NHS: Standards of Care and Commissioning

Lord Warner Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Warner]

My Lords, I am grateful to my noble friend for securing this warm-up debate before the Government’s legislative juggernaut reaches this House. In the time available, I want to confine myself to talking about commissioning because good commissioning has a significant impact on achieving good service standards. For 20 years, we have been trying to establish an effective NHS commissioning system. Ken Clarke’s GP fundholding and partial purchaser/provider split was followed by Labour’s PCT commissioner model, again without a full purchaser/provider split. Just for good measure, I added on a practice-based commissioning dimension in 2006 which many PCTs were pretty effective at thwarting. Now we are to have another legislative go. That is a summary of the history of commissioning.

All too often, PCT commissioners have lacked the know-how, competence and muscle to commission effectively. Too often, they have been unable to manage demand, keep in check acute hospital expenditure and hold hospitals to account. We know from the Care Quality Commission data that there are too many PCTs with poor track records on quality and financial management. The House of Commons Health Select Committee’s excellent reports on PCT commissioning make for depressing reading. It is not, in my view, unreasonable to decide that PCTs have had their chance and failed overall, so we should try a more clinically driven model of commissioning, as the Government wish to do. In many ways, this is a logical development from practice-based commissioning. However, the Government must learn the lessons of past mistakes in designing a new commissioning model if they are not simply to repeat those mistakes.

The population size of many commissioning bodies has been too small for effective health-risk pooling. When I hear the BMA say that there is a new commissioning consortium with a population of 18,000 people, I despair. I managed to reduce the number of PCTs from 302 to 150, but could not secure agreement politically to go down to 50. That would have given us commissioning bodies with populations of about half a million to 1.5 million people. I believe that is the kind of population we should be looking for in commissioning the full range of services that the Government wish to give to those kinds of consortia. The amount of high-quality commissioning capability in the NHS that we had in 2005 was insufficient to service the number of bodies involved. That remains the case today and the added trouble is that the amount of money available to pay for them has become even smaller in size.

When the Bill comes to this House, we are going to have to probe the area of commissioning forensically. We will need to ensure that there is a proper system of licensing or accrediting commissioners, however the function is organised. We need to ensure that commissioning bodies have the data collection and the analytical, financial, contracting and clinical expertise to commission safely and cost-effectively the range of services that they will be legally required to commission with about £60 billion of public money a year, on present estimates. The National Commissioning Board must have the authority and capacity to prevent people without the competence to commission getting their hands on big slugs of public money. The board has to be able to remove and replace inefficient, incompetent or overspending commissioners in a timely way. Those are the kind of issues we should be considering when we come to that Bill.

In conclusion, as a former commissioner of social care I found it jolly useful to have a diversity of service providers so, unlike a number of people, I congratulate the Government on going for a bit more competition and extending the market for providers—not just from the private sector but with good providers from within the NHS and good mutuals, of which I suspect we will see a lot more in future. We will have a lot of time to discover what the Government’s thinking is on some of these issues as we take the Bill forward in this House.

Public Bodies Bill [HL]

Lord Warner Excerpts

Monday 28th March 2011 Lords Chamber

I believe that the fear of many professional bodies and patient groups is that by disassembling the HFEA, we could end up with something much worse. It would seem prudent to do the review and the consultations before we determine the outcome. There is no hurry; one can wait until the new, all-purpose medical regulatory authority is established, and then decide what to do. If not, there is great risk so I hope that the Government will accept this amendment and believe that they would be greatly relieved if they did.

[Lord Warner]

My Lords, I support this amendment. I am conscious that I must guard against triumphalism after the Youth Justice Board amendment earlier, but I raise that because there are some similarities, in that the Government could walk into the same situation. With the Youth Justice Board, we had a situation where a body was functioning perfectly well and the Government tried to change it before they knew or could explain what to put in its place to safeguard the development of youth justice and the future delivery of services. The Government are in danger of falling into exactly the same position with the HFEA and the HTA: two bodies functioning perfectly well, which have international reputations and which, certainly in the HTA’s case, are of relatively recent origin in their passage through Parliament. It is far from clear what the Government will do for a new set of arrangements that go wider than those two bodies and embrace a new agency of health research.

