerated within that financial envelope to meet those objectives.

[Lord Prior of Brampton]

My Lords, we certainly do not want to go back to the days when junior doctors were working very long and unsafe hours but nor should we ignore the fact that they do not, by and large, like being treated as shift workers. The continuity of care is very important to most professional doctors. As for the actual negotiations, I have not been directly involved with them so I do not know to what extent the junior doctors have been asked to consider what my noble friend Lord Lansley has suggested. However, what he says has much merit.

Health and Social Care: State Pension

Debate between Lord Lansley and Lord Prior of Brampton

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I am afraid that I cannot today give my noble friend that chink or that hope, because we are supporting the NHS’s plan, which was developed and produced by the NHS. We believe that it would be wrong to set up an alternative at this stage.

[Lord Lansley (Con)]

My Lords, would my noble friend agree that, while the Government are fully funding the NHS five-year forward view, which is very welcome, the sustainability of NHS funding depends on the sustainability of social care services as well? Before establishing any other commissions, would not it be advisable for the Government to make progress on implementing the Dilnot commission’s recommendations? In that respect, will the Government specifically consider enabling that to proceed by removing the exemption on one’s principal personal residence when calculating the means test for domiciliary social care?

[Lord Prior of Brampton]

My Lords, as my noble friend knows, the Government accepted the findings of the Dilnot review but felt that now was not the right time to introduce them, given the financial pressures on local government. We are committed to introducing the Dilnot reforms by the end of this Parliament.

Four Seasons Group

Debate between Lord Lansley and Lord Prior of Brampton

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.

Alcohol

Debate between Lord Lansley and Lord Prior of Brampton

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—

--- Later in debate ---

[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

Debate between Lord Lansley and Lord Prior of Brampton

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

Debate between Lord Lansley and Lord Prior of Brampton

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.