I am grateful to the Minister for his letter of 22 March about the Government’s ideas for taking forward the transfer of functions of the HFEA and the HTA using this Bill’s powers. However, I am not at all sure that I am much clearer about how things will work out in practice because the Government seem to be saying in that letter that they have a lot of options for changing things but seem rather uncertain about which option to pursue. On the Minister’s own admission the Government cannot say at this stage what approach they prefer to take on transferring functions. That is a fairly big lacuna in the Government’s thinking. If they cannot say how they want to change these functions with some degree of clarity and when this new agency will be set up, it is asking quite a lot of Parliament to take it on trust that we should plonk a couple of organisations of some standing and good functioning in Schedule 5 of the Bill and hope it will all turn out okay eventually. That seems to be the situation—with the greatest respect to the Minister—that we are placed in at this moment.

Part of the problem, it seems to me, is that the Government are very unclear on when they will actually set up the new research agency. The proposed agency commands a huge amount of support across this House and indeed in the world outside. Many of us have long wanted to see that kind of comprehensive, coherent health research agency in place, but it is not an easy job to do. It will be quite a complicated business setting that up. I do not know, and I am not sure that the Government know, when they will have this body up and working and where they will get the funding from. They will need to carry on running existing agencies at a time of some degree of financial restraint and set up a new body to take over those functions in an orderly way. In my time in the public sector I have rarely seen changes of that kind implemented without some extra costs. I have read the Chancellor’s statement, in which we all live happily ever after on this particular issue. I would really like to know from the Minister whether the Department of Health has actually got the funding. Has it got a game plan for implementing this agency? When will it come on stream? We need to know that to make any sensible judgments about the transferring of functions.

The noble Lord, Lord Willis, has drawn attention to the complications around licensing in relation to clinical research and clinical practice in these areas. These are complex issues. If we do not know in detail when the agency will be operational and what functions it will have transferred to it, it seems a great leap of faith to put these two bodies in Schedule 5 with a strong commitment from the Government that they are going to act on Schedule 5 and make changes in the functioning of these bodies but without knowing precisely what those changes will actually mean.

I found the penultimate paragraph of the Minister’s letter to me of 22 March particularly puzzling. He claims that the mechanism in this Bill reduces the risk of opening up the whole HFEA primary legislation for debate. Like other noble Lords, I view that with deep, deep scepticism. The idea that we can open up a debate about the functions of the HFEA being transferred from it to another body without opening up many of the public concerns around that body and similarly with the HTA seems to me, if I may put it as brutally as this, extremely naive. It is not going to happen. Once you start tinkering with these two bodies of great sensitivity, as I am well aware of from taking the HTA legislation through this House, you are actually opening Pandora’s box. You cannot be sure what the outcome will be in terms of public concerns.

I think that we have to go a long way further down the track in understanding the Government’s thinking and how this will all work with the establishment of the new health research agency. I do not believe that it is either smart politically or sensible managerially to be heading off in this direction without knowing where the finishing post is.

Public Bodies Bill [HL]

Lord Warner Excerpts

Wednesday 9th March 2011 Lords Chamber

[Baroness Thornton]

My Lords, I shall speak also to Amendments 93, 150 and 151. On Second Reading, many noble Lords expressed their disquiet at the inclusion in the Bill of the HFEA and the HTA. At the time, I wondered if they were included because the Minister’s department insisted that the Department of Health had to offer something up to the Bill, so the poor old HFEA and HTA were the sacrificial lambs. Indeed, in its own review of the arm’s-length bodies, the Department of Health gives a much more measured suggestion of the deliberation and consultation before decisions were taken about the HFEA and HTA over a timescale that is the life of this Parliament. Unless something has changed about the expected length of this Parliament, it seems precipitate and unnecessary to include these bodies in the Bill.

In a meeting convened by the Minister—the noble Earl, Lord Howe—to discuss this important matter with interested parties, which I was pleased to attend, he was concerned to reassure us about the consultation and discussion to take place before decisions were reached. We can add to those reassurances the proposal, as I understand it, that in the next Session—in other words, after May 2012—primary legislation will be introduced to establish a new science regulator in the department. If that is the case, the passage of that legislation would allow proper consultation and scrutiny across the field including the work of the HFEA and the HTA, which is the way in which such reforms should be carried out. So I ask again: why is it necessary for these bodies to be included in the Bill?

The HFEA and the HTA almost symbolise the concerns that noble Lords have expressed in relation to the constitutional propriety of the Bill in giving Ministers powers to amend primary legislation. Both organisations would have their work and their regulation fragmented unnecessarily when they need to be left alone to get on with the jobs that they do very well—although there is always room for improvement—until a proper period of consultation and pre-legislative scrutiny, which I am sure the noble Earl would wish to have, can precede the introduction of the science regulator Bill or whatever it will be called. That is the way to proceed.

What do these bodies do? The HTA licenses and inspects organisations that store and use human tissue for purposes such as research, patient treatment and post-mortem examination, teaching and public exhibitions. It also gives approval for organ and bone marrow donations from living people, including anatomy and stem cells and cord blood; public display—that is, the public display of any human body parts in various forms—post mortems; coroners; and transplants.

The advances made by science throw up new and sometimes complex ethical issues for the HTA to address. The cavalier use of body parts for research without the knowledge or consent of patients and their families was a huge scandal, leading to public indignation. Many in your Lordships’ House will recall the time and the thought given to the creation of a regulatory framework that would command public confidence. I fail to see what has changed that can allow any slackening off of the responsibility that the HTA bears for the use of human tissue.

The HFEA is the UK’s independent regulator of treatment using eggs and sperm and of treatment and research involving human embryos. It sets standards for and issues licences to centres and provides authoritative information for the public, particularly for people seeking treatment, donor-conceived people and donors. Very importantly, it also determined a policy framework for fertility issues which are sometimes ethically and clinically complex. The HFEA Act 2008 includes provisions for research on different types of embryos and changes the definition of legal parenthood for cases involving assisted reproduction. Therefore, the work of both bodies is of enormous scientific importance apart from anything else.

The arm’s-length body review in July 2010 concluded that the HFEA carries out essential functions which satisfy,

“the criteria for being undertaken by an arm’s-length body”.

The review states that the HFEA,

“deals with issues that are judicially and ethically complex and contentious”.

The HFEA is a world-respected model which has been used by other jurisdictions to deal with extremely technical and legally complex areas of practice. We have to ask what will happen to the high level of expertise and experience in both organisations and whether it will be in the public interest to transfer regulatory functions to other organisations where this knowledge may be lost to the detriment of patient safety.

I know that some noble Lords, particularly some of our very respected medics, for sometimes differing reasons have expressed the view that time has moved on since the original reason was established for setting up these bodies, human fertilisation is not the novelty that it once was, these medical procedures no longer need the attention of their own regulator and therefore change is necessary. That is a powerful argument but I disagree with it, or at least I have yet to be convinced. It seems to me that the powerful reasons that brought these two bodies into existence, and the reason we in Parliament paid such close attention to establishing their duties, responsibilities and independence, are still as potent today as they were when they were founded. These are not primarily medical or scientific reasons but concern the need to maintain public confidence in the uses to which human tissue is put, and sometimes in the very controversial issues arising out of human fertility and procreation.

Time and consideration need to be given to the contribution to scientific research made by the HTA and the HFEA, and, of course, they should carry out their respective functions in a cost-effective and efficient manner with appropriate public accountability. We may wish to see change in the way that the HTA and the HFEA functions are carried out but I believe many of the changes needed could be achieved without their inclusion in the Bill. Change should be helpful in achieving the broader stated aims of reducing bureaucracy and saving money rather than simply focusing on a reduction in the number of arm’s-length bodies. By and large, by the way, I believe that both bodies have sought to make and have succeeded in making improvements in their work and functions in recent times. I believe that more now even than at Second Reading, given the Government’s proposals on research. As the proposals for the reorganisation of the NHS are discussed it seems to me that the future of the HTA and the HFEA need more time and much more consideration. Apart from anything else, the CQC, which it is proposed should become the healthcare regulator for the HTA and fertility treatment, will have neither the time nor the expertise to carry out this function until it has swallowed the regulation of the whole of the rest of medical and social care. One might imagine that if a scandal arises in four or five years’ time regarding either fertility regulation or the use of human tissues, the excuse will be given that the CQC was too preoccupied with the rest of its enormous brief to give these matters the important attention that they warrant. I beg to move.

[Lord Warner]

My Lords, I have added my name to Amendments 92 and 93 in part in a spirit of helpfulness—I hope that is the case—to the Minister as I have traversed the same ground as him on Department of Health arm’s-length bodies. In 2003-04, I was the Minister who reviewed DH arm’s-length bodies and halved their number. Therefore, I cannot claim to be against reducing the number of Department of Health arm’s-length bodies. Indeed, my sins are fully catalogued by this Government in annexe B of their document on the arm’s-length body review, which was published last year. Therefore, I own up fully to these past misdemeanours. However, as I have previously said about the Government’s own arm’s-length body review, although I do not necessarily agree with every aspect of it, it comprises a serious, comprehensive, clear and coherent set of proposals, unlike some of the things which emerged from other departments under this Bill. Therefore, I do not in any way wish to argue that it was not a thorough piece of work.

--- Later in debate ---

[Lord Warner]

I am sorry to interrupt the Minister. I have been listening intently to what he has said. I am extremely confused about the order in which things are going to be done. As I understood what he was saying, we are going to get a series of orders that transfer functions through a process of consultation, which I welcome, but we may or may not know at that point what the Government are going to do about setting up a health research agency, either by statute or otherwise. As I understood him, we could be in the position of being asked to agree those orders before we know what the final endgame is. It would be helpful if, before the next stage of the Bill, the Minister could set this out more clearly for us in writing so that we can understand the sequence. I found it rather difficult to understand.

[Earl Howe]

I must apologise to the Committee if I was not sufficiently clear and I will be happy to write to those who have participated in this debate to make the position clearer. I was seeking to say that we do not wish to take a disjointed, piecemeal approach. There is a natural flow of process that, if Parliament agrees, can lead us to a position where we are able in one move, so to speak, to transfer the various functions more or less simultaneously—although I would not wish to undertake that the whole thing would be done on the same day—so as to arrive at that point.

In our view it is desirable to consult during the late summer of this year. We will then set about the process of designing statutory instruments based on that consultation and go out to consultation on them. All being well, we will then introduce a second-Session health Bill that will have within it the provisions to establish a single research regulator, assuming that that is what we decide to do. Therefore, the whole process should work in a seamless way. However, I shall be very happy to write to noble Lords setting that out.

I return to the point at which I left off, which is to express the hope that the noble Baroness will not press her amendment this evening. I hope that she will accept our assurance that we have a clear intention to consult on the proposed transfers of functions and that she will be willing to withdraw the amendment.

NHS: White Paper

Lord Warner Excerpts

Monday 12th July 2010 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness identifies two particularly important issues. How will GPs be held to account for the clinical care that they provide? The data emanating from their performance will be transparent and published. The consortia will monitor the performance of each practice. They will identify outliers, whether good or bad, and act accordingly. We do not have those information systems sufficiently in place—I hope that, over the next 18 months or so, there will be time to develop the systems needed for consortia to do this—but it is vital that GPs are held to account for their performance and they will be incentivised in their remuneration to provide high quality.

The noble Baroness made an important point about loss leaders among providers. The NHS commissioning board will license a provider only if it is satisfied that the quality of care delivered by that body is of an adequate standard. I think that the board will look with great care at the practice of introducing loss-leader services and rule out, if there is any doubt at all, quality being compromised in the process.

[Lord Warner]

My Lords, I warmly welcome some of those ideas in the White Paper that build on the previous Government’s reforms such as choice and competition. However, is the Minister aware—as am I from my own experience as a Minister—that many in the NHS do not wish to be liberated? What will be his approach to those areas where GPs’ consortia do not live up to the standards required of the commissioning board? What will he do to ensure that we do not lose the benefits of regional specialised commissioning, which it has taken many years to bring to the level of quality that exists today?

[Earl Howe]

My Lords, I shall be brief because time is against us. I agree with the noble Lord that we must not lose the gains that we have made in specialised commissioning following the Carter reforms. He will see that the national commissioning board will retain responsibility not only for national specialised commissioning but for regional specialised commissioning. That will safeguard the quality of those services.

The noble Lord referred to GPs who do not wish to commission or who are in some way found wanting in their performance. Our experience to date—a number of consortia have been formed around the country, all of which are working encouragingly well—suggests that those GPs within the consortium who are in the lead and are the most go-ahead are best placed to bring up to standard their colleagues who are perhaps struggling. We have witnessed that in a number of instances. Those GPs who are incapable of being brought up to an adequate standard may be subject to a question over their future. In certain consortia, we have seen GPs retiring from NHS service.

NHS: Budget

Lord Warner Excerpts

Wednesday 23rd June 2010 Lords Chamber

[Earl Howe]

My noble friend makes an extremely good point. Much of the thrust of what we are trying to do is to achieve much greater local ownership by clinicians, staff and managers of the problems that we can all identify. The ideas that my noble friend has put forward already operate in many trusts, but they should be imposed more widely.

[Lord Warner]

My Lords, in his review will the Minister encourage his ministerial colleagues to enhance the coalition Government’s reputation for taking tough decisions by looking seriously at the number of acute hospitals that are failing financially and are unsustainable, especially in London? Is he willing to market-test the provider side of PCTs, which the Department of Health has identified as inefficient?

[Earl Howe]

My Lords, the noble Lord, with his knowledge of London, speaks with great authority and he will know that reconfiguration is high on the agenda in London. Efficiencies can be created, but we want to see local buy-in to those changes rather than any top-down prescription. On his second point, we are keen on the split between the commissioning and the provision of community services, so that we can get greater plurality of provision in community services.

Health: Government Spending

Lord Warner Excerpts

Monday 14th June 2010 Lords Chamber

[Earl Howe]

My Lords, there are several principles. A reduction in the number of arm’s-length bodies is only one of the possible outcomes. As I have said, we are not looking necessarily for a large-scale reduction in numbers, but we want to see both efficiency and the delivery of quality. With those two ends in view, the bodies that we end up with have to make sense in terms of what matters in our wider system reform, which is, as I have said, to deliver quality.

[Lord Warner]

My Lords, the Minister has said that he will be looking at functions in the review of bodies and that he will be looking to save one-third of running costs. In carrying out this review, will PCTs be examined carefully in terms of divesting themselves of their provider-arm functions so that they can concentrate on their commissioning functions?

[Earl Howe]

My Lords, strictly speaking, primary care trusts are not considered to be arm’s-length bodies, but the coalition agreement, which I am sure the noble Lord has read from cover to cover, indicates the new role and the functions envisaged for PCTs. Further details of our plans will be announced very soon.

Genomic Medicine: S&T Committee Report

Lord Warner Excerpts

Wednesday 9th June 2010 Lords Chamber

[Lord Warner]

My Lords, I begin by saying what a privilege it was to serve on this inquiry, which was so skilfully chaired by the noble Lord, Lord Patel. We owe him a great deal of gratitude for ensuring the presence of scientific stars of a positive World Cup standard, who appeared before us to give evidence that helped to inform our report. I also look forward to the appearance of my noble friend Lord Winston on the Front Bench. I wish only that the Labour Party had thought of the idea of guest spokesmen on the Front Bench when I was a Minister. I thank Tim Aitman and wish him a happy birthday and thank all the clerks’ office staff for the work that they put in.

This was an important report for the NHS and patients. It is based on extensive evidence-gathering. As a committee, we were fully seized of the state of the public finances, and we went to some trouble not to produce a wish-list of things to please scientists and damage the Government’s finances further. We have been hard-headed in the recommendations we have made, with a strong focus on things that will benefit patients. What is, however, clear is that in the world of genomic medicine things will not stand still but will change at a rapid pace whatever a UK Government do about this report. It looks as though linking therapies for identifiable individuals with common diseases is progressing very rapidly, and we cannot ignore, as the noble Lord, Lord Taverne, said, the speed of that progress.

The UK has traditionally been a world leader in the field of genetics and we were told consistently that it has punched above its weight in genomic research. That was reflected in the 2003 White Paper that I was involved in as the responsible Health Minister. The world moves on, with many advances overseas, especially in the US and China, but the UK still has a major advantage if we choose to use it wisely—a National Health Service, with universal population coverage and health data. This provides a strong scope for population-based approaches to early diagnosis of diseases and targeted personal drug therapies. Moreover, the cost of burgeoning genetic knowledge is falling rapidly, as the noble Lord, Lord Patel, described so well.

The pace of change presents serious challenges to government and the NHS. To be honest, I found the previous Government's response to our report disappointing and, if I may say so, in some respects slightly complacent. I note that respected bodies such as the Wellcome Trust, and others, were also disappointed in that response. Too much of it looked back to what the Government had done rather than forward to what the Government and the NHS needed to do, given the pace of change. I can see that there could be a case for setting up a Human Genomics Strategy Group, which seems to be the cornerstone of the previous Government's response, but my fear is that this will be a poorly resourced talking shop with no clear mission statement and without the authority to drive change. For me, the unwillingness to produce a new White Paper that looks ahead for five to 10 years and sets out a new agenda for genomics within an NHS context is a sign of the Department of Health's reluctance to define and drive a new agenda through a HGSG or alternative machinery. After so many years around government, I have developed an expertise in recognising bureaucratic inertia, which is what this could be interpreted as. So my first question to the Minister is whether he and his colleagues in the new Government are willing to revisit the issue of producing a forward-looking White Paper and creating a more sharply defined machinery for driving forward a new agenda in this area. That would be totally consistent with the efficiency and quality agenda for the NHS that the new Government wish to produce.

I shall confine myself to a few specific issues on the other points in the report around the translation of this new knowledge into patient benefit. The NHS in my experience has a mixed track record in translating discoveries from the lab to the bedside. There are four of these translation aspects in the report that I have concerns about. The first is extending the remit of NICE to evaluate validity, utility and cost-benefits of genomic tests for common diseases. The noble Baroness, Lady Finlay, has spoken in more detail about this critical area. We thought that it was best to place this responsibility on an existing, respected body, and I think that that was the right thing to do. However, as a former Minister responsible for NICE, I know how many new duties have been piled upon it. Can we be confident that NICE will have the resources, including the specialised expertise, to take on this demanding new role, and when can we expect to see this new role featuring substantively in NICE's work programme?

My second area of concern relates to pathology, on which the noble Earl, Lord Selborne, has spoken. We deliberately proposed centralising laboratory services for molecular pathology as a way of making the efficiency savings that would fund much of the new equipment that will be required and on the basis of evidence given to us, particularly in relation to Oxford from Sir John Bell.

Amalgamation also goes with the flow of the two reports on NHS pathology services by my noble friend Lord Carter of Coles, who, if I may put it this way, I unleashed on these services when I was a Minister nearly five years ago. However, never underestimate the capacity of parts of the NHS to resist change. As the committee indicated in its report, implementation of the Carter proposals has been painfully slow, given the scale of the possible savings that the noble Earl, Lord Selborne, described. The previous Government’s response on this issue was hardly galvanising, even though they sort of accepted our recommendation. Their proposal was that SHA medical directors were to lead work on pathology service redesign to bring together pathology and genetics laboratories. I certainly would not have bet the farm on this achieving change quickly in the face of longstanding resistance from many local consultant pathologists, but if SHAs are to be abolished in 2012, I would expect even less to happen between now and then.

Will the Minister have another look at this whole area, including the Carter recommendations, and come up with a more convincing plan that is also likely to deliver substantial savings and improve services? I remind him that when I was a Minister setting up the Carter review, we were thinking then in terms of 20 per cent savings on the cost of the pathology services by consolidation and amalgamation.

My third area of concern is commissioning, where the previous Government rejected the committee's recommendation that changes were needed in the commissioning of genetic tests because of the inconsistency across the NHS in the provision of genetic tests and genetic testing for subtypes of common diseases. The noble Lord, Lord Patel, has already referred to the risk of a postcode lottery with regard to the availability of these tests. The then Government wanted to rely on the web portal NHS evidence to inform commissioners, and on the current commissioning arrangements. The respected PHG Foundation has sided with the committee after expert workshops looked at this issue among others. In a report published last month, the foundation said that the DoH,

“should review how NHS funding mechanisms act as a barrier to the utilisation of new tests”,

and that, in effect, these make it difficult to realise cost savings throughout the healthcare economy. Given that the new Government have in mind new approaches to commissioning, this would seem a good opportunity to revisit the concerns over the commissioning of genetic tests that others have raised. Will the Minister be prepared to do this?

My final point relates to issue of medical bioinformatics, which is critical to success in this area, as other noble Lords have mentioned. All the evidence that we received suggested that a shortage of bioinformatics personnel and kit was likely to be one of the greatest impediments that the NHS would face in using the new genetic knowledge. I am pleased that the previous Government accepted that more secure funding for the European Bioinformatics Institute was needed. We hope that this will not be a victim of cuts. However, I have grave doubts about whether the DoH is doing enough to provide sufficient bioinformatics capability to the NHS through its Modernising Scientific Careers programme, which seems to be its process of choice. That is why we recommended the establishment of an institute of biomedical informatics. I encourage the Minister to get his colleagues to look again at this proposal, particularly drawing on the potential for savings, as a number of us have said, from consolidation in the pathology area.

I recognise that there is a lot of detail in these questions and that the Minister may well need to take further advice. We should say to him, though, that the Science and Technology Committee—I hope—will continue to keep a beady eye on this area and progress in it.

Mid Staffordshire NHS Foundation Trust

Lord Warner Excerpts

Wednesday 9th June 2010 Lords Chamber

[Baroness Knight of Collingtree]

My Lords—

[Lord Warner]

My Lords, I think that it is this side’s turn—

[Noble Lords]

Order.

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[Earl Howe]

I am grateful to my noble friend for her kind comments. The House will know what a champion she is of patient care and compassion in the health service. On her last point, it is of course for Robert Francis, who is in charge of the inquiry, to decide whom he calls as witnesses, but he has a completely free hand and I am sure that he will take note of my noble friend’s suggestion.

[Lord Warner]

My Lords, before I ask my question, I suggest that we register that the usual channels might discuss the sequencing of speakers from the government Benches and these Benches, because I am not sure that there is a correct interpretation.

I have no objections whatsoever to this wider inquiry. I hope that it will look carefully at the extent to which doctors, nurses and managers failed in their professional responsibilities. What the regulators and other bodies did might also be usefully looked at. However, does the Minister accept that it is easy in such circumstances to reach for something that cannot answer back, such as a target, to explain away what is essentially appalling clinical and managerial behaviour? That is clear from many other inquiries into what happened in Mid Staffordshire.

If the Minister wants seriously to consider targets, he might read some of the speeches made by previous Ministers, who made it crystal clear to the NHS that its overriding responsibility was to the care and safety of patients, not obsessively to implement targets. I know that there are conventions about looking at papers from previous Administrations, but I would certainly be prepared to waive that consideration. Will he also look at the extent to which John Reid, when he was Health Secretary, amended the way in which the four-hour target was implemented in response to concerns expressed by doctors? He might like to see the minutes of a meeting that I had with the College of Emergency Medicine. Members of the college came to see me as a Health Minister to ask me—beg me, almost—not to amend the four-hour target because of the improvements that it had produced for its members, for patients and for the way in which hospitals were run. Will he also look at the Nuffield Trust’s independent inquiry into targets, which also shows the benefits that they have brought to patients in terms of better access and shorter waiting times and which compares the experience in England, where there were targets, very favourably with that in the Celtic fringes, which did not have them?

[Earl Howe]

My Lords, we are not targeting the targets with this inquiry. They are not the main point at issue. The noble Lord is right that the main point at issue is the failure of care, but that is also, as we hope this inquiry will show, a systemic failure. That is the point of the inquiry. I do not doubt anything that he said about the commitment of previous Ministers to putting care above any rigid adherence to targets; I fully accept the good faith of Ministers in the previous Administration in that regard. However, the noble Lord will know that what Ministers say is very often not interpreted in the same way on the ground in the NHS. When people in the NHS hear things coming out of Whitehall, they are inclined to adhere rigidly to what they are told to do. That is part of the problem, but it is not the problem that I want to emphasise in this context. We need to understand how the wider performance management and regulatory system failed to spot the problems earlier and deal with them and why so few professionals felt that they could challenge what they saw. Understanding the lessons from that and the culture in which the events at Mid Staffs were allowed to happen will be key to informing and shaping our plans for the future.

Queen's Speech

Lord Warner Excerpts

Thursday 3rd June 2010 Lords Chamber

[Lord Warner]

My Lords, it is a great pleasure to follow the noble Baroness, Lady Murphy, with whose speech I largely agree. The Government would do well to take heed of many of the remarks that she and the noble Lord, Lord Patel, have made.

I shall speak today on adult social care and the NHS but, first, I congratulate the two Ministers on their new appointments. As one of the Ministers that the noble Earl, Lord Howe, has seen off, I congratulate him on his strong grasp of health and social care. Even when he was skewering me as a Minister, it was always done with elegance and with a sense of doing so in the best interests of the NHS.

I greatly enjoyed the maiden speech of the noble Lord, Lord Hill. It reminded me that it was one of his former boss’s ideas on GP fund holding that I pinched and turned into practised-based commissioning. I have never owned up to that publicly but this seems an appropriate occasion to do so.

I begin by congratulating the Government on administering a speedy coup de grâce to the ill-conceived Personal Care at Home Act. This has removed an important roadblock to achieving sustainable long-term reform in this area. Unlike the noble Lord, Lord Sutherland of Houndwood, I welcome the idea of an independent commission to look into this. I think that we need to dig quite a few people out of rather entrenched positions on some of these issues, and a commission of independent mind might help us to do that. However, it is important that it focuses quickly on the considerable amount of common ground that exists among different shades of opinion in this area. A few of us identified this common ground in March in a pamphlet produced on a cross-party basis with Sir Derek Wanless. I know that Ministers have seen that pamphlet but when we were writing it, it was very clear that there was a large measure of agreement on many issues in this area, and that is something on which the commission needs to build.

It is clear from the public debate so far that total funding for adult social care has to be increased significantly to cope with demography. It is also clear that there has to be a larger contribution from individuals and families who can afford it, rather than from the taxpayer. It is equally clear that risk-pooling through some form of insurance has a key role to play. These points are all well documented and well settled, and we need to build on them. We need to do more—and I hope that the commission will do this—to engage the insurance industry in ways forward in this area.

Before leaving the subject of social care, perhaps I may say a few words about the idea of a national care service. Like all parties, the Government rightly want to achieve more integration of health and social care for the benefit of service users. No one could disagree with that. However, I suggest that a better starting point for improved integration is the local commissioning role, rather than just concentrating on the provider side. This will particularly be the case if GPs are to be more powerful service commissioners in the future. We now need joint commissioning which supports more personal budgets and user choice and which creates greater diversity of service providers. It seems to me that the rather statist-sounding national care service is not self-evidently the best way to achieve this, and we need to look at that idea very carefully before we take it too much further forward.

I turn briefly to the subject of dementia, which has been raised a number of times today. I support and welcome the Government’s decision to prioritise dementia research but I would encourage them to think more widely about whether the current allocation of service and financial responsibilities for dementia between the NHS and social care is right. After all, dementia is very much an illness; it is a disease, and I wonder whether the NHS is bearing its full proportion of the burden in this area. Another look at that might change some of the calculations that the independent commission might have to make in adult social care. I do not have a strong view on that, but it is an area that we should look at again.

Turning to the NHS, the Labour Government’s record on investment in the NHS was outstanding. We recognised that that needed to be done after almost two decades of parsimony in the 1980s and 1990s. I shall not recite all the figures; many in this House have heard me recite them from the Front Bench many times. However, I emphasise one point: the independent evidence from the Nuffield Trust shows that the much maligned targets did a lot to improve services, however much NHS staff disliked them. Before we ditch targets we should consider whether, in a democratically parliamentary accountable system like the NHS, we have a few levers in Richmond House that enable us to satisfy the public that taxpayers’ money has been spent reasonably well.

Latterly—the noble Baroness, Lady Murphy, put it very well—my party lost its appetite for NHS reform and certainly lost its appetite for some of the agenda that was promised in the 2005 Labour election manifesto, particularly those parts about more competition and greater diversity of providers to give patients more choice. I am a little hesitant about asking the coalition Government to help to implement that Labour Party manifesto. I notice in the new health Bill that this Government are to make Monitor into a proper economic regulator, a move which I have long supported. This is a good opportunity to ditch, once and for all, the rather misguided idea of the NHS as a preferred provider. A good start could be made by starting with market-testing PCT provider services, which the Department of Health has already said are inefficient and lacking in good productivity. I wonder whether the noble Earl can say whether there will be a review of some of the mergers that have quietly taken place or are in prospect of some of these less than efficient PCT provider services.

There is not time for me to go into any other areas of the NHS. As the new Government tackle the very difficult financial challenges ahead, which the NHS has never faced in its history on this kind of scale, I hope we in this House can settle down and discuss all these changes, which would have been inevitable whoever had won the election, and start doing so in a constructive and non-partisan way.